Bronchiectasis | Jindal Chest Clinic - PowerPoint PPT Presentation

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Bronchiectasis | Jindal Chest Clinic

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"Bronchiectasis: A chronic lung disease marked by irreversible dilation and scarring of the airways." – PowerPoint PPT presentation

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Title: Bronchiectasis | Jindal Chest Clinic


1
Bronchiectasis
2
Bronchiectasis
  • Definition
  • Permanent destructive dilatation of the bronchi
    (following infection, destruction and fibrosis)
  • Types
  • Cystic
  • Cylindrical
  • Localized or diffuse

3
Etiology of bronchiectasis
  • Post-infectious, e.g. tuberculosis, pneumonia
    childhood infection such as measles, mumps,
    whooping cough
  • Connective tissue diseases, e.g. SLE, rheum
    arthritis, Sjögrens syndrome, relapsing
    polychondritis
  • Secondary to inhalation or aspiration,
  • e.g. a foreign body
  • Inflammatory bowel disease, e.g. ulcerative
    colitis
  • Allergic bronchopulmonary aspergillosis
  • Immune deficiency e.g. Secondary to ch lymphatic
    leukemia

4
Congenital causes of Bronchiectasis
  • Cystic fibrosis
  • Ciliary defects, e.g. primary ciliary dyskinesia,
    Youngs syndrome
  • Kartageners syndrome
  • Immune deficiency, e.g. IgA deficiency,
  • X-linked agammaglobulinemia,
  • Common variable immunodeficiency
  • Congenital defects e.g. tracheobronchomegaly
    (Mounier-Kuhn syndrome), pulmonary sequestration

5
Clinical Features
  • Chronic cough and expectoration
  • Sputum Purulent/ muco-purulent, foul-smelling,
    large volume, thick and tenacious
  • Haemoptysis, sometimes massive
  • Recurrent exacerbations
  • SIGNS General malnutrition, pallor, edema
  • Digital clubbing, osteoarthropathy
  • Chest Depends on site and extent of involvement
  • If large, signs of lung volume reduction
  • May be areas of bronchial breathing
  • Coarse crepitations, Occasional rhonchi

6
Investigations
  • General Anemia, Hypoglobulinemia
  • Chest radiography CXR, CT scan (HRCT)
  • Bronchography
  • Sputum examination For exacerbations.
  • AFB to exclude TB, if
    suspected
  • Smear for culture
  • ECG, ECHO for cardiac evaluation in suspected
  • chronic cor-pulmonale

7
Differential Diagnosis
  • Pulmonary tuberculosis
  • Cystic fibrosis
  • COPD
  • Allergic broncho-pulmonary aspergillosis
  • Interstitial lung diseases
  • Eosinophilic lung diseases
  • Hypersensitivity pneumonias

8
Radiological features
  • CXR May appear normal in early, limited disease,
  • left lower lobe hidden behind the heart in
    PA film.
  • Thickened bronchial lines- tram lines
  • Cystic shadows/ cavities with fluid levels
  • HRCT Almost diagnostic.
  • Clear demonstration of site of involvement,
  • Type of lesions, surrounding lung
    parenchyma,
  • focal pneumonitis, areas of atelectasis.
  • Clue to the underlying etiology (eg ABPA)

9
Complications
  • Recurrent pneumonias
  • Recurrent hemoptysis,
  • sometimes massive
  • Local lung destruction and cavitation
  • Aspergilloma formation (fungal ball) in a cavity
  • Metastatic spread
  • Pulmonary hypertension and
  • chronic cor pulmonale
  • Chronic malnutrition
  • Amyloidosis
  • Chronic respiratory failure if extensive lung
    destruction and fibrosi

10
Management
  • Bronchial hygiene Postural drainage, Chest
    physiotherapy
  • Antibiotics for infections
  • Expectorant and mucolytics
  • Management of complications, e.g hemoptyis,
  • pulmonary hypertension (Chronic cor
  • pulmonale), respiratory failure
  • Nutritional supplementation
  • Surgical management Resection, if localized
  • Management of hemoptysis
  • Lung transplantation ?

11
Recommendation for antibiotics use
  • Bacterial infection
    First choice Second
    line
  • Haemophilus influenzae

    Doxycycline,
  • or Moraxella catarrhalis
    Co-amoxiclav ciprofloxacin
  • Streptococcus pneumoniae
    Amoxicillin
    Clarithromycin
  • MRSA
    Rifampicin and Rifampicin
    and

  • trimethoprim
    doxycycline or

  • or IV vancomycin
    linezolid

  • or teicoplanin
  • Ps aeruginosa
    Ciprofloxacin Ceftazidime


  • and tobramycin


  • or colistin

12
Prevention of infections
  • Preventive vaccinations
  • Bronchial hygiene measures

  • - Chest physiotherapy

  • - Nebulization/

  • steam inhalation

  • - Respiratory muscle exercises
  • Long term antibiotic use - Oral

  • Nebulized

13
Kartageners Syndrome
  • Ciliary dyskinesia i.e. abnormal ciliary
    movements
  • Genetic abnormality
  • Clinical features Bronchiectasis
  • Situs inversus,
  • dextrocardia
  • Chronic
    sinusitis
  • Infertility

