- Clinical science
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.
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.
- Pulmonary infections; (i.e., bacterial, viral, fungal), especially severe or chronic infections
- Disorders of secretion clearance or mucous plugging
Bronchial narrowing or other forms of obstruction
- Immunodeficiency; (e.g., common variable immunodeficiency, hypogammaglobulinemia, )
- Chronic inflammatory diseases (e.g., , , )
- Chronic productive cough (lasting months to years) with copious mucopurulent sputum ; the following may be heard on auscultation:
- Hemoptysis: usually mild/self-limiting but severe hemorrhage that requires embolization may occur.
- 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!
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
- Chest x-ray (best initial test)
- Sputum culture and smear: to determine infectious etiology (i.e. bacteria, mycobacteria, and fungi)
- Blood tests
- Pulmonary function tests: findings consistent with obstructive pulmonary disease (i.e. ↓ FEV1/FVC ratio)
- Bronchoscopy: to visualize tumors, foreign bodies, or other lesions; may also be used in combination with bronchoalveolar lavage (BAL) to obtain specimens for staining and culture
Bronchiectasis cannot be ruled out with a chest x-ray!
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.
- Bronchopulmonary hygiene and chest physiotherapy: “cupping and clapping” and postural drainage, hydration, directed cough
- Antibiotic therapy of exacerbations
- Smoking cessation
- Vaccinations (i.e. seasonal influenza vaccine, pneumococcal vaccine)
- Bronchodilators, corticosteroids, and nebulized hypertonic saline are not routinely used but may be considered, especially in patients with notable obstructive symptoms.
- 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.