What is Bronchiectasis?
Bronchiectasis is defined as dilatation of the bronchi associated with chronic and recurrent inflammation conditions. It is a syndrome characterized by abnormal and permanent dilatations of the intrapulmonary airway which is frequently accompanied by chronic cough and an increase in bronchial secretion (produces abundant expectoration). Occasionally, bronchiectasis can be dry (without abundant expectoration or recurrent infection).
Its exact causes are still unknown and is considered a rare disease. The people most susceptible to this disease have difficulties with access to health-care resources; Therefore, bronchiectasis are less common in developed countries and more common in developing countries of South america, Africa and Asia.
The incidence of bronchiectasis has been estimated that it has declined in developed countries especially. Thanks to improvements in the nutritional status and sanitary conditions of the population, availability of vaccines, tuberculosis control programs and the development of the antibiotics. However, the use of high resolution computed tomography (HRCT) has increased diagnostic sensitivity, so it is now possible to diagnose this disease in patients who could not be diagnosed a few years ago. Bronchiectasis affects women more than men and they appear more frequently in the middle and advanced ages of life.
Bronchiectasis can be localized(affect a reduced area within the same lung) or diffused (when it affects several areas of both lungs or a whole lung). Bronchiectasis can be cylindrical (rectum-shaped), saccular (sac-shaped) or cystic (sac-filled or pus-filled).These are most frequent types of bronchiectasis.
Bronchiectasis Prognosis and Complications
The course of bronchiectasis is very variable, so that some patients may remain symptom free for many years while others persistently present symptoms.
At present the prognosis of the disease has improved greatly thanks to antibiotics. With good infection control, survival may be normal. Haemoptysis (discharge of blood through the mouth with cough) is very abundant and alarming, but these are uncommon. Sinusitis, pneumonia and lung abscess are more common as complications. Patients may also present empyema (collections of pus) in the brain.
The current importance of bronchiectasis is due to its ability to cause a progressive deterioration of the quality of life and lung function of the patient and the risk of a worsening in the prognosis of the disease has originated.
There are two factors that play a key role in the development of bronchiectasis which are inflammation and bronchial obstruction.Together with the individual susceptibility of the person make it to be more likely to have bronchiectasis.
Infection with bacteria or viruses are the cause of inflammation of the wall of the bronchi and destruction of their components. Before the development of antibiotics and vaccines, the measles, whooping cough, chicken pox and tuberculosis used to be the major infections triggers of bronchiectasis.
Currently infections by Staphylococcus aureus, Klebsiella, Haemophilus influenzae, Mycobacterium tuberculosis, adenovirus and influenza viruses seem to be most common germs that produce the appearance of bronchiectasis in people susceptible to allergies. These germs produce substances and toxins that destroy the mucosal lining internally the respiratory system, produce intense inflammation and cause destruction of tissue muscle and elastic of the walls of the bronchi. There is always bronchial obstruction, either because the inflammation or due to other processes. This obstruction favors the retention of secretions and occurrence of recurrent respiratory infections.
Lung cancer can also cause bronchiectasis, although it is not common.
In people with congenital conditions (those present at birth) or hereditary may be the necessary conditions for the inflammation and the bronchial obstruction end up causing the appearance of bronchiectasis. Within this group, cystic fibrosis stands out which is a very important cause of bronchiectasis in children and adolescents. It is a hereditary disease that causes the accumulation of thick secretions in the lungs, digestive tract and other areas of the body which can cause death at an early age.
Other Causes of Bronchiectasis
Other less frequent syndromes may also produce the onset of bronchiectasis, such as:
- Ciliary dyskinesia
- Kartagener syndrome
- Deficiency of immunoglobulins or antibodies
- Young’s syndrome
The symptoms of bronchiectasis are due to chronic infection and hypersecretion of mucus in dilated bronchi. Bronchiectasis usually causes symptoms in childhood and adolescence, but usually the first symptoms are not important because they are considered catarrh or recurrent bronchitis. In general, the clinical symptoms of bronchiectasis are of two types, respiratory and general:
Respiratory Symptoms: Sputum is the main symptom in people with bronchiectasis. It can be greenish or purulent (pus), sometimes smelly and with an unpleasant taste, cause bad breath and usually increase when changing position. Cough affects 90% of patients with bronchiectasis and is more frequent in the morning. The expulsion of blood by the mouth with the cough (hemoptysis) appears in half of the cases and can be more or less. The sensation of shortness of breath (dyspnea) affects 50% of patients and is due to bronchial obstruction and bronchial hyperreactivity (bronchial hyperreactivity is the obstructive response of the airways to certain stimuli which cause contraction Of the smooth muscle of the airways). Respiratory infections are also common in these patients whp are producing fever and worsening of the symptoms described above.
