Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Pulmonary Medicine 3 Bronchiectasis PPT-Powerpoint Presentations and lecture notes
APPROACH TO
BRONCHIECTASIS
&
LUNG ABSCESS
INTRODUCTION
NOT COVERED
QUICK RUN
CYSTIC FIBROSIS
THROUGH THE
CHILDREN 15
LECTURE
YEARS
DIAGNOSIS
ETIOLOGY
INVESTIGATIONS
AND
MANAGEMENT
LEARNING OBJECTIVES
? Definition
? Etiology
? Pathogenesis
? Clinical manifestations
? Diagnosis
? Treatment
CASE 1
? A 42-year-old man, gardener
? Long history of respiratory problems starting in early
childhood.
? Previously diagnosed as asthma.
? Frequent absence from work due to "recurrent chest
infections".
? Unaware of any neonatal issues but believes that he was born
at home without complications and is unsure of any previous
tests he has had as he is now estranged from his parents.
? Has a cousin with a "lung disease".
? Married but has "no kids"
INVESTIGATIONS
? Sputum culture: P. aeruginosa
? Sweat chloride = 73 meq/liter
? Cystic fibrosis genetics: genotype was F508del/R117H
? CYSTIC FIBROSIS: Multisystem disorder caused by
mutations in the gene that encodes the CF
transmembrane conductance regulator (CFTR) protein,
a chloride channel expressed in epithelial cells.
? More than 2000 CFTR mutations have been identified
to date, but only the functional importance of a small
number is known to cause the disease
HRCT THORAX
? An upper lobe predominant distribution of cylindrical, cystic and
varicose bronchiectasis associated with airway wall thickening, mucus
plugging and parenchymal opacities on a HRCT scan should raise the
suspicion of CF disease.
? The presence of nasal polyposis and/or chronic rhinosinusitis,
recurrent pancreatitis, malabsorption, diabetes, osteoporosis and
male infertility are other typical features of CF
DIAGNOSIS
Guidelines published by the Cystic Fibrosis Foundation in the
USA allows diagnosis if:
1. Clinical presentation of the disease and evidence of biochemical
and genetic markers of CFTR dysfunction.
2. Clinical features of the disease with concentration of chloride
>60mmol?L-1 at the sweat test or a concentration in the
intermediate range (30?59mmol?L-1) but two disease-causing
CFTR mutations.
3. CFTR genotype is undefined: CFTR physiologic tests, such as nasal
potential difference and intestinal current measurement, should
be performed.
MANAGEMENT
1. CFTR modulator therapies
2. Airway clearing techniques
3. Chest physical therapy
4. Humidification with sterile water or normal saline to facilitate
airway clearance
5. Antibiotics
6. Mucus thinners
7. Lung transplantation
CASE 2
? 45-year-old farmer with asthma since childhood.
? Complaints: Decline in his exercise tolerance and an
increase in cough which has become productive of
purulent sputum with occasional thick/solid components.
? Respiratory exacerbations not responding well to
standard steroid and antibiotic treatment.
? He was noted to have variable pulmonary infiltrates on
chest radiographs during these episodes
INVSETIGATIONS
? Marked peripheral blood eosinophilia
? Total IgE > 1000 IU/ ml
? Aspergillus specific IgE > O.35
ABPA: ABPA is an inflammatory disease caused by hypersensitivity to
the ubiquitous fungus Aspergillus fumigatus
? ABPA occurs most commonly in patients with asthma and CF
? ABPA is the cause of 1?10% of cases of bronchiectasis
? Most ABPA cases occur in the third and fourth decade without a sex
predilection.
DIAGNOSIS
? Long standing uncontrolled asthma/ Cystic fibrosis
? Brownish sputum
? Peripheral eosinophilia > 500/ mm3
? Total IgE > 1000 IU/ ml
? Specific IgE for A. fumigatus > 0.35
HRCT thorax:
? Central bronchiectasis
? High attenuation mucus
? Finger in glove/ TIB
? Tram track
? Mosaic attenuation
MANAGEMENT
1. Corticosteroids
2. Antifungals
3. Airway clearing techniques
4. Chest physical therapy
5. Mucus thinners
CASE 3
? 77-year-old retired librarian.