14
Allergic Broncho Pulmonary Aspergillosis
  • Hypersensitivity to aspergillus in the
    tracheo-bronchial tree in patients with chronic
    asthma.
  • Clinical Features Severe attacks, sputum
    production hard brown plugs hemoptysis
  • Radiology CXR and HRCT Fleeting opacities,
    typical patterns bronchiectasis proximal
    bronchi
  • Diagnosis Skin test Immediate delayed ve
  • Sputum for aspergillus ve
  • Serology ve Total Asperg
    specific IgE levels
  • Treatment Anti-inflammatory drugs (steroids),
  • Anti-biotics, anti-fungals

15
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16
Cystic Fibrosis
  • A common condition in Caucasians
  • 1 in 2500 live births
  • Genetic anomaly Autosomal recessive mutation on
    chromosome 7 leads to protein Cystic Fibrosis
    Transmembrane Regulator, CFTR) abnormality
  • Clinical Features Multi-organ problem
  • Bronchiectasis
    thick viscid sputum
  • Pancreatic
    insufficiency - diarrhoea
  • Liver disease
    biliary cirrhosis
  • Sweat glands
    function abnormality
  • Infertility
  • Low bone mass

17
Cystic Fibrosis- Diagnosis
  • Clinical features Failure to thrive
  • Intestinal
    obstruction
  • Adults
    Respiratory infections
  • Radiological investigations, CXR, HRCT
    scans etc
  • Positive sweat Test High sweat chloride
    Na
  • levels
    on pilocarpine stimulation
  • Gene analysis demonstration of CFTR
  • mutations

18
Cystic Fibrosis- Treatment
  • Treatment of respiratory infection with
    antibiotics Anti-pseudomonas cover
  • Reduce sputum viscosity- mucolytics
  • Improve airway clearance
  • Management of pancreatic insufficiency
  • Correction of malnutrition high calorie, high
    fat diet supplemental vitamins
  • Gene therapy
  • Lung transplantation

19
TUBERCULOSIS
  • History
  • Epidemiology
  • Introduction

20
What is TB ?
  • Infection caused by
  • Mycobacterium tuberculosis (Mtb)
  • i.e. Tubercle bacillus (T.b.)
  • Airborne spreads by aerosols
  • enters the lungs through inhalation

21
HISTORY
  • Ancient disease since BC era
  • Also known as
  • Consumption
  • Wasting
  • Phthisis
  • Yakshma
  • Kings evil
  • Kochs disease

22
TB in Antiquity
  • Clear evidence of spinal TB
  • Early Dynastic period (c.3400 BC) Egypt
  • Destruction and collapse of thoracic vertebrae
    with psoas abscess in the well preserved mummy of
    a member (Nesperehan) of 21st Dynasty priesthood
    of Amin.

  • Cave, 1939
  • Chinese Civilization
  • Lung fever and Lung cough (Chinese writings
    2698 BC). Symptom of emaciation, cough,
    expectoration of blood and pus cure was
    difficult bizarre remedies dung of animals
    man, the urine of women and infants, the lungs of
    the hog and the ashes of hair.

  • Hall, 1936

23
Babylon civilization
  • Mention of TB 1948 and 1905 BC
  • Code of Hammurabi His wife who is afflicted
    with the disease he shall not put away. She shall
    remain in the house which she has built and he
    shall maintain her as long as she lives.
  • Indo Aryans
  • A consumptive who is evidently master of
    himself, who has a good digestion, is not
    emaciated and is at the beginning of the disease
    the physician can cure and the physician who
    wants great fame cures a man attacked by
    consumption.
  • Webb, 1936

24
TB in ancient India (Rajyakshma)
  • Rig Veda (1500 BC)
  • Ayur-Veda (700 BC)
  • a consumptive at the beginning of disease
    the physician can cure
  • Laws of Manu (1000 BC)
  • sufferers from TB are unclean
  • Webb GB 1936 Brown L 1941 Keers RY 1978

25
Historical landmarks
  • Tubercle bacillus (Mycobacterium tuberculosis)
    Discovered on March 24, 1882 by Robert Koch
    (Awarded Nobel Prize in 1905)
  • Discovery of X-Ray (Wilhelm Roentgen, 1895)
  • Bacillus Calmette Guerin (BCG)
  • Chemotherapy Streptomycin (1944),
  • P.A.S., Isoniazid
    (1952)
  • Ethambutal,
    Rifampicin
  • Other new drugs
  • Regimens and Strategies

