• Clinical science

Bronchiectasis

Abstract

Bronchiectasis is an irreversible and abnormal dilation in the bronchial tree that results in chronic obstructive pulmonary disease (COPD). It is generally caused by cycles of bronchial inflammation in addition to mucous plugging and progressive airway destruction. Although the widespread use of antibiotics has made bronchiectasis rare, conditions such as cystic fibrosis (CF), severe or protracted pneumonia, immunodeficiency, and COPD continue to cause it. The most important clinical finding is a chronic cough with copious mucopurulent sputum. Other symptoms may include dyspnea, rhinosinusitis, and hemoptysis. Physical examination reveals crackles and rhonchi on auscultation, often accompanied by wheezing. High-resolution computer tomography is the best diagnostic test and shows thickened bronchial walls, a signet-ring appearance, and “tram track” lines. Treatment focuses on alleviating symptoms and preventing exacerbations, and includes pulmonary physiotherapy and antibiotics to treat underlying infections. In rare cases, massive hemoptysis may complicate bronchiectasis and necessitate surgery or pulmonary artery embolization.

Etiology

Bronchiectasis requires the combination of two important processes taking place in the bronchi: local infection or inflammation and either inadequate clearance of secretions, airway obstruction, or impaired host defenses.

References:[1][2][3][4][5][6]

Clinical features

  • Chronic productive cough (lasting months to years) with copious mucopurulent sputum ; the following may be heard on auscultation:
  • Rhinosinusitis
  • Dyspnea
  • Hemoptysis: generally mild/self-limiting
  • Nonspecific symptoms (i.e., fatigue, weight loss, pallor due to anemia)
  • Clubbing of nails (uncommon)
  • Exacerbations of bronchiectasis
    • Increased production of mucous above baseline
    • Low-grade fever

Bronchiectasis should be suspected in a patient with chronic cough producing large amounts of sputum!
References:[1][3][5]

Diagnostics

  • Imaging
    • Chest x-ray (best initial test)
      • Inflammation and fibrosis of bronchial walls lead to the appearance of parallel “tram track” lines
      • Thin-walled cysts (i.e., dilated bronchi forming sacs), possibly with air-fluid levels
      • Late-stage bronchiectasis: honeycombing
    • High-resolution computer tomography (HRCT): confirmatory test
      • Dilated bronchi; with thickened walls; possible signet-ring appearance; and tram track lines
      • Cysts, especially at bronchial ends in lower lobes, and honeycombing
  • Other tests

Bronchiectasis cannot be ruled out with a chest x-ray!
References:[1][3][4][7][8][5]

Treatment

Bronchiectasis is a permanent anatomical malformation and therefore cannot be cured. However, symptoms and advancement of the disease can be controlled. The treatment of any underlying cause is also very important.

  • Conservative
  • Invasive procedures
    • Surgical resection of bronchiectatic lung or lobectomy: indicated in pulmonary hemorrhage, inviability of bronchus, and substantial sputum production in unilateral bronchiectasis
    • Pulmonary artery embolization: indicated in pulmonary hemorrhage
    • Lung transplantation should be considered in severe disease.

References:[1][3][4][9][10]

Complications

We list the most important complications. The selection is not exhaustive.

Prevention

References:[3][9]