? Cough for many years with new symptoms of fatigue, weight
loss and fever.
? A chest CT scan was performed looking for a possible occult
malignancy and bronchiectasis was found.
DIAGNOSIS
? HRCT thorax: cylindrical bronchiectasis and tree-in-bud
pattern in middle and lower lobes
? Sputum for M. Tuberculosis: negative
? MGIT culture: MAC growth at 4 weeks
? Repeat MGIT: Positive for MAC
? Tests for immunodeficiency and ABPA: Negative
MANAGEMENT
1. Management of NTM as per the organism and clinical
picture
2. Airway clearing techniques
3. Chest physical therapy
4. Mucus thinners
CASE 4
? A 66-year-old woman with established idiopathic
bronchiectasis has had three to four exacerbations per year
for the past 3 years despite performing daily chest
physiotherapy.
? Produces large volumes of sputum daily despite performing
the active cycle of breathing technique.
? Testing for NTM, ABPA and other complications were
negative, but sputum shows persistent infection with P.
aeruginosa.
? One of the most common presentations of bronchiectasis
? Exacerbations are one of the most important manifestations of
bronchiectasis and P. aeruginosa is the most frequent
organism in severe bronchiectasis worldwide
? Cylindrical bronchiectasis is the most common morphological
pattern identified on CT scans
MANAGEMENT
1. Review current airway clearance regime.
2. Repeat sputum microbiology and repeat testing for NTM, ABPA
and ensuring the all possible treatable causes and comorbidities
have been identified.
3. First-line recommendation for P. aeruginosa with frequent
exacerbations is an inhaled antibiotic.
ETIOLOGY
INVESTIGATIONS FOR CAUSE
? COMORBIDITIES AND RELEVANT PAST HISTORY
? FULL BLOOD COUNT/ SERUM TOTAL IGE/ SKIN PRICK TEST TO A. FUMIGATUS
? SERUM Ig G/ IgA/ IgM
IN ALL
? BASELINE SPECIFIC ANTIBODY LEVELS AGAINST CAPSULAR POLYSACCHRIDES OF STREPTOCOCCUS
PNEUMONIAE
? SPUTUM CULTURE : ROUTINE AND MYCOBACTERIAL
CLINICALLY
STABLE
? HIV
? TEST FOR CYSTIC FIBROSIS/ PCD/ GERD
? RA, ANTI CCP , ANCA, ANA
CLINICALLY ? ALPHA 1 AT
SUSPECT ? BRONCHIAL ASPIRATION OR WASH
Hill A, Welham S, Sullivan A, Loebinger M. Updated BTS Adult Bronchiectasis Guideline 2018: a multidisciplinary
approach to comprehensive care. Thorax. 2018;74(1):1-3.
STEPWISE MANAGEMENT
AIRWAY CLEARANCE
Physiotherapy management-stepwise airway clearance.
ACBT
POSTURAL DRAINAGE
Airway clearance - exacerbations.
ANTIBIOTIC TREAMENT
FOR EXACERBATION
WHAT IS THE ROLE OF
SURGERY IN MANAGING
BRONCHIECTASIS?
RECOMMENDATIONS
? Consider lung resection in patients with localized disease whose
symptoms are not controlled by medical treatment optimized by a
bronchiectasis specialist. (D)
? Offer multidisciplinary assessment, including a bronchiectasis
physician, a thoracic surgeon and an experienced anesthetist, of
suitability for surgery and pre-operative assessment of
cardiopulmonary reserve post resection. (D)
LUNG TRANSPLANTATION
FOR BRONCHIECTASIS
Recommendations
? Consider transplant referral in bronchiectasis patients aged 65
years or less if the FEV1 is <30% with significant clinical instability
or if there is a rapid progressive respiratory deterioration despite
optimal medical management. (D)
? Consider earlier transplant referral in bronchiectasis patients with
poor lung function and the following additional factors: massive
haemoptysis, severe secondary pulmonary hypertension, ICU
admissions or respiratory failure (particularly if requiring NIV).(D)
LUNG ABSCESS
DEFINITION
Localized area of lung suppuration, leading to
necrosis of the lung parenchyma with or without
cavity formation.
