bronchiectasis
BRONCHIECTASIS
Bronchiectasis is an irreversible pathologic dilatation or ectasia of the bronchi due to repeated airway infection and inflammation.
It enhances susceptibility to bronchial infection and increases inflammatory reaction which causes further lung damage.
Classic symptoms of of bronchiectasis are cough with chronic sputum production along with recurring infective exacerbations and hemoptysis.

Diagnosis

  • Diagnosis is based on clinical history of daily viscid sputum production & characteristic CT findings
    • Rare variant: Dry bronchiectasis (Bronchiectasis sicca) which manifests by episodic hemoptysis w/ no sputum production [usually a sequela of tuberculosis (TB)]
  • Identify possible underlying etiologies that may have caused bronchiectasis

History

  • Assess the amount of sputum production within 24 hours & the frequency of exacerbation over the last 12 months

Physical Examination

  • General findings: Cyanosis, plethora, wasting, wt loss & finger clubbing
  • In advanced disease, cor pulmonale may be observed
  • Physical findings are nonspecific but persistent coarse crackles over any part of the lungs suggests bronchiectasis
  • Nasal polyps & sinusitis may be present

Laboratory Tests

Sputum Analysis
  • Sputum culture & smear for bacteria, mycobacteria & fungi
    • Reinforces the diagnosis of bronchiectasis & adds significance to the information regarding the etiologies & treatment
      • Isolation of Aspergillus fumigatus in sputum culture supports the diagnosis of ABPA as the underlying etiology
    • Frequently positive for Haemophilus influenza, Pseudomonas aeruginosa, Streptococcus pneumoniae
Pulmonary Function Tests
  • May reflect underlying diseases
  • May be normal in localized & mild bronchiectasis
  • The most common abnormality is an obstructive & restrictive airway defect, especially in patients w/ more severe disease
  • Useful in obtaining a functional assessment of the patient
Laboratory Tests
  • Complete blood count (CBC)
  • Serum immunoglobulins: Total IgG, IgA, IgM; IgE & IgG antibodies specific for Aspergillus; antibody titers for S pneumoniae
Other Diagnostic Studies to Confirm Underlying Etiologies
  • Recommended in patients w/ no evident cause of the disease; results may assist in the management & prognosis of the patient
  • The following diagnostic tests may be considered in the appropriate clinical setting:
    • Pilocarpine iontophoresis (sweat test) for cystic fibrosis
    • Rheumatoid factor & anti-cyclic citrullinated peptide antibodies for rheumatoid diseases
    • Aspergillus precipitins/IgG, IgE in blood & skin test for allergic bronchopulmonary aspergillosis (ABPA)
  • Flexible bronchoscopy to rule out obstruction by foreign bodies, etc

Imaging

Chest X-ray
  • The following findings are suspicious but non-diagnostic findings:
    • Linear atelectasis, dilated & thickened airways (tram or parallel lines; ring shadows on cross section) & irregular opacities representing mucopurulent plugs

High Resolution CT (HRCT) Scan

  • HRCT is the defining test for bronchiectasis, w/ sensitivity & specificity of 98% & 99%, respectively
  • Assess severity of the disease by measuring the number of bronchopulmonary segments affected or percentage of the lobes involved
  • Indications
    • There are suspicious clinical findings but a relatively normal chest radiograph
    • Abnormal chest radiograph & bronchiectasis is suspected
    • Management decisions must be made depending on extent of bronchiectasis
    • Presence of confounding diseases need to be defined
  • Findings
    • Diagnostic features:
      • Lacks normal tapering of bronchi
      • Bronchial diameter is larger than the accompanying pulmonary artery (called signet ring sign)
      • Peripheral airways are seen w/in 1 cm of the costal pleura
    • Other nonspecific findings:
      • Bronchial wall thickening
      • Dilated airways w/ air-fluid levels
      • Mucopurulent plugs or debris accompanied by post-obstructive air trapping
      • “Tree-in-bud” pattern when small airways are affected
      • More destructive bronchiectasis shows cysts on the bronchial wall
      • Consolidation of a segment or lobe maybe seen
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