Definition: Bronchiectasis is a dilatation of the medium sized bronchi with destruction of bronchial elastic and muscular elements.It is destruction and widening of the large airways. A person may be born with it (congenital bronchiectasis) or may develop it later in life.
Cylindrical or tubular bronchiectasis is characterized by dilated airways alone and is sometimes seen as a residual effect of pneumonia; varicose bronchiectasis (so named because its appearance is similar to that of varicose veins) is characterized by focal constrictive areas along the dilated airways that result from defects in the bronchial wall; and saccular or cystic bronchiectasis is characterized by progressive dilatation of the airways, which end in large cysts, saccules,or grape-like clusters (this finding is always indicative of the most severe form of bronchiectasis).
Cystic fibrosis causes about 50% of all bronchiectasis in the United States today. Recurrent, severe lung infections (pneumonia, tuberculosis, fungal infections), abnormal lung defenses, and obstruction of the airway by a foreign body or tumor are some of the predisposing factors. It can also be caused by routinely breathing in food particles while eating.
A heavy smoking habit probably also contributed to this gaunt appearance. Perhaps due to this childhood respiratory illnesses may develop bronchiectasis, a condition characterized by perpetually dilated bronchi and fits of coughing.
The risk of dying due to bronchiectasis, usually a rare lung disease, is 46 times higher than normal if the child's mother also drank the arsenic-contaminated water while pregnant, according to the study. These findings provide some of the first human evidence that fetal or early childhood exposure to any toxic substance can result in markedly increased disease rates in adults.
Etiology:
* Inflammatory diseases of bronchial wall, e. g. unresolved pneumonia, bronchopneumonia, whooping cough, measles, complicating chronic sinusitis and tuberculosis in childhood.
* Intra luminal obstruction, e. g. tenacious mucoid sputum in mucoviscidosis, foreign body, adenoma or carcinoma
* Extrinsic pressure on bronchi due to lymphadenopathy
CLINICAL FEATURES:
Symptoms:
i) Chronic productive cough occurring especially with the changes of posture. Sputum is purulent which often separates into three layers (Sediment, fluid & foam) on standing, large in amount having a fetid odor,
ii) Haemoptysis : It occurs in about 50% cases,
iii) Weight loss, asthenia, night sweats and fever are the result of co-existing lung infection.
iv) Co-existing sinusitis, chest pain due to pleurisy, shortness of breath on exertion and ankle edema may occur due to Cor pulmonale.
Signs :
i) On general examination-Emaciation, cyanosis and clubbing-of fingers seen in advanced cases.
ii) On chest examination:
Inspection: Retraction of Chest wall
Palpation : Diminished thoracic expansion. Mediastinum may be deviated to the side of lesion, movement diminished.
Percussion : Dullness on percussion.
Auscultation : Breath sound low pitched, coarse crepitation present .over the affected segments.
Investigations:
A. Blood :
R.B.C. : Polycythaemia secondary
R. B. C. : Polycythaemia secondartto pulmonary insufficiency may be present.
W. B. C. : Total count increased due to presence of infection.
E. S. R. : may raised.
B. Sputum:
Smears and cultures to rule out active tuberculosis.
C. X-ray chest:
Plain X-ray will show -Increased pulmonary markings at the lung bases together with multiple Radiolucencies (honey comb appearance) strongly suggestive of diagnosis.
D. Bronchography : It is the most diagnostic investigation.
Differential diagnosis:
Delayed diagnosis of an endobronchial foreign body may result in bronchiectasis, atelectasis, abscess formation, chronic pneumonia, bronchial stenosis, empyema, and fistula formation. In a child with chronic cough and atelectasis, bronchial obstruction from a foreign body should always be considered as a possible diagnosis. Wheezing and hemoptysis are frequent symptoms.
1. Chronic bronchitis :
* Winter cough" present for 3 months in a year for successive 2 years.
* History of smoking may be present.
* Wheeze, dyspnoea, tightness in the chest are common symptoms especially in the morning.
* Complications like ventilatory failure or cardiac failure may be present.
2. Tuberculosis
* Presenting features may be malaise, easy fatiguability, anorexia, weightloss, afternoon fever, cough and haemoptysis. In primary tuberculosis, peribronchial lymph nodes may become infected, enlarge, and compress a bronchus, which leads to obstruction and eventual bronchiectasis, or an infected lymph node may erode directly into a bronchus and cause obstruction as an endobronchial foreign body
* A few coarse crepitation usually situated over one or both lung apex usually
posteriorly may be heard.
* Signs of consolidation, cavitation, fibrosis may be appear
* Sputum rarely fetid
* Positive tuberculin test
* Chest X-ray is almost diagnostic.
3. Lung abscess :
* Symptoms like fever, sweats, cough, chest pain present
* Cough is nonproductive at onset.Expectoration of foul smelling brown or green or yellow sputum ir present, sputum may be blood stained.
* Chest pain often with coughing is common.
* Development of pulmonary symptoms 1-2 weeks after possible aspirations, bronchial obstruction or previous pneumonia.
The main finding, bronchiectasis may warrant the consideration of anatomical, infectious, and other causes. The replacement of bronchography by high-resolution computed tomography (CT) as a definitive imaging tool; and the similarities and differences between bronchiectasis and cystic fibrosis in terms of clinical features and management strategies.
Complications of Bronchiectasis:
i) Recurrent pneumonia
ii) Haemoptysis
iii) Brain abscess
iv) Empyema
v) Pyopneumothorax
vi) Pulmonary insufficiency
vii) Cor-pulmonale
viii) Amyloidosis
Management and treatment:
Treatment of bronchiectasis is aimed at controlling infections and bronchial secretions, relieving airway obstruction, and preventing complications. This includes prolonged usage of antibiotics to prevent detrimental infections, as well as eliminating accumulated fluid with postural drainage and chest physiotherapy. Surgery may also be used to treat localized bronchiectasis, removing obstructions that could cause progression of the disease.
Medical:
i) postural drainage :
The patient should assume the position that gives maximum drainage and it should be carried out at least for 10-15 minutes at a time for 2-3 times daily. The first drainage is in the morning and the last at bed time.
ii) Steam inhalation with Tinc. Benzoin Co., 2 teaspoonful in a pint of boiling water 2-3 times daily.
iii) Proper Antibiotics after C/S Cap.Tetracycline (250 mg) 2 cap. stat and then 1 cap 6 hourly. Or,
Cap. Ampicillin (250 mg)
2 cap. stat and then, 1 cap 6 hourly.
Or,
Tab. penicillin V (250 mg)
2 Tab. stat and then 1 Tab. 6 hourly.
Smoking must be prohibited.
iv) if not improved-
SURGERY should be considered after doing bronchogram if patient's lung is healthy enough.
a) If confined to one lobe then lobectomy.
b) If lobectomy is not possible, a permanent tracheostomy or tracheal fistula
may permit better drainage by allowing frequent catheter aspiration
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