Type of liquefactive necrosis of the lung tissue
and formation of cavities (more than 2 cm)
containing necrotic debris or fluid caused by
microbial infection.
ACUTE
DURATION
CHRONIC
PRIMARY
LUNG ABSCESS
AETIOLOGY
SECONDARY
BRONCHOGENIC
WAY OF
SPREADING
HEMATOGENIC
CLASSIFICATION (CONTD.)
? ACCORDING TO THE DURATION:
? Acute (less than 6 weeks);
? Chronic (more than 6 weeks)
? BY ETIOLOGY:
? Primary (aspiration of oropharyngeal secretions, necrotizing
pneumonia, immunodeficiency);
? Secondary (bronchial obstructions, haematogenic dissemination,
direct spreading from mediastinal infection, from sub phrenic space,
coexisting lung diseases)
? WAY OF SPREADING:
? Bronchogenic (aspiration of oropharyngeal secretions, bronchial
obstruction by tumour, foreign body, enlarged lymph nodes,
congenital malformation);
? Haematogenic (abdominal sepsis, infective endocarditis, septic
thromboembolisms)
DIFFERENTIATING ACUTE
FROM CHRONIC
ACUTE
CHRONIC
CIRCUMSCRIBED
IRREGULAR
NOT WELL DEFINED
WELL DEFINED
FILLED WITH NECROTIC
DEBRIS
FILLED WITH THICK DEBRIS
DIFFERENTIAL DIAGNOSIS
? Excavating bronchial carcinoma (squamo-cellular or microcellular)
? Excavating tuberculosis
? Localized pleural empyema
? Infected emphysematous bullae
? Cavitary pneumoconiosis
? Hiatus hernia
? Pulmonary hematoma
? Hydatid cyst of lung
? Cavitary infarcts of lung
? Wegener's granulomatosis
DIAGNOSIS
? Diagnostic bronchoscopy is a part of diagnostic protocol
for taking the material for microbiological examination
and to confirm intrabronchial cause of abscess-tumor or
foreign body.
? Sputum examination is useful for identification of
microbiological agents or confirmation of bronchial
carcinoma
MANAGEMENT
STANDARD CONSERVATIVE THERAPY: MEDICAL MANAGEMENT
? It is recommended to treat lung abscess with broad spectrum
antibiotics, due to poly microbial flora, such as Clindamycin (600
mg IV on 8 h) and then 300 mg PO on 8 h or combination
ampicilin/sulbactam (1.5-3 gr IV on 6 h).
? Alternative therapy is piperacilin/tazobactam 3.375 gr IV on 6 h or
Meropenem 1 gr IV on 8 h.
? For MRSA it is recommended to use linezolid 600 mg IV on 12 h or
vancomycin 15 mg/kg BM on 12 h.
MANAGEMENT
SURGICAL
? Endoscopic drainage of lung abscesses is described as an alternative to chest
tube drainage and is performed during the bronchoscopy with usage of laser.
? Per cutaneous trans thoracic tube drainage
? Surgical resection of lung abscess is the therapy of choice for about 10% of
patients.
? Lobectomy is the resection of choice for large or central position of abscess.
Atypical resection or segmentectomy are satisfactory procedures, if it is
possible to remove complete abscess and if necessary surrounding lung tissue
with necrotizing pneumonia
THANK YOU
BRONCHIECTASIS
DEFINITION
? Bronchiectasis (broncos, airways; ectasia, dilatation) is a
morphologic term used to describe abnormal,
irreversibly dilated and thick walled bronchi.
? This is an anatomic definition that evolved from
Laennec's original description in 1819 of ectatic bronchi
in pathologic specimens.
La?nnec RTH. On mediate auscultation, or a treatise on the diagnosis of diseases of the lungs and heart. Paris: J.-A.
Brosson et J.-S. Chaud?; 1819.
