00:00
How do you made the diagnosis?
Well, a chest x-ray is a very
insensitive test for bronchiectasis.
00:05
Only half of patients
with bronchiectasis
will have an
abnormal chest x-ray.
00:09
This example here
of a chest x-ray
shows really quite
severe bronchiectasis.
00:14
However, that's unusual.
00:15
Most patients of bronchiectasis
will not have an abnormal x-ray,
or anywhere as nearer
as abnormal x-ray as this one.
00:24
And so the diagnosis
requires a CT scan,
which I'll discuss in a second.
00:28
The second thing you need to do
after confirm the diagnosis,
you need to assess the severity.
00:32
And that's done clinically
by turning, by asking the patient
how many infections
a year they get?
And how much sputum
they produce each day?
Clearly, patients who are having
six infections a year
have more severe disease
than those who are having
only one infection a year.
00:45
And if somebody is
producing half a cup of <inaudible>
of phlegm each day,
that marks them out as somebody
with quite marked disease
compared to those who
only produce a teaspoon for
or only intermittent amounts
of sputum.
00:56
Lung function is very important
because as I've mentioned,
obstructive lung disease
is the modality
that causes death and respiratory
failure in this patients.
01:03
So, you need to do spirometry.
01:06
And it's known that
if you have somebody
who has colonized
their pseudomonas
then they will have
more severe disease
so sputum culture
identify those patients.
01:13
And you used to test
to identify the potential cause
of bronchiectasis as well.
01:19
Now, the CT appearances
are dilated bronchi.
01:23
The bronchus is bigger
than the accompanying vessel.
01:25
That's the basic
underlying principle
of diagnosing bronchiectasis
in the CT scan.
01:30
The other thing
about the bronchi
is that the bronchi
should normally taper
as they go out
to the periphery,
in bronchiectasis
they stayed non-tapering.
01:37
And you may get the consequences
of airway obstruction
visible on the CT scan
with air trapping
on the <inaudible>
And when patients have really
active disease bronchiectasis
This is all goo, and gunk
present in the small airways
and that shows up as what we called
tree in bud changes.
01:53
And the cause of bronchiectasis is
somewhat indicated by the CT scan.
01:57
So most cases of bronchiectasis
are both lower lobes,
but some cases
cystic fibrosis,
allergic bronchopulmonary
aspergillosis
tends to be more upper lobe.
02:08
So how do you identify
the potential cause? The history.
02:11
Somebody has rheumatoid arthritis
and bronchiectasis
there is likely
to the rheumatoid arthritis
that's causing
the bronchiectasis.
02:17
If you ask the patient,
they said "Yes I had these
problems my cough and phlegm
ever since a bad
whooping cough as a child."
I would suggest that there
was a childhood infection
that caused the bronchiectasis.
02:28
Fertility problems
up airways disease
indicates patients
who may have cystic fibrosis,
or ciliary dyskinesia.
02:34
And this CT scan here, what you see
is a very focal area bronchiectasis.
02:38
Other tests you might want to do
IgG levels that's very simple
to measure in the blood,
and will identify patients
who have IgG deficiency
and that's important
because they can be treated
with IgG replacement therapy.
02:48
There are
various blood tests for
allergic bronchopulmonary
aspergillosis
which I will discuss later.
02:53
And then if you really do think
somebody has cystic fibrosis,
you need to do the test for that
again, which I'll discuss later.
02:59
And primary ciliary dyskinesia
there are some
very specialized tests
on the particular centers,
for cilia function
that you might consider doing.
03:07
How do we treat bronchiectasis?
The fundamental treatment
is to try and prevent
the recurrent infections,
and minimize
chronic phlegm production.
03:17
And we do that
by advising the patient,
teaching the patient
how to clear their chest of phlegm.
03:22
So, they do
regular physiotherapy.
03:23
And that will reduce the
effective exacerbation frequency.
03:28
You should treat the cause clearly.
03:30
So, if somebody's IgG deficient,
you give them
intravenous immunoglobulin
replacement therapy
and that has a very
beneficial effect on their health.
03:37
You need to know what
the bugs are present
in that patient's lung,
so that you can guide,
that will help guide
your antibiotic therapy.
03:44
So sputum culture is important.
03:45
And when patients present
with infective exacerbations,
we will treat them
with antibiotics.
03:50
And unlike normal
acute bronchitis,
they will need treatment
for 10 to 14 days.
03:55
That will ensure
that the infective exacerbations
are less likely to recur quickly.
04:00
Many patients
bronchiectasis get treated
for four or five days
of antibiotics.
04:03
And then the affection comes back
within three or four weeks.
04:06
Whereas, if they given 14 days
worth of antibiotics the first time,
actually, they'll stay clear of
infection, for several months.
04:12
And the antibiotics are dictated
by which pathogen
Haemophilus influenzae,
Moraxalla, pneumococcus.
04:18
We normally treat amoxicillin,
coamoxiclav, doxycycline.
04:21
When patients develop
pseudomonas colonization
then we are limited in which
antibodies we can give the patient,
and rarely the only oral one
that's beneficial is ciprofloxacin.
04:31
And they frequently need
intravenous antibiotics.
04:34
If somebody is getting
recurrent exacerbations,
then prophylactic antibiotics
might be necessary
and they can be given as
tablets or nebulized form.
04:43
And because of the
airways obstructions
associated with bronchiectasis
you may need to treat the patient
with inhalers, etc.
04:50
As you would normally,
for somebody with COPD or asthma.