Bronchiectasis

Question 1

Define the morphology of bronchiectasis and the clinical consequences?

Answer 1

Chronic inflammation of the lung causing permanent dilatation of airways and thickening.

The chronic inflammation also causes squamous cell metaplasia and loss of cilia.

The disease is characterised by chronic productive cough, excessive sputum production, bacterial colonisation and recurrent infection.

Question 2

Describe the typical presentation of patients with bronchiectasis?

Answer 2

May present with non specific pulmonary symptoms:
Chronic cough with large quantity of purulennt sputum production.
Recurrent LRTI
Dysopnea
Chest Pain
Haemoptysis
Halitosis

Question 3

What are the causes of bronchiectasis?

Answer 3

Congenital:
-Cystic Fibrosis
Primary Cillary Dyskinesia (immotile cillia syndrome)

Acquired:

• Most commonly occurs post inf: Tb, Pneumonia, Measles, RSV.
• Following recurrent aspiration pneumonias.
• Allergic Bronchopulmonary Aspergillosis (ABPA)
• Foreign body

Note: smoking independently is not a risk factor (differs to COPD)

Question 4

What are the physical signs of bronchiectasis?

Answer 4

Productive cough worse in the morning as the sputum production from the night has not been cleared.

Coarse Crackles are present in 70% usually bilateral

Large airway ronchi (snoring sound) 44%

Wheeze 30%

Clubbing

May be signs of LRTI

COPD:
Less sputum production
No clubbing

Question 5

What investigations would you do in suspected bronchiectasis?

Answer 5

Bloods:
FBC (infection)
Immune testing if suspected

Microbiology:
Sputum culture

Imaging:
CXR
High resolution CT

Invasive:
Bronchoscopy may be indicated if the bronchiectasis affects a single lobe this is to rule out a foreign body,

Note: can have any picture on spirometry therefore its not a useful investigation.

Question 6

How is bronchiectasis managed?

Answer 6

Smoking cessation (although it is not an independent risk factor, it is more likely to predispose to infection)

Immunisations: Influenza and pneumococcus

Physiotherapy: to be taught the airway clearance techniques

Mucolytics: carbocisteine.

Azithromycin to act as a neutrophill mobiliser.

Question 7

How should LRTI in patients with bronchiectasis be treated?

Answer 7

Patients should be educated to recognise signs and symptoms of LRTI and should be given antibiotics to start empirically.

1st line:
Amoxicillin 500 mg tds for 14days

If penicillin allergic Clarithromycin 500mg bd should be used.

In patients that are colonised with pseudomonas (this often indicates worsening disease) Ciprofloxacin should be used.