PREVALENCE
US1
UK2
INDIA
? Prevalence increased
? Prevalence in women
? There is no good data on
every year from 2000 to
566/lakh ; men= 486/lakh
bronchiectasis in India
2007 by an annual
? Women and age more
? EMBARC INDIA REGISTRY
percentage change of
than 60 years associated
(European Multi Centre
8.74%.
with higher rate of
Bronchiectasis Audit and
? Increased with age
hospitalization
Research Collaboration)
(peak= 80-84 years)
? Higher in women
1. McShane P, Naureckas E, Tino G, Strek M. Non?Cystic Fibrosis Bronchiectasis. American Journal of Respiratory and Critical Care
Medicine. 2013;188(6):647-656.
2. Hil A, Welham S, Sullivan A, Loebinger M. Updated BTS Adult Bronchiectasis Guideline 2018: a multidisciplinary approach to
comprehensive care. Thorax. 2018;74(1):1-3.
BURDEN
LONGER HOSPITAL STAY
FREQUENT OPD VISITS
INCREASED EXPENDITURE ON
MEDICINES
RISK FACTORS FOR MORTALITY
LOW FEV1
MALE
MORTALITY RATE= 10-16%
INCREASED DYSPNOEA GRADE
ADVANCED AGE
COPD
P. aeruginosa SPUTUM POSITIVITY
? Goeminne PC, Scheers H, Decraene A, Seys S, Dupont LJ. Risk factors for morbidity and death in non?cystic fibrosis bronchiectasis: a
retrospective cross-sectional analysis of CT diagnosed bronchiectatic patients. Respir Res 2012;13:21.
? Weycker D, Edelsberg J, Oster G, Tino G. Prevalence and economic burden of bronchiectasis. Clin Pulm Med 2005;12:205?209.
PATHOGENESIS
COLES'S VISCIOUS CYCLE MODEL
PULMONARY
INFECTION/
TISSUE INJURY
ROBUST
BACTERIAL
INFLAMMATORY
COLONIZATION
RESPONSE
AIRWAYS
ABNORMAL
DESTRUCTION
MUCUS
AND
CLEARANCE
DISTORTION
Cole PJ. Inflammation: a two-edged sword--the model of
bronchiectasis. Eur J Respir Dis Suppl 1986;147:6?15.
PATHOLOGY
Hematoxylin and eosin stain of the bronchial
wall
in a patient with bronchiectasis (left) versus a
normal subject (right).
A: Pseudostratified columnar, ciliated
epithelium
B: thickened epithelium with intraepithelial
lymphocytes
C: submucosa with dense infiltrate of
lymphocytes and plasma cells
D: blood vessel with reactive endothelial
cells.
BRONCHIECTATIC
NORMAL
TYPES
REIDS
CLASSIFICATION
CYLINDRICAL
VARICOSE
SACULAR/CYSTIC
Reid LM. Reduction in bronchial subdivision in bronchiectasis. Thorax
1950;5:233?247.
TYPES OF BRONCHIECTASIS
ETIOLOGY
IN WHOM TO
SUSPECT ?
PERSISTENT PURULENT OR MUCO
PURULENT SPUTUM
+
IN HEALTHY??1
COPD FREQUENT
HIV/ SOLID ORGAN OR
EXACERBATORS WITH
BONE MARROW
SPUTUM CULTURE
TRANSPLANT/
IBD/ GERD/ CTD/
RA WITH RECURRENT
SEVERE/ POORLY
POSITIVE FOR P.
IMMUNOSUPRRESIVE
RHINOSINUSITIS
CHEST INFECTIONS
CONTROLLED ASTHMA
AERUGINOSA WHEN
THERAPY FOR
STABLE
LYMPHOMA OR
VASCULITIS
Hil A, Welham S, Sullivan A, Loebinger M. Updated BTS Adult Bronchiectasis Guideline
2018: a multidisciplinary approach to comprehensive care. Thorax. 2018;74(1):1-3.
ALGORITHM FOR
EVALUATION OF
BRONCHIECTASIS
Cantin L, Bankier A, Eisenberg R. Bronchiectasis. American Journal of Roentgenology.
2009;193(3):W158-W171.