General Symptoms: General symptoms are usually scarce, although it is not strange that there is tiredness, lack of appetite or loss of weight. In children there may be a growth retardation. In developed cases, fingers can appear in a characteristic shape similar to that of a drum stick.
Physical examination provides few data to diagnose bronchiectasis. When the doctor listens to the patient with stethoscope,doctor can listen in the lower part of the lungs (lung bases), a decrease of the ventilation or the presence of respiratory noise (whistles, crackles, etc.) which indicate that the lung is injured and contains secretions into its interior.
Diagnosis of Bronchiectasis
Complementary examinations include a blood count (blood test which will reflect all the elements or components of the blood, their number and their ratio) may show an increase in the number of white blood cells (leucocytosis) if there is a respiratory infection.
If the infection is sustained and prolonged, it is possible to find anemia as underlying cause. In patients with severe respiratory repercussions, there may be an increase in the number of red blood cells or the amount of hemoglobin as the body’s response to lack of oxygen.
Gasometry (a test that measures the amount of oxygen and carbon dioxide present in the blood, in addition to the acidity of the blood) is only useful in advanced stages of the disease and may show the existence of low levels of oxygen in blood. If there is infection of bronchiectasis, should be obtained for sputum samples to be processed and analyzed in the laboratory.
Chest X-ray is another test that should be done to those who may have bronchiectasis. It may be especially normal in the early stages of the disease while at other times more or less extensive lesions are seen that mainly affect the lung bases. Diagnosis of bronchiectasis generally requires the use of a high-resolution computed tomography.This is the one of the best test to detect this problem. It shows dilated airways and thickened walls.
Bronchoscopy is not performed routinely, although it may be useful in doubtful cases.This method allows to obtain samples of the mucosa of the bronchi and helps to identify bronchial obstructions. Paranasal sinus radiography allows the diagnosis of an associated sinusitis which is a relatively frequent complication of patients with bronchiectasis.
In patients with bronchiectasis, you should also have a spirometry test to see if it is altered lung function.
Complementary Tests to Diagnose Bronchiectasis
Sometimes, it is necessary to perform other tests to try to find the cause of bronchiectasis:
- Sweat test or genetic tests when cystic fibrosis is suspected.
- Determination of immunoglobulins in the blood when immune system disease is suspected.
- Precipitins and sputum culture in patients with asthma and bronchiectasis to rule out an allergic pulmonary aspergillosis which is a lung disease caused by a fungus called Aspergillus.
- Levels of alpha-1 antitrypsin in blood is measured.
- Bronchial biopsy to rule out other lung diseases.
Treatment of bronchiectasis aims to control bronchial infections and secretions, relieve airway obstruction and prevent possible complications that may occur.
The two most important measures in the treatment of bronchiectasis are respiratory physiotherapy and antibiotics.
Respiratory physiotherapy: its main objective is to eliminate respiratory secretions, reduce airway resistance, reduce respiratory effort, improve gas exchange, increase exercise tolerance and improve quality of life. There are passive techniques which are performed by a physiotherapist and there are active techniques which are performed by the patient without help from another person by using mechanical devices or not. Some of the most used techniques are:
- Postural drainage: the purpose of this measure is to mobilize the secretions with the help of gravity to be able to expel them to the outside. The position that the patient should adopt depends on the location of the lesion. In addition, expectorants or mucolytics of various types can be used (mucolytics are substances that decrease the viscosity of mucus and phlegm, fluidizing them and facilitating their expulsion).
- Thoracic expansion exercises: Respiratory boosters may be used for thoracic expansion exercises. If they can not be achieved, you can use more everyday objects like balloons.
- Thoracic Percussion: Consists of repeated tapping with the fingertips (in infants) or hollow hand (in older children and adults) on the different areas of the chest to help mobilize the secretions. This measure is combined with postural drainage.
Antibiotics: Antibiotic are currently only used in crises of worsening symptoms. The most commonly used antibiotics are amoxicillin-clavulanic and cephalosporins such as ceftriaxone. Sometimes it takes up to three weeks of treatment for adequate control of the disease. Bronchodilators (generally used in the form of aerosols) are indicated to treat bronchial reactivity.
Surgery:This is performed only when bronchiectasis is well localized and difficult to control,cause haemoptysis (coughing up of blood) and when there is frequent and repetitive pneumonia. Another surgical option in some patients is lung transplantation.
As a summary it can be said that the treatment of bronchiectasis is based on the following actions:
- Treatment of the cause if this is known
- Treatment of colonization or infection of the bronchi by microorganisms that can cause disease
- Treatment of respiratory secretions (respiratory and mucolytic physiotherapy)
- Treatment of complications (hemoptysis, respiratory failure and mucous plugs)
- If it is necessary, surgical intervention (surgery or lung transplantation)