Bronchiectasis: Diagnosis and Management

00:00 Okay, so that's the destructive cycle happening inside the lungs.

00:04 Now let's connect that to the real world.

00:07 The classic day-to-day picture is one of chronic symptoms.

00:10 The number one complaint is going to be a chronic cough, and it's not a dry cough.

00:14 They're bringing up a lot of thick mucopurulent sputum.

00:18 Mucopurulent is just a term meaning it's full of mucus and neutrophilic pus, which makes perfect sense given the cycle of injury and inflammation we just discussed.

00:28 Patients often have dyspnea, or shortness of breath.

00:32 They can also experience pleuritic chest pain when the pleura becomes inflamed and wheezing when the more proximal airways become constricted due to the inflammatory mediators.

00:43 Something that can be quite alarming for patients is hemoptysis, which is coughing up blood.

00:49 This happens because those damaged airways are inflamed and have fragile blood vessels that easily bleed.

00:56 And of course, a hallmark of this condition is recurrent infections in those flabby, dilated, distal airways, which really drives that whole vicious cycle forward.

01:07 In very advanced disease, the problems can get even more serious.

01:12 All that permanent damage leads to loss of lung parenchyma, including a lot of the vasculature in those areas.

01:19 The right heart wants to keep pumping the same volume of blood into what is now fewer vessels.

01:26 And the end result can be pulmonary hypertension or high blood pressure in the lungs.

01:31 When the pressure in the lungs gets too high, the right side of the heart has to work overtime to pump against it.

01:37 And eventually, that can lead to right heart failure.

01:39 Finally, with so much energy being spent on breathing and fighting infection, patients can experience significant wasting and weight loss.

01:46 Okay, so a patient comes in with these signs and symptoms.

01:50 How do we definitively figure out that bronchiectasis is the problem? That brings us to our next segment, diagnosis.

01:58 The first thing we're going to do is a physical exam.

02:01 When you put your stethoscope on the chest, you may hear a few things on the pulmonary exam.

02:07 You might hear crackles due to fluid in the alveoli.

02:09 You can also frequently hear ronchie due to fluid in the larger airways.

02:14 And you might hear wheezing due to the inflammatory mediators causing proximal airway constriction.

02:20 On the oropharynx exam, and because of the chronic purulent sputum, you might notice halitosis.

02:26 Now, in more advanced disease, you can start to see physical evidence of chronic hypoxia.

02:32 This can manifest as cyanosis, which is that bluish tint to the skin.

02:37 And while it's much less common, chronic cyanosis can lead to digital clubbing, technically called hypertrophic pulmonary osteoarthropathy.

02:44 And you may see a flushed reddened complexion or plethora from the body making extra red blood cells to compensate for the chronic hypoxia.

02:54 And if that right heart failure has developed, you'll likely find evidence of that too, including peripheral edema, jugular venous distension, and an enlarged liver or hepatomegaly.

03:07 But really, the definitive diagnosis comes from imaging.

03:11 We often start with a chest X-ray.

03:13 If you look at this chest radiograph, you can see it's not normal.

03:16 You may be able to see some thickening of the airway walls and some airway dilation.

03:21 But the X-ray can be subtle.

03:23 So the gold standard is a high-resolution CT scan or HRCT.

03:28 This is much more sensitive and specific than your standard issue plain film chest X-ray.

03:33 The key finding we're looking for is airway dilation.

03:36 And these images show some classic examples.

03:39 Look at image A.

03:40 The arrow is pointing to what radiologists call cylindrical bronchiectasis.

03:45 The airway is dilated but still looks like a tube.

03:48 You can clearly see the parallel tram lines that represent the thickened airway walls.

03:53 Now look at B.

03:55 This is called varicose bronchiectasis.

03:57 You can see the airway wall is more irregular and beaded, kind of like a varicose vein.

04:02 And finally, image C shows the most severe form, saccular bronchiectasis.

04:08 Here the airways are destroyed and look like a cluster of cysts or sacs.

04:13 This is where mucus and bacteria get trapped, driving that vicious cycle.

04:18 And to bring this all full circle, I want you to look at this last image here.

04:22 We just saw what severe cystic bronchiectasis looks like on a CT scan.

04:27 Well, this is what it looks like in real life.

04:30 This is a gross specimen of a resected lung from a patient with a primary diagnosis of cystic fibrosis.

04:38 For many years, the patient's underlying CF led to many rounds of infection and neutrophilic damage that eventually culminated in bronchiectasis.

04:47 You can see how the bronchi are massively dilated all the way out to the periphery.

04:53 And all that yellow material, that is the thick pus filling those airspaces that we've been talking about.

04:59 Okay, so even once we've confirmed the diagnosis of bronchiectasis, the work isn't quite done.

05:05 It is important to try and figure out the cause.

05:09 To do that, we have a number of diagnostic tests.

05:11 I will routinely do a sputum analysis to see what bugs are growing in there.

05:16 This is critical for guiding antibiotic therapy.

05:19 Then we test for those specific causes I showed you in the long table during our discussion of etiology.

05:25 We can do things such as a sweat chloride test for cystic fibrosis.

05:29 We can also check an alpha-1 antitrypsin or AAT level for AAT deficiency.

05:35 We can look for an elevated eosinophil count and IgE levels for a condition called allergic bronchopulmonary aspergillosis.

05:43 And we can order autoimmune markers if we suspect a connective tissue disease.

05:49 With diagnosis covered, let's move on to management.

05:52 Okay, so when we approach management, it's really important to remember that we can't reverse the permanent damage to the airways.

06:00 But the goal is to break that vicious cycle we talked about and improve the patient's quality of life.

06:07 The approach has several key parts.

06:10 First and foremost, if we can find an underlying cause, we treat that.

06:14 Next, a huge part of daily management is all about getting that thick mucus out.

06:19 We need to improve mucus clearance.

06:22 We do this with things like chest physiotherapy, deep breathing exercises, and humidification to keep the mucus hydrated and less viscous.

06:30 To manage the airflow obstruction, we can use medications like bronchodilators to open the airways, and sometimes corticosteroids to help with the inflammation.

06:39 Overall, the most important step is to control any infections.

06:43 This means using antibiotics, which can be empiric or ideally guided by those sputum cultures we talked about.

06:49 Preventive care is also key here, so we strongly encourage vaccinations and smoking cessation.

06:55 Finally, for very specific and severe cases, there are surgical options.

07:00 This isn't for most patients, but can include bronchial artery embolization in the cases where there is severe bleeding, a lung resection if the disease is very localized, or in the most end-stage cases, lung transplantation.

07:13 So that's a very thorough discussion about bronchiectasis, from the underlying causes and pathophysiology, all the way through diagnosis and treatment.

07:23 I hope this was helpful, and thanks for watching.