Title: Bronchiectasis | Jindal Chest Clinic
1Bronchiectasis
2Bronchiectasis
- Definition
- Permanent destructive dilatation of the bronchi
(following infection, destruction and fibrosis) - Types
- Cystic
- Cylindrical
- Localized or diffuse
3Etiology 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
4Congenital 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
5Clinical 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
6Investigations
- 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
7Differential Diagnosis
- Pulmonary tuberculosis
- Cystic fibrosis
- COPD
- Allergic broncho-pulmonary aspergillosis
- Interstitial lung diseases
- Eosinophilic lung diseases
- Hypersensitivity pneumonias
8Radiological 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)
9Complications
- 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
10Management
- 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 ?
-
-
11Recommendation 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
12Prevention of infections
- Preventive vaccinations
- Bronchial hygiene measures
-
- Chest physiotherapy -
- Nebulization/ -
steam inhalation -
- Respiratory muscle exercises - Long term antibiotic use - Oral
-
Nebulized
13Kartageners Syndrome
- Ciliary dyskinesia i.e. abnormal ciliary
movements - Genetic abnormality
- Clinical features Bronchiectasis
- Situs inversus,
- dextrocardia
- Chronic
sinusitis - Infertility
14Allergic 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
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16Cystic 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
-
17Cystic 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
18Cystic 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
19TUBERCULOSIS
- History
- Epidemiology
- Introduction
20What is TB ?
- Infection caused by
- Mycobacterium tuberculosis (Mtb)
- i.e. Tubercle bacillus (T.b.)
- Airborne spreads by aerosols
- enters the lungs through inhalation
21HISTORY
- Ancient disease since BC era
- Also known as
- Consumption
- Wasting
- Phthisis
- Yakshma
- Kings evil
- Kochs disease
22TB 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
23Babylon 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
24TB 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
25Historical 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
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27Kochs 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
28Epidemiology
- 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
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30TB is the leading single infectious cause of
death in South-East Asia
Number of deaths (1000s)
Deaths from infectious agents in South-East Asia
31TB is the leading single infectious cause of
death in India
32TB is a Leading Killer of Women
Deaths among women
33Tuberculosis 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
34TB Epidemiology in India
- TB infection (Mx ve) 40
- Prevalence (sputum ve) 0.23
- Mortality 0.04
- Overall prevalence 0.51
35Burden 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
36Risk 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
38HIV 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.
39TB and AIDS
Lifetime Risk of TB
40Homeostasis unbalanced in infections
Host defenses
Pathogens
41TB 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
42Sequence of TB infection
- Inhalation of Mtb localization in
tracheo-bronchial tree - Recruitment of macrophages and lymphocytes.
Macrophages transform as Langhans cells - 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)
44Bacillary multiplication
- 1 Bacillus
- 20 hrs
- 2 bacilli
- 10 days
- 5000 (Nodule)
- 1 month
- gt 1 billion (large cavity)
45Natural 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
46Continuing Infection
- One Sputum positive
- (untreated, undetected)
- Infects
- 6-12 persons in 1st year
- upto 24 in 2 year life span
47The National Problem
- Large pool of patients
- Renewed and perpetuated
- Difficult to approach
- Difficult to find, hold and treat
- Shortage of beds
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