Bronchiectasis

Bronchiectasis: Excerpt from Handbook of Diseases

A condition marked by chronic abnormal dilation of bronchi and destruction of bronchial walls, bronchiectasis can occur throughout the tracheobronchial tree or can be confined to one segment or lobe. However, it’s usually bilateral and involves the basilar segments of the lower lobes. This disease has three forms: cylindrical (fusiform), varicose, and saccular (cystic).

It affects people of both sexes and all ages. Because of the availability of antibiotics to treat acute respiratory tract infections, the incidence of bronchiectasis has dramatically decreased in the past 20 years. Its incidence is highest among the Inuit of the Arctic and the Maoris of New Zealand. Bronchiectasis is irreversible once established.

Causes

The different forms of bronchiectasis may occur separately or simultaneously. In cylindrical bronchiectasis, the bronchi expand unevenly, with little change in diameter, and end suddenly in a squared-off fashion. In varicose bronchiectasis, abnormal, irregular dilation and narrowing of the bronchi give the appearance of varicose veins. In saccular bronchiectasis, many large dilations end in sacs.

This disease results from conditions associated with repeated damage to bronchial walls and abnormal mucociliary clearance, which cause a breakdown of supporting tissue adjacent to airways. Such conditions include:

❑  mucoviscidosis (cystic fibrosis)

❑  immunologic disorders (agammaglobulinemia, for example)

❑  recurrent, inadequately treated bacterial respiratory tract infections, such as tuberculosis, and complications of measles, pneumonia, pertussis, or influenza

❑  obstruction (by a foreign body, tumor, or stenosis) in association with recurrent infection

❑  inhalation of corrosive gas or repeated aspiration of gastric juices into the lungs

❑  congenital anomalies (uncommon), such as bronchomalacia, congenital bronchiectasis, immotile cilia syndrome, and Kartagener’s syndrome, a variant of immotile cilia syndrome characterized by situs inversus viscerum, bronchiectasis, and either nasal polyps or sinusitis.

With bronchiectasis, hyperplastic squamous epithelium denuded of cilia replaces ulcerated columnar epithelium. Abscess formation involving all layers of the bronchial wall produces inflammatory cells and fibrous tissue, resulting in dilation and narrowing of the airways. Mucus or fibrous tissue obliterates smaller bronchioles, and peribronchial lymphoid tissue becomes hyperplastic. Extensive vascular proliferation of bronchial circulation occurs and produces frequent hemoptysis.

Signs and symptoms

Initially, bronchiectasis may be asymptomatic. When symptoms do arise, they’re often attributed to other illnesses. The patient usually complains of frequent bouts of pneumonia or hemoptysis. The classic sign, however, is a chronic cough that produces copious, foul-smelling, mucopurulent secretions, possibly totaling several cupfuls daily. Characteristic findings include coarse crackles during inspiration over involved lobes or segments, occasional wheezes, dyspnea, sinusitis, weight loss, anemia, malaise, clubbing, recurrent fever, chills, and other signs and symptoms of infection.

Advanced bronchiectasis has been associated with chronic malnutrition and amyloidosis as well as right-sided heart failure and cor pulmonale due to hypoxic pulmonary vasoconstriction.

Diagnosis

A history of recurrent bronchial infections, pneumonia, and hemoptysis in a patient whose chest X-rays show peribronchial thickening, areas of atelectasis, and scattered cystic changes suggests bronchiectasis.

In recent years, computed tomography scanning has supplanted bronchography as the most useful diagnostic test for bronchiectasis. It’s sometimes used with high-resolution techniques to better determine anatomic changes. Bronchoscopy doesn’t establish the diagnosis of bronchiectasis, but it does help to identify the source of secretions. Bronchoscopy can also be instrumental in pinpointing the site of bleeding in hemoptysis.

Other helpful laboratory tests include:

❑ sputum culture and Gram stain to identify predominant organisms

❑ complete blood count to detect anemia and leukocytosis

❑ pulmonary function studies to detect decreased vital capacity, expiratory flow, and hypoxemia; these tests also help determine the physiologic severity of the disease and the effects of therapy, as well as help evaluate patients for surgery.

Evaluation may also include urinalysis and an electrocardiogram. (The latter is normal unless cor pulmonale develops.) When cystic fibrosis is suspected as the underlying cause of bronchiectasis, a sweat electrolyte test is useful.

Treatment

Typically, an oral or I.V. antibiotic is given for 7 to 10 days or until sputum production decreases. For severe cases, several different antibiotics may be used sequentially in a continuous regimen to minimize bacterial resistance. If the patient has bronchospasm and thick, tenacious sputum, a bronchodilator, combined with postural drainage and chest percussion, can help remove secretions. Bronchoscopy may be used to help mobilize secretions.

Hypoxia requires oxygen therapy, and severe hemoptysis requires lobectomy, segmental resection, or bronchial artery embolization if pulmonary function is poor.

Special considerations

❑  Provide supportive care, and help the patient adjust to the permanent changes in lifestyle that irreversible lung damage necessitates. Thorough patient teaching is vital.

❑  Administer an antibiotic, as needed, and explain all diagnostic tests.

❑  Perform chest physiotherapy, including postural drainage and chest percussion designed for involved lobes, several times per day. The best times to do this are early morning and just before bedtime. Instruct the patient to maintain each position for 10 minutes. Then, perform percussion, and tell him to cough.

Clinical tip  To help prevent bronchiectasis, treat bacterial pneumonia vigorously and stress the need for immunization to prevent childhood diseases.

❑ Review patient teaching guidelines. (See Teaching about bronchiectasis.)

Pictures

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

More About Bronchiectasis

• Back to disease: Bronchiectasis: Introduction
• Next Book Extract About Bronchiectasis: Stridor (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

 » Next page: Stridor (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

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