1. Chapter 13 Bronchiectasis

2. C E A B D
Figure Bronchiectasis. A, Varicose bronchiectasis. B, Cylindrical bronchiectasis. C, Cystic (saccular) bronchiectasis. Also illustrated are excessive bronchial secretions (D) and atelectasis (E), which are both common anatomic alterations of the lungs in this disease.

3. Three Forms of Bronchiectasis
Cylindrical bronchiectasis
Also called Tubular bronchiectasis
Varicose bronchiectasis
Also called Fusiform bronchiectasis
Cystic bronchiectasis
Also called Saccular bronchiectasis

4. Anatomic Alterations of the Lungs
Chronic dilation and distortion of bronchial airways
Excessive production of often foul-smelling sputum
Bronchospasm
Hyperinflation of alveoli (air-trapping)
Atelectasis, and parenchymal fibrosis
Hemorrhage secondary to bronchial arterial erosion

5. Etiology Acquired bronchiectasis Congenital bronchiectasis
Recurrent pulmonary infection
Bronchial obstruction
Inhalation and aspiration
Congenital bronchiectasis
Kartagener’s syndrome
Systemic disorders

6. Overview of the Cardiopulmonary Clinical Manifestations Associated with Bronchiectasis
The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by
Excessive Bronchial Secretions
Bronchospasm
Increased Alveolar-Capillary Membrane Thickness

9. Figure 9-11. Bronchospasm clinical scenario (e.g., asthma).
Figure Bronchospasm clinical scenario (e.g., asthma).

10. Figure 9-9. Alveolar consolidation clinical scenario.

11. Figure 9-10. Increased alveolar-capillary membrane thickness clinical scenario.

12. Clinical Data Obtained at the Patient’s Bedside Depending on the amount of bronchial secretions, and the degree of bronchial destruction and fibrosis associated with bronchiectasis, the disease may create either an obstructive lung disorder, or a restrictive lung disorder, or a combination of both. If the disease is limited to a relatively small portion of the lungs—as it often is—the patient may not have any of the following clinical manifestations.

13. The Physical Examination
Vital Signs
Increased
Respiratory rate (Tachypnea)
Heart rate (pulse)
Blood pressure

14. The Physical Examination (Cont’d)
Use of accessory muscles of inspiration
Use of accessory muscles of expiration
Pursed-lip breathing

15. The Physical Examination (Cont’d)
Increased anteroposterior chest diameter (barrel chest)
Cyanosis
Digital clubbing

16. The Physical Examination (Cont’d)
Peripheral edema and venous distension
Distended neck veins
Pitting edema
Enlarged and tender liver

17. The Physical Examination (Cont’d)
Cough, sputum production, and hemoptysis
Chronic cough with production of large quantities of foul-smelling sputum is a hallmark of bronchiectasis.

18. The Physical Examination (Cont’d)
Chest Assessment Findings
When primarily obstructive in nature:
Decreased tactile and vocal fremitus
Hyperresonant percussion note
Diminished breath sounds
Wheezing
Rhonchi

19. The Physical Examination (Cont’d)
Chest Assessment Findings
When primarily restrictive in nature (i.e., over areas of atelectasis and consolidation):
Increased tactile and vocal fremitus
Bronchial breath sounds
Crackles
Whispered pectoriloquy
Dull percussion note

20. Clinical Data Obtained from Laboratory Tests and Special Procedures

21. Pulmonary Function Test Findings When Primarily Obstructive in Nature
(Moderate to Severe Bronchiectasis)
Forced Expiratory Flow Rate Findings
FVC FEVT FEV1/FVC ratio FEF25%-75
   
FEF50% FEF PEFR MVV
   

22. Pulmonary Function Test Findings
When Primarily Obstructive in Nature Moderate to Severe Bronchiectasis
Lung Volume & Capacity Findings
VT IRV ERV RV VC
N or  N or N or  
IC FRC TLC RV/TLC ratio
N or  N or  N or 

23. Pulmonary Function Test Findings When Primarily Restrictive in Nature
(Moderate to Severe Bronchiectasis)
Forced Expiratory Flow Rate Findings
FVC FEVT FEV1/FVC ratio FEF25%-75
 N or  N or  N or 
FEF50% FEF PEFR MVV
N or  N or  N or  N or 

24. Pulmonary Function Test Findings
When Primarily Restrictive in Nature Moderate to Severe Bronchiectasis
Lung Volume & Capacity Findings
VT IRV ERV RV VC
N or     
IC FRC TLC RV/TLC ratio
   N

25. Arterial Blood Gases Bronchiectasis
Mild to Moderate Stages
Acute Alveolar Hyperventilation with Hypoxemia
(Acute Respiratory Alkalosis)
pH PaC HCO Pa02
   (slightly) 

26. PaO2 and PaCO2 trends during acute alveolar hyperventilation.

27. Arterial Blood Gases Bronchiectasis
Severe Stage
Chronic Ventilatory Failure with Hypoxemia
(Compensated Respiratory Acidosis)
pH PaC HCO Pa02
N   (Significantly) 

28. PaO2 and PaCO2 trends during acute or chronic ventiliatory failure.

29. Arterial Blood Gases Bronchiectasis
Acute Ventilatory Changes Superimposed On
Chronic Ventilatory Failure
Because acute ventilatory changes are frequently seen in patients with chronic ventilatory failure, the respiratory care practitioner must be familiar with and alert for the following:
Acute alveolar hyperventilation superimposed on chronic ventilatory failure
Acute ventilatory failure (acute hypoventilation) superimposed on chronic ventialtory failure.