INVESTIGATION: RADIOLOGY
? BASELINE CHEST RADIOGRAPH
? THIN SECTION CT [HRCT THORAX]
CT FEATURES OF BRONCHIECTASIS
vBRONCHIAL DILATATION SUGGESTED BY
? BRONCHOARTERIAL RATIO >1 (INTERNAL AIRWAY LUMEN VS ADJACENT PULMONARY ARTERY)
? LACK OF TAPERING
? AIRWAY VISIBILITY WITHIN 1CM OF COSTAL PLEURAL SURFACE OR TOUCHING MEDIASTINAL
PLEURA.
vINDIRECT SIGNS
? BRONCHIAL WALL THICKENING
? MUCUS IMPACTION
? MOSAIC PERFUSION / AIR TRAPPING ON EXPIRATORY CT
CHEST RADIOGRAPH
CYLINDRICAL
BRONCHIECTASIS
WITHIN I CM OF
PLEURA
TRAM TRACK SIGN
SIGNET RING SIGN
VARICOSE
BRONCHIECTASIS
VARICOSE
CYSTIC BRONCHIECTASIS
MUCUS IMPACTION
CYSTIC
CLUSTERS
MOSAIC PERFUSION
BLACK
WHITE
INVESTIGATIONS FOR CAUSE
? COMORBIDITIES AND RELEVANT PAST HISTORY
? FULL BLOOD COUNT/ SERUM TOTAL IGE/ SKIN PRICK TEST TO A. FUMIGATUS
? SERUM Ig G/ IgA/ IgM
IN ALL
? BASELINE SPECIFIC ANTIBODY LEVELS AGAINST CAPSULAR POLYSACCHRIDES OF STREPTOCOCCUS
PNEUMONIAE
? SPUTUM CULTURE : ROUTINE AND MYCOBACTERIAL
CLINICALLY
STABLE
? HIV
? TEST FOR CYSTIC FIBROSIS/ PCD/ GERD
? RA, ANTI CCP , ANCA, ANA
CLINICALLY ? ALPHA 1 AT
SUSPECT ? BRONCHIAL ASPIRATION OR WASH
Hill A, Welham S, Sullivan A, Loebinger M. Updated BTS Adult Bronchiectasis Guideline 2018: a multidisciplinary
approach to comprehensive care. Thorax. 2018;74(1):1-3.
STEPWISE MANAGEMENT
AIRWAY CLEARANCE
Physiotherapy management-stepwise airway clearance.
ACBT
POSTURAL DRAINAGE
Airway clearance - exacerbations.
ANTIBIOTIC TREAMENT
FOR EXACERBATION
WHAT IS THE ROLE OF
SURGERY IN MANAGING
BRONCHIECTASIS?
RECOMMENDATIONS
? Consider lung resection in patients with localized disease whose
symptoms are not controlled by medical treatment optimized by a
bronchiectasis specialist. (D)
? Offer multidisciplinary assessment, including a bronchiectasis
physician, a thoracic surgeon and an experienced anesthetist, of
suitability for surgery and pre-operative assessment of
cardiopulmonary reserve post resection. (D)
LUNG TRANSPLANTATION
FOR BRONCHIECTASIS
Recommendations
? Consider transplant referral in bronchiectasis patients aged 65
years or less if the FEV1 is <30% with significant clinical instability
or if there is a rapid progressive respiratory deterioration despite
optimal medical management. (D)
? Consider earlier transplant referral in bronchiectasis patients with
poor lung function and the following additional factors: massive
haemoptysis, severe secondary pulmonary hypertension, ICU
admissions or respiratory failure (particularly if requiring NIV).(D)
LUNG ABSCESS
DEFINITION
Localized area of lung suppuration, leading to
necrosis of the lung parenchyma with or without
cavity formation.
Type of liquefactive necrosis of the lung tissue
and formation of cavities (more than 2 cm)
containing necrotic debris or fluid caused by
microbial infection.
ACUTE
DURATION
CHRONIC
PRIMARY
LUNG ABSCESS
AETIOLOGY
SECONDARY
BRONCHOGENIC
WAY OF
SPREADING
HEMATOGENIC
CLASSIFICATION (CONTD.)
