• Clinical science

Bronchiectasis

Summary

Bronchiectasis is an irreversible and abnormal dilation in the bronchial tree that 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: either local infection or inflammation along with either inadequate clearance of secretions, airway obstruction, or impaired host defenses. These processes result in the permanent dilation of airways.

References:[2][1][3]

Clinical features

Bronchiectasis should be suspected in patients with a chronic cough that produces large amounts of sputum.
References: [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 it should be confirmed with CT!
References:[6][7][3][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.

References:[8][2][1][3][5]

Complications

References: [5]

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

Prevention

References:[5]

  • 1. Magis-Escurra C, Reijers MH. Bronchiectasis. BMJ clinical evidence. 2015; 2015. pmid: 25715965.
  • 2. Gao Y, Guan W, Liu S, et al. Aetiology of bronchiectasis in adults: A systematic literature review. Respirology. 2016; 21(8): pp. 1376–1383. doi: 10.1111/resp.12832.
  • 3. Chang AB, Bush A, Grimwood K. Bronchiectasis in children: diagnosis and treatment. The Lancet. 2018; 392(10150): pp. 866–879. doi: 10.1016/s0140-6736(18)31554-x.
  • 4. Gao Y, Guan W, Zhu Y, Chen R, Zhang G. Antibiotic-resistant Pseudomonas aeruginosa infection in patients with bronchiectasis: prevalence, risk factors and prognostic implications. International Journal of Chronic Obstructive Pulmonary Disease. 2018; Volume 13: pp. 237–246. doi: 10.2147/copd.s150250.
  • 5. Kasper DL, Fauci AS, Hauser S, Longo D, Jameson LJ, Loscalzo J . Harrisons Principles of Internal Medicine . New York, NY: McGraw-Hill Medical Publishing Division; 2016.
  • 6. King PT. The pathophysiology of bronchiectasis. Int J Chron Obstruct Pulmon Dis. 2009; 4: pp. 411–419. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793069/.
  • 7. Chalmers JD, Chang AB, Chotirmall SH, Dhar R, McShane PJ. Bronchiectasis. Nature Reviews Disease Primers. 2018; 4(1). doi: 10.1038/s41572-018-0042-3.
  • 8. Çoruh B, Pomerantz B. Bronchiectasis. http://www.merckmanuals.com/professional/pulmonary-disorders/bronchiectasis-and-atelectasis/bronchiectasis. Updated July 1, 2013. Accessed February 14, 2017.
  • 9. Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J. 2017; 50(3): p. 1700629. doi: 10.1183/13993003.00629-2017.
last updated 11/06/2020
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