Bronchiectasis for surgery

1. Bronchiectasis
Yonas Ademe, MD, FCS-ECSA
Assistant Professor of Surgery
Dec, 2021
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2. Introduction
• It is defined as a pathologic and permanent
dilation of bronchi
• This condition may be localized to certain
bronchial segments or it may be diffuse
throughout the bronchial tree, typically
affecting the medium-sized airways
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3. Etiology
• Congenital
– Congenital causes tend to produce a diffuse pattern of bronchial
involvement
– Cystic fibrosis, primary ciliary dyskinesia, and immunoglobulin
deficiencies (e.g., selective IgA deficiency)
• Acquired
– Infectious
• TB remains an important worldwide cause of bronchiectasis
• MAC
• Adenoviruses and influenza viruses are the predominant childhood
viral infections associated with the development of bronchiectasis
– Inflammatory
• Inhalation of toxic gases such as ammonia
• Allergic bronchopulmonary aspergillosis
• Sjögren's syndrome
• Alpha1-antitrypsin deficiency
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4. Pathogenesis
• The common pathway shared by all of the causes of
bronchiectasis is impairment of airway defenses or deficits in
immunologic mechanisms that permit bacterial colonization
and establishment of chronic infection leading to airway
damage
• The dilated airways are usually filled with thick purulent
material; more distal airways are often occluded by
secretions or obliterated by fibrous tissue
• The vascularity of affected bronchial walls increases,
bronchial arteries become hypertrophied, and abnormal
anastomoses form between the bronchial and pulmonary
arterial circulation
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5. Cont.
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6. Classification
• Based on pathologic morphology:
– Saccular (cystic): peripheral balloon-type bronchial
dilation
• The most common type after bronchial obstruction or
infection
– Cylindrical: uniformly dilated bronchi
• A feature of TB
– Varicose: an irregular or beaded pattern of dilated
bronchi (a mixture of the above two)
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7. Cont.
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8. Cont.
• Based on degree of lung involvement
– Focal
• Commonly involves the left lower lobe followed by
lingula and right middle lobe
• Bronchial obstruction
• Infection
– Diffuse
• Congenital
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9. Clinical Manifestations
• The clinical course is characterized by progressive
symptoms and respiratory impairment
– Acute exacerbations may be triggered by viral or bacterial
pathogens
• A daily persistent cough and purulent sputum production
are the typical symptoms of bronchiectasis
– The quantity of daily sputum production (10 mL to >150 mL)
tends to correlate with disease extent and severity
• Increasing resting and exertional dyspnea are the result of
progressive airway obstruction
• Hemoptysis
– May become more frequent as the disease progresses
– Attributable to chronically inflamed, friable airway mucosa
• In more advanced stages, massive bleeding may result from erosions
of the hypertrophied bronchial arteries
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10. Cont.
• Often, patients with bronchiectasis may
appear asymptomatic or have a dry
nonproductive cough ("dry bronchiectasis")
– These patients are prone to have involvement of
the upper lobes
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11. Diagnosis
• CT scanning
– Current gold standard of diagnosis
– Both mild and severe forms of bronchiectasis are
readily demonstrated
• CXR
– Although less sensitive, may reveal characteristic
signs of bronchiectasis such as:
• Lung hyperinflation
• Bronchiectatic cysts
• Dilated, thick-walled bronchi forming tram track–like
patterns radiating from the lung hila
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12. Cont.
• Bronchoscopy
– Diagnosis
• Foreign body, tumor, sputum culture
– Treatment
• Removal of excessive sputum and foreign body
• Spirometry
– To determine the severity of airway obstruction
and thereby evaluate the course of disease
• Sputum culture
• Sputum AFB
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13. Treatment
• Standard therapy
– Optimization of secretion clearance from the
tracheobronchial tree
• Chest physiotherapy based on vibration, percussion,
and postural drainage is widely accepted as the basis for
therapy
• Expectorant and mucolytics
– Use of bronchodilators to reverse any airflow
limitation
– Correction of reversible underlying causes
whenever possible
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14. Cont.
• Cont.
– Acute exacerbations should be treated with
courses of broad-spectrum antibiotics tailored to
culture and sensitivity profiles
• Usually, a 2- to 3-week course of IV antibiotics, followed
by an oral regimen, will result in a longer-lasting
remission
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15. Cont.
• Surgery
– Resection of a localized bronchiectatic segment or
lobe
• Because resection may not always be clinically practical,
bronchial artery embolization is an alternative
• Conserve as much normal parenchyma as possible
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16. Cont.
• Cont.
– Indications
• Patients with refractory symptoms while on maximal
medical therapy
• Patients with massive hemoptysis secondary to
hypertrophied bronchial arteries
• Underlying etiology
– Contraindications
• Multifocal disease
• Any uncorrectable predisposing factor (e.g., ciliary
dyskinesia)
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17. Cont.
• Cont.
– Pre-op
• Control infection
– As a rule, neither pre-op pulmonary function measurement nor
surgical intervention should be undertaken during an infectious
episode
» Sensitivity-oriented antibiotics should be used immediately
for 7 to 10 days
• Control sputum output
– Postural drainage and chest physiotherapy should be ordered for
10 days
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18. Cont.
• Cont.
– Patients with end-stage lung disease from
bronchiectasis may be potential candidates for a
bilateral lung transplant
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19. The end!
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