? ACCORDING TO THE DURATION:
? Acute (less than 6 weeks);
? Chronic (more than 6 weeks)
? BY ETIOLOGY:
? Primary (aspiration of oropharyngeal secretions, necrotizing
pneumonia, immunodeficiency);
? Secondary (bronchial obstructions, haematogenic dissemination,
direct spreading from mediastinal infection, from sub phrenic space,
coexisting lung diseases)
? WAY OF SPREADING:
? Bronchogenic (aspiration of oropharyngeal secretions, bronchial
obstruction by tumour, foreign body, enlarged lymph nodes,
congenital malformation);
? Haematogenic (abdominal sepsis, infective endocarditis, septic
thromboembolisms)
DIFFERENTIATING ACUTE
FROM CHRONIC
ACUTE
CHRONIC
CIRCUMSCRIBED
IRREGULAR
NOT WELL DEFINED
WELL DEFINED
FILLED WITH NECROTIC
DEBRIS
FILLED WITH THICK DEBRIS
DIFFERENTIAL DIAGNOSIS
? Excavating bronchial carcinoma (squamo-cellular or microcellular)
? Excavating tuberculosis
? Localized pleural empyema
? Infected emphysematous bullae
? Cavitary pneumoconiosis
? Hiatus hernia
? Pulmonary hematoma
? Hydatid cyst of lung
? Cavitary infarcts of lung
? Wegener's granulomatosis
DIAGNOSIS
? Diagnostic bronchoscopy is a part of diagnostic protocol
for taking the material for microbiological examination
and to confirm intrabronchial cause of abscess-tumor or
foreign body.
? Sputum examination is useful for identification of
microbiological agents or confirmation of bronchial
carcinoma
MANAGEMENT
STANDARD CONSERVATIVE THERAPY: MEDICAL MANAGEMENT
? It is recommended to treat lung abscess with broad spectrum
antibiotics, due to poly microbial flora, such as Clindamycin (600
mg IV on 8 h) and then 300 mg PO on 8 h or combination
ampicilin/sulbactam (1.5-3 gr IV on 6 h).
? Alternative therapy is piperacilin/tazobactam 3.375 gr IV on 6 h or
Meropenem 1 gr IV on 8 h.
? For MRSA it is recommended to use linezolid 600 mg IV on 12 h or
vancomycin 15 mg/kg BM on 12 h.
MANAGEMENT
SURGICAL
? Endoscopic drainage of lung abscesses is described as an alternative to chest
tube drainage and is performed during the bronchoscopy with usage of laser.
? Per cutaneous trans thoracic tube drainage
? Surgical resection of lung abscess is the therapy of choice for about 10% of
patients.
? Lobectomy is the resection of choice for large or central position of abscess.
Atypical resection or segmentectomy are satisfactory procedures, if it is
possible to remove complete abscess and if necessary surrounding lung tissue
with necrotizing pneumonia
THANK YOU
CASE 1
? A 42-year-old man, gardener
? Long history of respiratory problems starting in early
childhood.
? Previously diagnosed as asthma.
? Frequent absence from work due to "recurrent chest
infections".
? Unaware of any neonatal issues but believes that he was born
at home without complications and is unsure of any previous
tests he has had as he is now estranged from his parents.
? Has a cousin with a "lung disease".
? Married but has "no kids"
INVESTIGATIONS
? Sputum culture: P. aeruginosa
? Sweat chloride = 73 meq/liter
? Cystic fibrosis genetics: genotype was F508del/R117H
? CYSTIC FIBROSIS: Multisystem disorder caused by
mutations in the gene that encodes the CF
transmembrane conductance regulator (CFTR) protein,
a chloride channel expressed in epithelial cells.
? More than 2000 CFTR mutations have been identified
to date, but only the functional importance of a small
number is known to cause the disease
HRCT THORAX
? An upper lobe predominant distribution of cylindrical, cystic and
varicose bronchiectasis associated with airway wall thickening, mucus
plugging and parenchymal opacities on a HRCT scan should raise the
suspicion of CF disease.