30. Moderate to Severe Stages
Oxygenation Indices
Moderate to Severe Stages
QS/QT D V C(a-v) ER Sv02
  N N  

31. Moderate to Severe Stages
Hemodynamic Indices
Moderate to Severe Stages
CVP RAP PA PCWP CO SV
   N N N
SVI CI RVSWI LVSWI PVR SVR
N N  N  N

32. Abnormal Laboratory Tests and Procedures
Increased hematocrit and hemoglobin
Elevated white blood count if acutely infected
Sputum examination
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Anaerobic organisms

33. Radiologic Findings Chest Radiograph
When the bronchiectasis is primarily obstructive in nature
Translucent (dark) lung fields
Depressed or flattened diaphragms
Long and narrow heart (pulled down by diaphragms)
Areas of consolidation and/or atelectasis may or may not be seen

34. Figure 13-2. Gross cystic bronchiectasis
Figure Gross cystic bronchiectasis. Posteroanterior chest radiograph showing overinflated lungs. There are multiple ring opacities, most obvious at the lung bases, ranging from 3 to 15 mm in diameter. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)

35. Figure 13-3. Left lower lobe bronchiectasis
Figure Left lower lobe bronchiectasis. The marked volume loss of left lower lobe is indicated by a depressed hilum, vertical left mainstem bronchus, mediastinal shift, and left-sided transradiancy. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)

36. Figure 13-4. Ciliary dyskinesia syndrome—Kartagener’s syndrome
Figure Ciliary dyskinesia syndrome—Kartagener’s syndrome. This 62-year-old woman gave a 40 year history consistent with bronchiectasis. The aortic arch, descending aorta, heart, and gastric air bubble are all on the right side. There is diffuse complex pulmonary shadowing with many ring opacities. Broad-branching band shadows can just be seen through heart and represent dilated fluid-filled airways.

37. Figure 13-5. Cylindrical bronchiectasis
Figure Cylindrical bronchiectasis. Left posterior oblique projection of a left bronchogram showing cylindrical bronchiectasis affecting the whole of the lower lobe except for the superior segment. Few side branches fill. Basal airways are crowded together, indicating volume loss of the lower lobe, a common finding in bronchiectasis. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)

38. Figure 13-6. Cystic (saccular) bronchiectasis
Figure Cystic (saccular) bronchiectasis. Right lateral bronchogram showing cystic bronchiectasis affecting mainly the lower lobe and posterior segment of the upper lobe. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)

39. Figure 13-7. Varicose bronchiectasis
Figure Varicose bronchiectasis. Left posterior oblique projection of left bronchogram in a patient with the ciliary dyskinesia syndrome. All basal bronchi are affected by varicose bronchiectasis. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)

40. Radiologic Findings (Cont’d) Computed Tomography (CT Scan)
The bronchial walls may appear as follows:
Thick
Dilated
Characterized by ring lines or clusters
Signet ring-shaped
Flamed-shaped

41. Figure 13-8. Signet ring sign in patient with cystic fibrosis.

42. Figure 13-9. Cylindrical bronchiectasis
Figure Cylindrical bronchiectasis. A and B, Examples from two patients. Airways parallel to the plane of the section in anterior segment of an upper lobe show changes of cylindrical bronchiectasis; bronchi are wider than normal and fail to taper as they proceed toward the lung periphery.

43. Figure 13-10. Varicose bronchiectasis
Figure Varicose bronchiectasis. Patient with allergic bronchopulmonary aspergillosis and cystic fibrosis. The bronchiectatic airways have a corrugated, or beaded, appearance.

44. Figure 13-11. Cystic bronchiectasis (advanced) in the upper lobes.

45. General Management of Bronchiectasis
General treatment includes:
Controlling pulmonary infections
Controlling airway secretions
Preventing complications

46. General Management of Bronchiectasis (Cont’d)
Respiratory care treatment protocols
Oxygen Therapy Protocol
Bronchopulmonary Hygiene Therapy Protocol
Lung Expansion Therapy Protocol
Aerosolized Medication Therapy Protocol
Mechanical ventilation protocol

47. General Management of Bronchiectasis (Cont’d)
Other medications commonly prescribed
by the physician
Expectorants
Antibiotics

48. Classroom Discussion Case Study: Bronchiectasis