Bronchiectasis

Physical Examination

Surroundings:

• Presence of purulent sputum in a pot next to the bedside

• Inhalers by the bedside

On examination:

• Clubbing of fingers

• Scarring may be visible

• Reduced chest expansion

• Coarse inspiratory crepitations that change in character with coughing

• Wheezing and inspiratory clicks may be heard

Other positive findings:

• Signs of bronchiectasis

• Evidence of complications such as respiratory failure or cor pulmonale or infection

• Signs of possible underlying causes such as cystic fibrosis, Kartagener’s Syndrome, connective tissue disease, or Yellow Nail Syndrome

• Signs of treatment such as fever or body mass index included in Bronchiectasis Severity Index

Investigations for Bronchiectasis

Laboratory Tests

• Full blood count (FBC):

  • Identify anemia or evidence of inflammation.

• Sputum cultures:

  • Identify causative organisms e.g. Haemophilus influenzae, Pseudomonas aeruginosa.

• Sputum for acid-fast bacilli (AFB):

  • To rule out tuberculosis as an etiological factor.

• Serum immunoglobulins:

  • Assess for immunodeficiency, e.g. Common Variable Immunodeficiency.

• Cystic fibrosis (CF) tests:

  • Sweat chloride test and/or genetic tests to rule out CF.

• Rheumatoid factor & anti-CCP:

  • Check for rheumatoid arthritis (associated with bronchiectasis).

• Alpha-1 antitrypsin levels:

  • Rule out Alpha-1 antitrypsin deficiency, especially if early-onset or if there's a coexistent COPD.

Imaging

• High-resolution computed tomography (HRCT) of the chest:

  • Gold standard to confirm bronchiectasis.

  • Shows dilated and thick-walled bronchi, "tram-line" and "signet ring" appearances.

• Chest X-ray:

  • Initial imaging; may show bronchial wall thickening and cystic changes, but less sensitive than HRCT.

Invasive tests

• Bronchoscopy:

  • Inspect airways, rule out obstruction (e.g. tumor), and obtain samples.

• Lung function tests:

  • Assess severity, with focus on forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC).

Other tests

• Allergy testing:

  • Identify allergic bronchopulmonary aspergillosis (ABPA) or other allergic triggers.

• Serum precipitins:

  • For hypersensitivity pneumonitis or farmer’s lung.

• Aspergillus IgE & skin prick test:

  • For suspected ABPA.

• Ciliary function tests and nasal brushings:

  • For suspected primary ciliary dyskinesia.

Management

General Management:

• Patient education and counseling.

• Smoking cessation.

• Pulmonary rehabilitation.

• Vaccinations: Covid, influenza and pneumococcal vaccinations

Medical Management:

• Antibiotics: empirical antibiotics based on sputum culture results; long-term, low-dose antibiotics to prevent exacerbations.

• Airway clearance techniques: postural drainage and percussion, positive expiratory pressure (PEP) therapy, high-frequency chest wall oscillation (HFCWO).

• Bronchodilators: beta-agonists, anticholinergics.

• Anti-inflammatory therapy: inhaled corticosteroids and oral corticosteroids for acute exacerbations.

Surgical Management:

• Surgery may be considered in bronchiectasis cases with localised disease and recurrent infections, lobectomy or lung transplant

Other Management:

• Management of associated comorbidities such as sinusitis, gastroesophageal reflux disease (GERD), and allergic bronchopulmonary aspergillosis (ABPA).

Causes of Bronchiectasis

• Cystic fibrosis: A genetic disorder that causes thick, sticky mucus that can lead to bronchiectasis.

• Primary ciliary dyskinesia (PCD): A rare genetic disorder that affects the cilia in the respiratory tract, leading to impaired mucus clearance and increased risk of bronchiectasis.

• Immunodeficiency syndromes: Conditions like HIV/AIDS or common variable immunodeficiency (CVID) weaken the immune system, leading to frequent respiratory infections that can cause bronchiectasis.

• Autoimmune diseases: Disorders such as rheumatoid arthritis, systemic lupus erythematosus (SLE), and Sjögren's syndrome can cause bronchiectasis.

• Allergic bronchopulmonary aspergillosis (ABPA): A hypersensitivity reaction to Aspergillus fumigatus, a fungus found in the environment, can cause bronchiectasis.

• Recurrent respiratory infections: Frequent infections like pneumonia or bronchitis can cause permanent damage to the bronchial tubes and lead to bronchiectasis.

• Obstructive lung diseases: Conditions like chronic obstructive pulmonary disease (COPD) or asthma can lead to bronchiectasis.

• Environmental factors: Exposure to pollutants like smoke, chemicals, or dust can cause bronchiectasis.

Complications of Bronchiectasis

• Respiratory failure

• Hemoptysis

• Recurrent pneumonia

• Cor pulmonale

• Pleural effusion

• Empyema

• Lung abscesses

• Atelectasis

• Amyloidosis

• Osteoporosis