Bronchiectasis

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Introduction

• An abnormal and permanent dilatation of medium sized airway due to damage of their walls.
• Usually arises from repeated bacterial or viral infections which result in inflammation and destruction of the structural components of the bronchial tree.
• May be focal or diffuse

Aetiology

• Congenital or acquired causes.
• The most important cause is severe or repeated respiratory infections.

Other causes include:

• Cystic fibrosis
• Other hereditary disorders e.g. ciliary dyskinesia
• Immunodeficiency disorders
• Autoimmune disorders e.g. rheumatoid disease, ulcerative colitis, Sjogren syndrome
• Mechanical factors e.g. chronically enlarged lymph nodes with pressure effect, lung tumour
• Inhaled toxic substances e.g. silica, cola dust, tobacco smoke.

Clinical features

• Persistent or recurrent cough
• Purulent fetid sputum
• Haemoptysis
• Pleuritic chest pain

With or without a history of preceding pneumonic illness.

• Digital clubbing
• Crepitations, rhonchi and wheezes
• Cor pulmunale and right ventricular failure in chronically hypoxic patients

Differential diagnoses

• Pulmonary tuberculosis
• Lung abscess
• Chronic bronchitis
• Bullous emphysema

Complications

• Massive haemoptysis
• Lung abscess
• Mycotic abscess
• Pulmonary amyloidosis
• Ventilatory failure
• Cor pulmunale and right ventricular failure

Investigations

• Chest radiograph: cystic spaces with air-fluid levels
• Bronchography: saccular, cylindrical or varicose bronchial dilatations
• CT scan (of the chest)
• Bronchoscopy: biopsys of endobronchial lesion
• Sputum microscopy, culture, Ziehl Nielson microscopy
• Ventilatory function test: obstructive pattern

Treatment goals

• Eliminate underlying pathology
• Improve mucus clearance
• Control infection
• Reverse airflow obstruction

Drug treatment

Empirical antibiotics in acute exacerbations

Amoxicillin

Adult: 500mg – 1g orally every 8 hours for 5 – 7 days

Child: 40mg/kg orally in 3 divided doses daily

Cotrimoxazole

Adult: 960mg orally every 12 hours for 5 – 7 days

Child: 6 weeks to 5 months: 120mg orally;

6 months – 5 years: 240mg;

6-12years: 480mg

Appropriate antibiotics as soon as culture results are available.

Bronchodilators

Salmeterol

Adult: 2 puffs (50 micrograms) twice daily. Can be doubled in severe airway obstruction

Child: same as adult dose (for children > 4years)

Salbutamol

Adult: 1 – 2 puffs (100 – 200micrograms) 3 – 4 times daily

Child: usually 100 microgram ( 1puff) may be increased to 200 microgram with more severe symptoms.

Supportive measures

• Supplemental oxygen
• Postural drainage or suction
• Cessation of cigarette smoking

Notable adverse drug reactions, contraindications, and caution

• Prescribers / dispensers should consult product literature to confirm the strength of various aerosol preparations.
• Salbutamol: palpitations, tremors, nervous tension, muscle cramps, sleep disturbances, tachycardia, peripheral vasodilation, hypotension.

Prevention

• Avoidance of smoking
• Timely and effective treatment of bacterial infections
• Respiratory care during childhood measles