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Bronchiectasis

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Bronchiectasis

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Bronchiectasis is a chronic respiratory condition characterized by abnormal, permanently damaged and dilated bronchi. 

This review presented here is of non-cystic fibrosis 
bronchiectasis called simply as bronchiectasis here 

Previously termed ” Orphan’s disease ” as was thought to be rare occurrence in the developed world Found in all age groups ie adults and children Affects women more than men Prevalence increases with age Incidence / Prevalence hard to determine One study has shown the incidence has increased in the UK over the last decade and it now affects > 1 % of people aged 70 and older Overall was considered to be in decline due to 
♦ effective treatment and management of childhood respiratory conditions
♦ vaccination pro grammes
♦ control of pulmonary TB Renewed interest in the condition ( unrelated to cystic fibrosis) possibly due to
♦ better diagnosis with HRCT ( high resolution CT )
♦ significant associated morbidity
♦ ageing population with COPD
♦ significant cost associated with treatment for eg frequent hospital admissions Delay in diagnosis , investigation and management is common ie it remains under-diagnosed and is easily missed

Causes- Idiopathic Post-infective for eg following respiratory tract infections as pneumonia , pertussis , pulmonary TB , mycoplasma , influenza Immunodeficiency Disorders of mucociliary clearance COPD Connective tissue disease eg
Rheumatoid arthritis, Marfans Gastric or foreign body aspiration Allergic bronchopulomonary aspergillosis Inflammatory bowel disease Asthma Non tuberculous mycobacteria . Approximately 40 % of adults and children with bronchiectasis have 
no clear initiating event or underlying cause.

Suspect in adults if -Persistent productive cough and
○ young age at presentation
○ h/o symptoms for several yrs
○ breathlessness
○ absence of smoking hx
○ daily expectoration of large volume of sputum
○ haemoptysis – can be frank ( up to 10 ml ) or massive ( > than 235 mL )
○ sputum colonisation with P aeruginosa
 Unexplained haemoptysis or non- productive cough Pleuritic chest pain , wheezing , fever , wt loss , weakness ( less specific symptoms)
 Patients with COPD may have bronchiectasis alone or in addition and consider further referral for investigation / referral if
○ management is not straightforward
○ slow recovery from respiratory tract infections
○ recurrent exacerbations
○ no h/o smoking
 People with confirmed immune deficiency Men with primary infertility ( particularly with azospermia or immotile sperm ) In children if -Chronic moist / productive cough , particularly between viral episodes or Positive bacterial culture for Staphylococcus aureus , Haemophilus influenzae , Psuedomonas aeruginosa , non-tuberculosis mycobacteria or Burkholderia cepacia complex Asthma that does not respond to treatment Episode of severe pneumonia , particularly if there is incomplete resolution of symptoms , physical signs of radiological changes Pertussis like illness failing to resolve after 6 months Persistent and unexplained physical signs or chest XR abnormalities Localised chronic bronchial obstruction Respiratory symptoms in children with structural or functional disorders of oesophagus and upper resp tr Unexplained haemoptysis Respiratory symptoms with any clinical features of cystic fibrosis , primary ciliary dyskinesia or immunodeficiency

R/o Asthma
 COPD
 Pneumonia
 Lung cancer
 Interstitial lung disease
 Tuberculosis

HRCT

Improve symptoms
 Prevent 
complications
 Prevent decline in lung function
 Treat any underlying medical condition
 Reduce bacterial load and prevent 2° airway inflammation and damage
 Pul rehabilitation

Complications –Infective exacerbations Haemoptysis – more than 235 mL ( 2/3rd of a mug full ) can 
be life threatening Pneumothorax and rib fractures Respiratory failure Rt sided heart failure Anxiety and depression Problems related to chronic coughing as
○ social embarrassment
○ urinary incontinence
○ sexual problems Fatigue/ tiredness Nutritional deficiency 
( chronic inflammatory state and breathlessness )

Treating exacerbations – Send sputum sample before starting antibiotic Ask to stop the long term antibiotic ( if on Rx ) Issue 10-14 days of Rx without waiting for results of culture
○ look at previous culture results
○ be guided by local protocols if available
○ First line choice if previous culture NA – Amoxicillin 500 mg ,Clarithromycin 500 mg bd , Doxycycline 200 stat then od , Erythromycin 500 mg qds Consider salbutamol for wheeze in acute phase Do not use steroid unless coexisting asthma or COPD Advice about airway clearing tech – most are taught by physio Review response to empirical Rx – once sensitivity becomes available but if the person is responding well cont without changing abx based on results Change the antibiotic based on sensitivity if the person has failed to respond to initial empirical Rx

Referral –Following an exacerbation CKS advices to change the antibiotic to a new one based on sensitivity and inform the respiratory team. It would be prudent to seek adv from the specialist consultant / nurse , in view of A4Medicine Refer to a specialist team if 3 or more infective exacerbations / year Chronic colonization with Pseudomonas aeruginosa , oppurtunist mycobacteria or MRSA For consideration of long term antibiotic Rx If bronchiectasis is associated with ♦ Rh arthritis ♦ immune deficiency ♦ inflammatory bowel disease ♦ primary ciliary dyskinesia ♦ allergic bronchopulmonary aspergillosis ♦ advanced disease

References
 Non-cystic fribrosis bronchiectasis MP Smith J R Coll Physicians Edinb 2011 ; 41 :132-9 Non-cystic fribrosis bronchiectasis : its diagnosis and management Arch dis child-Educ Pract Ed 2010 ; 95 : 73-82 British Thoracic Society guideline for non- CF bronchiectasis Volume 65 Issue Suppl thorax July 2010 Bronchiectasis A guide for primary care Volume 41 , No 11 , November 2012 Bronchiectasis is increasing in the UK , study shows BMJ 2015 ; 351 @h5916 Bornchiectasis in Adults – Management in Primary Care British Thoracic Society Guidelines Bronchiectasis CKS NHS Bronchiectasis BMJ 2010 ;341: c2766 Bronchiectasis Oxford Handbook of Respiratory Medicine -Stephen Chapman et al Oup Oxford Narrative review Management of bronchiectasis in adults Simone K Visser et al

 

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