26
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27
Kochs postulates
  • The organism should be found in each case of the
    disease
  • It should not be found in other diseases
  • It should be isolated
  • It should be cultured
  • It should, when inoculated, produce the same
    disease
  • It should be recovered from the inoculated animal

28
Epidemiology
  • Incidence vs Prevalence
  • Risk factors
  • Disease burden
  • Morbidity and mortality
  • Global health challenge
  • Higher incidence in low income countries
  • India accounts for about 30 of global cases

29
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30
TB is the leading single infectious cause of
death in South-East Asia
Number of deaths (1000s)
Deaths from infectious agents in South-East Asia
31
TB is the leading single infectious cause of
death in India
32
TB is a Leading Killer of Women
Deaths among women
33
Tuberculosis A Global Emergency
  • TB kills 5,000 people a day 2 million each year
  • One third of the worlds population is infected
    with TB
  • More than 100,000 children will die needlessly
    from TB this year
  • Hundreds of thousands of children will become TB
    orphans this year
  • HIV and MDRTB will make the TB epidemic much more
    severe unless urgent action is taken

34
TB Epidemiology in India
  • TB infection (Mx ve) 40
  • Prevalence (sputum ve) 0.23
  • Mortality 0.04
  • Overall prevalence 0.51

35
Burden of TB in India
  • 2 million new patients per year
  • Over 450,000 deaths from TB annually
  • TB kills more woman than all other causes of
    maternal mortality combined
  • More than 100,000 women rejected (due to TB)
  • More than 300,000 children leave schools to work
    as a result of parental TB
  • Annual cost of disease Rs. 12,000 crores
  • Annual direct costs Rs. 30 crores
  • Productive work days lost 100 million per year

36
Risk Factors
  • Immuno-deficiency states
  • HIV infections
  • Patients with malignancies, leukaemias, lymphomas
  • Patients on immuno-suppressant drugs (e.g.
    steroids)
  • Malnutrition, drug-users, psychiatric disorders
  • 3. Close contacts of patients
  • Infants of sputum ve mothers

37
  • 4. Poverty living in crowded, slum areas
  • poorly ventilated houses
  • 5. Alcoholism
  • 6. Tobacco smoking
  • 7. Patients with other diseases (comorbidities)
  • - Diabetes
  • - Hypothyroidism
  • - Silicosis (silico-tuberculosis)
  • 8. Post-operative gastrectomy

38
HIV Infection TB Risk
  • Annual risk about 10
  • Life time risk of TB w.r.t. HIV
  • - Negative 5-10
  • - Positive 50
  • COINFECTION (HIV TB)
  • App. 1/3 of 20 million HIV pts.

39
TB and AIDS
Lifetime Risk of TB
40
Homeostasis unbalanced in infections
Host defenses
Pathogens
41
TB An Infection
  • Tubercle bacillus (T.b)
  • Mycobacterium tuberculosis (MTB)
  • Airborne spreads by aerosols enters the lungs
    through inhalation
  • Interplay between the bacillus and the host
    defences
  • Establishment of infection Lesions in the lungs
    / lymph nodes / GIT/ other organs
  • Spread to other sites/ organs
  • Complications and Sequelae

42
Sequence of TB infection
  1. Inhalation of Mtb localization in
    tracheo-bronchial tree
  2. Recruitment of macrophages and lymphocytes.
    Macrophages transform as Langhans cells
  3. Engulfed by alveolar macrophages (defence cells)
    either get killed or destroy the cells to
    penetrate alveolar walls and enter the
    lymphatics/ blood vessels, reach regional LN

43
  • Langhans cells and lymphocytes form granulomas
    (Primary lesion)
  • Primary lesion and regional lymphatics and LN
    together called Primary Complex (of Ranke)
  • Fibrous capsule formation may lie dormant in the
    LN (Latent TB) or spread through lymphatics/
    blood stream to bones, liver, spleen, GIT etc.
  • Impart delayed type, cell-mediated immunity
    (demonstrated by Tuberculin or Mantoux test)

44
Bacillary multiplication
  • 1 Bacillus
  • 20 hrs
  • 2 bacilli
  • 10 days
  • 5000 (Nodule)
  • 1 month
  • gt 1 billion (large cavity)

45
Natural history of untreated Primary TB
  • Time from Infection TB involvement
  • 3-8 wks Primary complex
  • 3-6 mths Meningeal,
    miliary,pleural
  • Up to 3 yrs GIT, Bones
    joints, LNs
  • About 8 yrs Renal tract
  • 3 yrs onwards Post primary disease

46
Continuing Infection
  • One Sputum positive
  • (untreated, undetected)
  • Infects
  • 6-12 persons in 1st year
  • upto 24 in 2 year life span

47
The National Problem
  • Large pool of patients
  • Renewed and perpetuated
  • Difficult to approach
  • Difficult to find, hold and treat
  • Shortage of beds

48
  • THANK YOU
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