1. Bronchiectasis By :Fatma elbadry

3. Bronchiectasis (broncos, airways; ectasia, dilatation) is amorphological term used to describe abnormal irreversibly dilated and often thick-walled bronchi. Definition : Bronchiectasis represents the end stage of a variety of pathologic processes that cause destruction of the bronchial wall and its surrounding supporting tissues. The clinical manifestations include chronic cough and copious mucopurulent expectoration, often lasting months to years

4. PREVALENCE: Bronchiectasis was a common disabling and fatal condition in the pre-antibiotic era. It remains an important cause of suppurative lung disease in the developing world . the prevalence has recently been estimated to be 52 per 100,000.

5. PATHOPHYSIOLOGY The abnormal bronchial dilatation in bronchiectasis affects the medium-sized bronchi, but often extends to the more distal bronchi and bronchioles. : gross examination The affected bronchi and bronchioles are so prominent as to be visible all the way to the pleural surface. These dilated and ectatic bronchi are commonly filled with purulent secretions

7. Microscopically, bronchiectasis is associated with loss of cilia, cuboidal and squamous metaplasia hypertrophy of bronchial glands, and lymphoid hyperplasia. Intense infiltration of the bronchial wall with neutrophils, lymphocytes and monocytes is seen.

8. chronic bacterial endobronchial infection and inflammation damage or destroy mucociliary defenses, leading to secretion stasis, which in turn propagates furthers bacterial infection, and increases airway inflammation and bronchial dilatation Bacterial colonization and/or infection of the airways alone is not sufficient to produce true bronchiectasis. It seems likely that focal disturbances resulting in airway obstruction or impairment of drainage and/or systemic conditions, resulting in uncoordinated air - way clearance or impaired immune response are required

12. CLASSIFICATION USING RADIOLOGY: : 1 cylindrical bronchiectasis the bronchi are regularly outlined (tubular), dilated in diameter 2 Saccular or cystic bronchiectasis : Very dilated airways clustered into saccules, cysts, or grapelike clusters walls, oftencoming to a straight abrupt end, instead of a taper ing end, due to obstruction of the peripheral bronchial tree by secretions, casts, and inflammatory wall edema : 3 Varicose bronchiectasis (illusion to varicose veins) is marked by the presence of irregular dilatations, and tortuosity of the airways

13. Cylindrical bronchiectasis with signet-ring appearance. Note that the luminal airway diameter is greater than the diameter of the adjacent vessel

14. Cystic and cylindrical bronchiectasis of the right lower lobe on a posterior-anterior chest radiograph .

15. Varicose bronchiectasis with alternating areas of bronchial dilatation and constriction.

16. This CT scan depicts areas of both cystic bronchiectasis and varicose bronchiectasis.

17. PREDISPOSING OR ASSOCIATED FACTORS: Previously bronchial damage secondary to childhood respiratory tract infections such as pneumonia, pertussis, complicated measles, and tuberculosis were implicated as common causes of bronchiectasis. Typical offending organisms that have been known to cause bronchiectasis include Klebsiella species, Staphylococcus aureus, Mycobacterium tuberculosis, Mycoplasma pneumoniae, nontuberculous mycobacteria, measles virus, pertussis virus, influenza virus, herpes simplex virus, and certain types of adenovirus. Once a patient develops bronchiectasis , many of these same organisms colonize the damaged bronchi and may result in ongoing damage and episodic infectious exacerbations. The organisms found most typically include Haemophilus species and Pseudomonas species

20. Traction bronchiectasis : Traction bronchiectasis is distortion of the airways secondary to mechanical traction on the bronchi from fibrosis of the surrounding lung parenchyma. Toxic gas exposure: Exposure to toxic gas may often cause irreversible damage to the bronchial airways and cystic bronchiectasis. Commonly suspected agents include chlorine gas and ammonia.

22. High - Resolution Computed Tomography localize and describe areas of parenchymal abnormality, and identify bronchiolar abnormalities and mucus plugging to the level of fifth- and sixth-order bronchi. It also can identify focal areas of air trapping as an indicator of small airway disease. It is indicated in the evaluation of bronchiectasis when surgical resection is contemplated, bronchiectasis is strongly suspected clinically and routine chest radiographs are normal

23. Airway dilatation can be detected by finding tramlines or end-on-ring appearance. A luminal diameter more than times the adjacent vessel is indicative of bronchiectasis Bronchial wall thickeningmay also be seen. small airway plugging with debris (tree-in-bud) may also be seen

24. BACTERIOLOGY The most frequent microorganisms are H. influenzae and P. aeruginosa and are often implicated as the cause of periodic exacerbations Colonization with P. aeruginosa, in particular, has been associated with more severe impairment of lung func- tion, more intense inflammatory response, and more extensive lung disease. Other pathogens that may require specific treatment include Nocardia asteroides, Aspergillus fumigatus, and environmental Mycobacterium spp.

25. TREATMENT: The treatment of bronchiectasis is aimed at controlling infection, reducing inflammation, and improving bronchial hygiene, with surgical resection of affected areas being useful in selected patients. Control of Infection Antibiotics are indicated to treat an acute exacer- bation. However, they have been used variably to prevent recurrent infections by suppression and/or elimination of attendant flora. Antibiotics are directed at commonly isolated pathogens such as H. influenzae, S. pneumoniae, and P. aeruginosa. Oral fluoroquinolones are often used as ini- tial antibiotic choices for treatment durations of 10 to 14 days.

26. In the face of failure to respond to treatment or the occurrence of frequent exacerbations over short periods of time sputum cultures and sensitivity tests should be done to help define antibiotic selection e.g., atypical mycobacteria or fungae. Severe exacerbations due to P. aeruginosa require the intravenous administration of two antipseudomonal antibiotics and potential hospitalization.

27. Bronchial Hygiene Airway mucus clearance is a problem in bronchiectasis. Chest percussion and postural drainage have been the traditional method of facilitating mucus clearance. Alternative therapies . Autogenic drainage, mechanical vibration with ultrasonic devices, positive expiratory pressure, and Flutter valve use without the assistance of another caregiver have been shown to achieve good chest clearance

28. Mucus Clearance Mucus hypersecretion is a prominent feature of chronic inflammatory airways disease .Maintenance of hydration with oral and/or intravenous fluids is considered useful in preventing inspissated sputum retention Humidification of inhaled air or oxygen as an adjunct to chest physical therapy has been shown to significantly in- crease the wet weight of sputum produced. The use of nebulized normal or hypertonic saline and acetylcysteine may be considered as important adjuncts to chest physical therapy,

29. Bronchodilators As these patients show signs of airway obstruction and hyperreactivity Bronchodilators are frequently used Anti - inflammatoryTherapy Persistent endobronchial inflammation isknown to play asignificant role in the pathogenesis of bronchiectasis, and anti - inflammatory therapy may be beneficial

30. Surgery: surgical resection of the most severely affected segments, bleeding segments, or areas harboring resistant tuberculosis or atypical mycobacteria may confer significant benefits in terms of symptom control, reduction of tenacious sputum production, elimination of large-volume bronchial bleeding, reduction of acute infective episodes, and improved quality of life. Lung transplantation is now considered a viable option in advanced cases, vaccinations against S. pneumoniae and influenza Smoking cessation should be emphasized as amatter of routine. If evidence of exercise and/or nocturnal desaturation should be considered for oxygen supplementation to delay the onset of pulmonary hypertension and cor pulmonale and improve exercise tolerance. Miscellaneous

31. thank you