? The presence of nasal polyposis and/or chronic rhinosinusitis,
recurrent pancreatitis, malabsorption, diabetes, osteoporosis and
male infertility are other typical features of CF
DIAGNOSIS
Guidelines published by the Cystic Fibrosis Foundation in the
USA allows diagnosis if:
1. Clinical presentation of the disease and evidence of biochemical
and genetic markers of CFTR dysfunction.
2. Clinical features of the disease with concentration of chloride
>60mmol?L-1 at the sweat test or a concentration in the
intermediate range (30?59mmol?L-1) but two disease-causing
CFTR mutations.
3. CFTR genotype is undefined: CFTR physiologic tests, such as nasal
potential difference and intestinal current measurement, should
be performed.
MANAGEMENT
1. CFTR modulator therapies
2. Airway clearing techniques
3. Chest physical therapy
4. Humidification with sterile water or normal saline to facilitate
airway clearance
5. Antibiotics
6. Mucus thinners
7. Lung transplantation
CASE 2
? 45-year-old farmer with asthma since childhood.
? Complaints: Decline in his exercise tolerance and an
increase in cough which has become productive of
purulent sputum with occasional thick/solid components.
? Respiratory exacerbations not responding well to
standard steroid and antibiotic treatment.
? He was noted to have variable pulmonary infiltrates on
chest radiographs during these episodes
INVSETIGATIONS
? Marked peripheral blood eosinophilia
? Total IgE > 1000 IU/ ml
? Aspergillus specific IgE > O.35
ABPA: ABPA is an inflammatory disease caused by hypersensitivity to
the ubiquitous fungus Aspergillus fumigatus
? ABPA occurs most commonly in patients with asthma and CF
? ABPA is the cause of 1?10% of cases of bronchiectasis
? Most ABPA cases occur in the third and fourth decade without a sex
predilection.
DIAGNOSIS
? Long standing uncontrolled asthma/ Cystic fibrosis
? Brownish sputum
? Peripheral eosinophilia > 500/ mm3
? Total IgE > 1000 IU/ ml
? Specific IgE for A. fumigatus > 0.35
HRCT thorax:
? Central bronchiectasis
? High attenuation mucus
? Finger in glove/ TIB
? Tram track
? Mosaic attenuation
MANAGEMENT
1. Corticosteroids
2. Antifungals
3. Airway clearing techniques
4. Chest physical therapy
5. Mucus thinners
CASE 3
? 77-year-old retired librarian.
? Cough for many years with new symptoms of fatigue, weight
loss and fever.
? A chest CT scan was performed looking for a possible occult
malignancy and bronchiectasis was found.
DIAGNOSIS
? HRCT thorax: cylindrical bronchiectasis and tree-in-bud
pattern in middle and lower lobes
? Sputum for M. Tuberculosis: negative
? MGIT culture: MAC growth at 4 weeks
? Repeat MGIT: Positive for MAC
? Tests for immunodeficiency and ABPA: Negative
MANAGEMENT
1. Management of NTM as per the organism and clinical
picture
2. Airway clearing techniques
3. Chest physical therapy
4. Mucus thinners
CASE 4
? A 66-year-old woman with established idiopathic
bronchiectasis has had three to four exacerbations per year
for the past 3 years despite performing daily chest
physiotherapy.
? Produces large volumes of sputum daily despite performing
the active cycle of breathing technique.
? Testing for NTM, ABPA and other complications were
negative, but sputum shows persistent infection with P.
aeruginosa.
? One of the most common presentations of bronchiectasis
? Exacerbations are one of the most important manifestations of
bronchiectasis and P. aeruginosa is the most frequent
organism in severe bronchiectasis worldwide
? Cylindrical bronchiectasis is the most common morphological
pattern identified on CT scans
MANAGEMENT
1. Review current airway clearance regime.
2. Repeat sputum microbiology and repeat testing for NTM, ABPA
and ensuring the all possible treatable causes and comorbidities
have been identified.
3. First-line recommendation for P. aeruginosa with frequent
exacerbations is an inhaled antibiotic.
THANK YOU
This post was last modified on 08 April 2022