1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. BRONCHIECTASIS Presented By ABDULRAHMAN ALBARQI Medical Student

3. DEFINITION Destruction of the bronchial-tree walls resulting in irreversible dilation of the bronchial airways and mucociliary transport mechanism impairement which lead to pooling of the mucus in the bronchail tree Diffuse Focal

4. Pathogenesis and Aetiology Vicious circle theory Acqiured (mostly infection) Congenital infection Damage to bronchi Mucus clearance impairment Pooling of mucus

5. ACQUIRED CAUSES Infection : Bacterial : - mycobacterium tuberculosis - haemophilus influenzae - P. aeruginosa - staph. aureus Viral (mostly in children) : - RSV - Measles

6. ACQUIRED CAUSES Bronchial obstruction : - foreign body - mucus plug - tumors - post- infection bronchial stenosis - hilar lymphadenopathy

7. ACQUIRED CAUSES Other causes: - GIRD and aspiration pneumonia - Allergic bronchopulmonary aspergillosis (ABPA) - AIDS - Traction bronchiectasis - Toxic gas exposure (chlorine, ammonia)

8. CONGENITAL CAUSES Cystic fibrosis Young syndrome primary ciliary dyskinesia (kartenger syndrome) immunodeficiencey (hypogammaglobulinemia) Alpha1-antitrypsin deficiency (AAT)

9. Rheumatoid arhtritis SLE IBD Marfan syndrome Sacroidosis

10. CLINICAL FEATURES Symptoms : Chronic history of Cough (90%) Copious and purulent sputum (90%) Rhinosinusitis (70%) Dyspnea (70%) Chest pain, haemoptysis, wheezing ( 20%) Urinary incontinence (12% men vs 47% women) Weight loss

11. CLINICAL FEATURE Predisposing factors: - severe respitratory infection in childhood - recurrent chest infection - congenital anomally - systemic disease

12. PHYSICAL EXAMINATION Basal crackles ( 60% ) Ronchi ( 44%) Wheezing (34) Finger clubbing (3%)

13. DIFFERENTIAL DIAGNOSIS Asthma COPD Pulmonary T.B Chronic bronchitis pneumonia

14. INVESTIGATIONS Lab studies : - CBC : typically anemia and in neutrophil polycythemia advanced cases eosinophills ABPA

15. INVESTIGATIONS Sputum analysis: Eosinophilia + golden mucus plugs in ABPA Culture and gram staining: H. Influenzae (42%) P.Aeruginosa (18%) Other: S pneumoniae, M catarrhalis, M. tuberculosis No growth (30-40%)

16. INVESTIGATIONS Other specific tests : -Serum immunoglobuline -Sweat test and genetic analysis (CF) -AAT level (ATT deficiency) - IgE level ABPA

17. IMAGING Chest x-ray : - low senstivity and specificity -mild cases normal chest x-ray -Moderate cases increase lung marking - Severe cases cysts + fluid levels

18. IMAGING MILD BRONCHIECTASIS Presented with haemoptysis Normal chest radiograph

19. IMAGING MODERATE BRONCHIECTASIS - Coarse white lines extending out from hila

20. IMAGING SEVERE BRONCHIECTASIS Cysts with fluid level

21. IMAGING

22. CT scan -The criterion standard for bronchiectasis diagnosis -Senstivety 84% - 97% -Specificity 82% - 99% -Peribronchial thickening, dilated bronchioles.

24. IMAGING The anatomical distribution of the bronchiectasis may give a clue for the cause : -Infection lower lobes, lingula,RT middle lobe -Right middle lobe alone mechanical obstruction -Upper lobes(distal bronchi) CF and T.B -Upper lobes (proximal bronchi) ABPA

25. MANAGEMENT Antibiotics and chest physiotherapy are the mainstay modalities management of underlying conditions Immunizations for influenza and pneumococcal pneumonia Immunizations for measles, rubella, and pertussis should be confirmed Bronchodilators Corticosteroid

26. MANAGEMENT Antibiotic : Mildly ill patient amoxicillin tetracycline, macrolide moderate-to-severe I.V antibiotic : - aminoglycoside - cephalosporin - fluoroquinolone Patient with CF tobramycin

27. MANAGEMENT Antibiotic : Very frequent infections regular antibiotic : - daily antibiotics for 7-14 days of each month - alternating antibiotics for 7-10 days with antibiotic free periods of 7-10 days

28. MANAGEMENT Physiotherapy : - postural drainage and percussion - intrapulmonic percussive ventilation devices - Vest system

29. MANAGEMENT - Bronchodilators: to reverse the bronchospasm associated with airway hyperreactivity and improving mucociliary clearance. -Corticosteroid : to reduce the amount of tissue damage caused by the offending organism

30. Thank you