Bronchiectasis

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In  bronchiectasis, the medium and smaller sized bronchi and bronchioles are damaged. Their ciliated epithelium is destroyed by inflammation and scarring, which in a vicious cycle of infection and further scarring leads to permanent dilatation and bronchial wall thickening. The mucus lining of these airways become colonized by bacteria and generate copious amounts of purulent and often offensive sputum. The disease, if not treated is characterized by frequent infective exacerbations with  progressively worsening lung function.

Causes

  • Childhood pneumonia e.g. whooping cough, post measles
  • Post-pulmonary tuberculosis 
  • Chronic rhinosinusitis with post-nasal drip 
  • Asthma and COPD
  • Fibrosing lung disease of any cause e.g. rheumatoid lung disease 
  • Immune deficiency states e.g. HIV infection, agammaglobulinaemia
  • Inherited disorders e.g. cystic fibrosis, primary ciliary dyskinesia should be considered in young children presenting with bronchiectasis

Symptoms

  • Persistent cough over many months
  • Copious purulent sputum which is sometimes offensive 
  • Haemoptysis in over one third of cases during exacerbations
  • Intermittent systemic symptoms - fever, night sweats and weight loss
  • Chest pain 
  • Difficulty in breathing

Signs

  • Weight loss
  • Fever
  • Clubbing
  • Dull percussion note 
  • Bronchial breath sounds 
  • Coarse crepitations

Investigations

  • FBC, ESR
  • Sputum culture and sensitivity, gram stain
  • Sputum AFBs
  • Chest X-ray 
  • CT scan of the chest
  • Pulse oximetry

TreatmentTreatment Objectives

  • To treat infection
  • To aid sputum clearance
  • To minimize cough and sputum production
  • To prevent exacerbations
  • To diagnose and treat underlying disorders

Non-pharmacological treatment

  • Chest physiotherapy - Postural drainage, Sputum clearance techniques 
  • Breathing exercises 
  • Improve nutrition
  • Encourage adequate fluid intake
  • Encourage physical exercise 

Pharmacological treatment 

Acute infective exacerbation

1st Line Treatment

Evidence Rating: [C]

  • Amoxicillin + Clavulanic Acid, oral,  

Adults

1 g 12 hourly for 14 – 21 days

Children

>12 years; One 500/125 tablet 12 hourly

6-12 years; 5ml of 400/57 suspension 12 hourly 

1-6 years; 2.5ml of 400/57 suspension 12 hourly 

1month-1 year; 0.25ml/kg body weight of 125/31 suspension 8 hourly 

< 1 month; 0.25ml/kg body weight of 125/31 suspension 8 hourly 

And

  • Azithromycin, oral, (for patients allergic to penicillin, given as mono-therapy)

Adults

500 mg once daily for 6-14 days

Children

10 mg/kg once daily for 6-14 days

Referral Criteria

  • Refer all suspected cases to a specialist for confirmation and further management.