Bronchiectasis

Bronchiectasis is a chronic suppurative lung disease. It is caused by abnormal dilation of bronchial walls due to loss of elasticity and muscular tone. It results in chronic inflammation, with abnormal retention of secretions, oedema, scarring and ulceration of the bronchial wall. Recurrent infections can cause further dilation of bronchial walls, resulting in a vicious cycle of impaired clearance, infection, and bronchial damage.

Traction bronchiectasis is bronchiectatic dilation caused by adjacent lung fibrosis.

Smoking is not associated with bronchiectasis, although bronchiectasis is seen in 30% of COPD.

Relevant physical signs

• General inspection: cachectic, in respiratory distress, cyanosed, polycythaemic, accessory items (sputum containers, supplemental oxygen, inhalers etc)
• Hands: tar stains, clubbing, wasting of dorsal interossei, peripheral cyanosis
• CO₂ retention flap
• Pulse: bounding pulse in CO₂ retention
• Eyes: partial ptosis, meiosis, anhydrosis (Horner’s syndrome in Pancoast tumour)
• Mouth: central cyanosis
• Neck: JVP (elevated in right heart failure), trachea location
• Cervical lymph nodes (ddx: malignancy)
• Chest:
  • Inspection:
    • Thoracotomy scars to suggest previous lobectomy / pneumonectomy
    • VATS scars (minimally-invasive surgery)
  • Palpation:
    • Apex beat (if displaced and associated with pulmonary hypertension)
    • Parasternal heave (pulmonary hypertension)
    • Palpable P2 (pulmonary hypertension)
    • Chest expansion (3x front, 3x back)
  • Percussion
    • Usually normal in bronchiectasis
    • May be hyper-resonant in co-existent COPD
    • May be dull if super-imposed pneumonia
  • Auscultation
    • Coarse inspiratory creps which change on character with coughing
    • May have wheeze (airway collapsibility or co-existent COPD)
    • Vocal phremitus usually normal
• Complete examination by looking at temperature chart to look for evidence of fever, do neurological examination as metastatic brain abscesses can complicate bronchiectasis, examine for hepatosplenomegaly as it can cause systemic amyloidosis

Differential diagnosis of crepitations with cough

• Bronchiectasis
• Pulmonary fibrosis (creps usually more fine, symmetrical and bilateral)
  • Cough usually non-productive
• Lung abscess
• Lung malignancy

 Causes of bronchiectasis

• Post-infectious (except TB, usually lower lobes / RML / lingula lobe)
  • Tuberculosis (upper lobes)
  • Measles
  • Pertussis
• Obstructive
  • Intraluminal: chronic aspiration, foreign body (RML / RLL)
  • Luminal: lung tumour, obstructive airways disease
  • Extra-luminal: compression from mediastinal lymphadenopathy
• Muco-ciliary defects
  • Cystic fibrosis
  • Kartgener’s syndrome
• Immunodeficiency
  • Acquired / congenital hypogammaglobulinaemia
  • Acquired immunodefiency syndrome
• Rheumatological
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Sjorgren’s syndrome
  • Inflammatory bowel disease
• Allergic bronchopulmonary aspergillosis (upper lobe, central bronchi)
• Yellow nail syndrome (bronchiectasis, bilateral pleural effusions, lymphedema, yellow nails)
• Pulmonary fibrosis
• Idiopathic

Complications

• Haemoptysis
• Pneumonia / lung abscess / empyema
• Pneumothorax / lung collapse
• Metastatic brain abscess
• Respiratory failure
• Pulmonary hypertension
• Amyloidosis

Investigations

• Blood tests to look for signs of infection: full blood count
• Chest radiograph:
  • Tram lines
  • Dilated, thickened airways
  • Ring shadows (bronchi seen end-on)
  • Assess extent and distribution of bronchiectasis
  • Also useful for looking for superimposed infection
• Electrocardiogram: right ventricular hypertrophy / strain
  • Dominant R wave in V1
  • ST depression with T wave inversion in right precordial leads and inferior leads (V2, V3, II, III and aVF)
• Lung function tests
  • May be normal in bronchiectasis
  • If there is significant airway obstruction, either from collapsibility or co-existent COPD, may see obstructive pattern (FEV₁/FVC < 70%)
  • Approximately 40% of patients will demonstrate reversibility with a beta agonist
  • Restrictive patterns may occur in severe disease with extensive scarring
• High resolution computed tomography
  • Non-contrast CT scan of lungs. 1cm slices acquired in 1s in full inspiration.
  • Signet ring sign: dilated bronchi adjacent to pulmonary arteriole (1.5x size)
  • Lack of tapering of bronchial tree, extension to within 1cm of pleura

Management

• Patient education, stop smoking
• Multidisciplinary team: postural drainage, chest physiotherapy
• Vaccinate against haemophilus, influenza, pneumococcus
• Bronchodilators if co-existent obstructive airway disease present
• Screen for infective exacerbation
  • Symptoms: increasing dyspnea / cough / sputum production / change in character of cough, increased wheezing, fever, malaise
  • Signs: change in examination findings from baseline
  • Radiological evidence of new infection
  • Microbiology: S. aureus, Pseudomonas, S. pneumoniae, Haemophilus, Klebsiella, Aspergillus spp.
  • Empirical antibiotic therapy: beta lactam plus fluoroquinolone for Pseudomonas
• Surgery: lobectomy for localized bronchiectasis not responding to medical therapy
  • Lung transplantation in cystic fibrosis
• Haemoptysis
  • >150ml is more than dead space
  • Lie on affected side
  • Suction aggressively
  • Intubate with large ETT to secure airway
  • Large bore cannulae for fluid resuscitation
  • BAE +/- surgery

Summary

Sir, this patient has bronchiectasis. On examination of the chest, there are bilateral coarse crepitations, the character of which alters with coughing. Chest expansion is reduced bilaterally. Percussion note and vocal phremitus are normal. He is clubbed and tachypnoeic at rest. He is not tachycardic, and there is no bounding pulse / flap to suggest carbon dioxide retention. A bedside sputum examination revealed purulent, blood-stained sputum. There was no cyanosis or evidence of pulmonary hypertension. There is no cervical lymphadenopathy or signs of a Pancoast tumour to suggest a mitotic lesion.

Other differentials would include pulmonary fibrosis, a lung abscess or a mitotic lung lesion. As such, I would like to complete my examination by looking at the temperature chart. I would like to further investigate this patient by performing a chest radiograph to look for localisation of his bronchiectasis, an electrocardiogram to look for evidence of right heart strain / hypertrophy, lung function tests to look for co-existent obstructive airways disease and a high-resolution computed tomography scan to confirm the diagnosis and assess disease severity.