Respiratory: Bronchiectasis Flashcards
(40 cards)
Define what is meant by bronchiectasis [1]
Bronchiectasis is the abnormal dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall
What are the risk factors for bronchiectasis? [4]
- Cystic fibrosis
- Host immunodeficiency
- Previous infections
- Primary ciliary dyskinesia
Which infections can cause bronchiectasis? [3]
- Pneumonia
- Whooping cough (pertusis)
- TB
Which inherited diseases can cause bronchiectasis? [4]
- (Alpha-1-antitrypsin deficiency)
- Connective tissue disorders (e.g., rheumatoid arthritis)
- Cystic fibrosis
- Yellow nail syndrome
Describe the classic triad of yellow nail syndrome [3]
- Yellow fingernails
- Bronchiectasis
- Lymphoedema
TOM TIP: Yellow nail syndrome is characterised by yellow fingernails, bronchiectasis and lymphoedema. Patients are stable and have good clinical signs, making it a good choice for OSCEs. As it is rare, examiners will score high marks if you can combine these features and name the diagnosis.
Describe the pathophysiology of bronchiectasis [7]
Cole’s ‘vicious cycle hypothesis:
A deficit in mucociliary clearance +/- immune function
→
Microorganism acquisition, colonisation and infection
→
Chronic inflammation
→
Dilation and thickening of bronchi
→
Bronchial wall oedema and increased mucus production
→
More infections
→
Further inflammation and damage.
Describe the three morphological types of bronchiectasis [3]
Tubular/cylindrical:
- most common type
- the morphology is of smooth uniform dilatation of the bronchi with loss of normal tapering. **
- This type is associated with the ‘signet ring sign**’ due to an increased bronchoarterial ratio and the ‘tram-track sign’ due to parallel bronchial walls.
Varicose:
- relatively uncommon, the bronchi are irregular with dilatation interspersed with areas of constriction.
Cystic:
- associated with cystic fibrosis, dilated bronchi that are cyst like and filled with either air or fluid.
What is the name for this sign of tubular bronchiectasis? [1]
Signet ring sign
What is the name for this sign of tubular bronchiectasis? [1]
Tram track sign
Describe the classical symptoms of bronchiectasis [5]
- Shortness of breath
- Chronic productive cough: may produce large amounts of purulent sputum and sometimes haemoptysis
- Recurrent chest infections
- Weight loss
- Fever
- Chest pain
- GORD
Describe the classical signs of bronchiectasis [5]
- Scattered crackles throughout the chest that change or clear with coughing
- Scattered wheezes and squeaks
- Sputum pot by the bedside
- Oxygen therapy (if needed)
- Weight loss (cachexia)
- Finger clubbing
- Signs of cor pulmonale (e.g., raised JVP and peripheral oedema)
When taking a history and examining the patient, it is also important to consider other systems of the body too, as these may reveal co-morbid conditions associated with the development of bronchiectasis
.
Which do these include? [4]
Joints:
- RA
GI:
- IBD
- Cystic fibrosis
- GORD
Sputum culture is used to identify colonising and infective organisms. The most common infective organisms are? [2]
Haemophilus influenza
Pseudomonas aeruginosa
Describe what CT [7] and CXR [2] would reveal when investigating for bronchiectasis? [2]
High resolution chest CT
- Test of choice
- Thickened & dilated airways
- May show fluid-filled cysts; these represent superimposed infection and warrant a course of systemic antibiotics.
- Tram line or signet ring appearance
- Bronchoarterial ratio > 1: the internal airway lumen is larger than the adjacent pulmonary artery (signet ring sign)
- Lack of tapering: bronchi should taper in diameter as they travel distally from the lung hila to the periphery
- Bronchus visible within 1cm of pleural surface: normal, non-dilated airways cannot usually be seen within 2cm of the pleura
CXR:
- the majority of X-rays will be abnormal in those with bronchiectasis but findings are non-specific and further imaging is required.
- They are also useful for ruling out other possible causes such as TB or malignancy
Asides from imaging investigations, describe what else you would investigate for bronchiestasis [7]
Sputum culture
- Most commonly Haemophilus influenzae and Pseudomonas aeruginosa
FBC:
- may reveal high eosinophil count in bronchopulmonary aspergillosis
specific IgE or skin prick test to Aspergillus fumigatus
serum alpha-1 antitrypsin phenotype and level
serum immunoglobulins
- to identify individual immunoglobulin deficiencies as underlying aetiology
Rheumatoid factor
Serum HIV antibody
Describe most common pattern seen on post-bronchodilator spirometry in bronchiectasis
Post-bronchodilator spirometry: most commonly an obstructive pattern is seen, although mixed, restrictive, and normal results are also possible.
How would you distinguish between bronchiectasis and:
- COPD [2]
- Asthma [2]
COPD Differences:
- Sputum more likely to be clear (except during infection)
- Smoking stronger RF
Asthma:
- Dysopnea more associated with triggers
NB: Both diseases can co-exist with bronchiectasis
How would you distinguish between bronchiectasis and:
- Lung cancer [2]
- TB [2]
Lung cancer:
* Similarities: cough, haemoptysis, chest pain
* Differences: weight loss, hoarse voice
Tuberculosis:
* Similarities: cough, haemoptysis
* Differences: weight loss, night sweats
TOM TIP: The key features to remember with bronchiectasis are [4]
TOM TIP: The key features to remember with bronchiectasis are finger clubbing, diagnosis by HRCT, Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.
Describe the treament algorithm for bronchiestasis for the initial presentation? [5]
initial presentation
1ST LINE: exercise and improved nutrition.
- Including vitamin D supplementation
- Higher BMI has beneficial outcomes
- Excercise is considered form of airway clearance
PLUS –
airway clearance therapy (ACT):
- maintenance of oral hydration; percussion, breathing, or coughing strategies
- positioning and postural drainage; positive expiratory pressure devices; and oscillatory devices
- recommended for 15 to 30 minutes, 2 or 3 times daily
PLUS –
self-management plan
CONSIDER –
inhaled bronchodilator:
- salbutamol inhaled
CONSIDER –
mucoactive agent
- hypertonic saline
BMJ BP
acute exacerbation: mild to moderate underlying disease if is first or new presentation of Pseudomonas aeruginsoa
1ST LINE –
short-term oral antibiotic:
- For adults, prescribe amoxicillin 500 mg three times a day for 7–14 days
PLUS –
increased airway clearance
PLUS –
continued maintenance therapy:
- Healthy diet & exercise
- Higher BMI
- Nebulised bronchodilators
- Nebulised hyperosmolar agents, such as hypertonic saline,
How many acute exacerbations in a year would indicate treatment to be escalated in a stepwise manner? [1]
≥ 3 exacerbations in one year despite following the initial management
Describe how treatment for bronchiectasis would be escalated in a stepwise manner if they were suffering ≥ 3 exacerbations in one year despite following the initial management?
3 or more exacerbations per year despite maintenance therapy
1ST LINE –
reassess physiotherapy ± mucoactive treatment
PLUS –
continued maintenance therapy
- Azithromycin 500 mg three times a week, or
- Azithromycin 250 mg daily, or
- Offer a minimum of 6 months treatment, but up to 1 year may be required.
CONSIDER –
long-term antibiotic
CONSIDER –
surgery:
- Surgical resection is considered in patients with localised disease whose symptoms are not controlled by optimal medical treatment
- Complete resection of the bronchiectatic area is associated with the best results
CONSIDER –
treatment of respiratory failure
When giving long term antibiotic therapy to those with bronchiestasis, if people have concurrent Pseudomonas aeruginosa infection, first-line therapy is []
inhaled colistin.
