Daily Archive 25.12.2019

Bronchiectatic disease

Bronchiectasis is an irreversible expansion of the bronchi caused by destructive changes in the bronchial wall. The main manifestations of bronchiectasis are cough with purulent sputum, hemoptysis, relapse of bronchopulmonary infection.  

Etiology and pathogenesis of bronchiectasis

The leading role in the development of bronchiectasis belongs to bronchopulmonary infections – bacterial (Staphylococcus aureus, Klebsiella, Pfeiffer’s bacillus, Mycobacterium tuberculosis), Viral (adenovirus, influenza, measles), fungal, mycoplasma. Of great importance is also a violation of the clearance (cleansing) of the bronchial tree as a result of bronchial obstruction or impaired mucociliary transport. Bronchial obstruction is observed with aspiration of foreign bodies, neoplasms of the respiratory tract (laryngeal papillomatosis, bronchogenic lung cancer), an increase in bronchopulmonary lymph nodes (with sarcoidosis, tuberculosis, histoplasmosis), as well as chronic obstructive pulmonary diseases (bronchial asthma, chronic bronchitis). Violation of mucociliary transport can be caused by damage to the cilia (fixed cilia syndrome, of which Kartagener syndrome is a variation – the reverse location of organs, sinusitis, bronchiectasis) or a change in the properties of bronchial secretion (with cystic fibrosis, ai-antitrypsin deficiency). Bronchiectasis occurs in patients with immunodeficiency (congenital agammaglobulinemia, acquired deficiency of class A and G immunoglobulins), congenital anatomical defects of the tracheobronchial tree (tracheobronchomegaly, tracheoesophageal fistula), blood (pulmonary aneurysm) and lymphatic vessels. Recurrent aspiration pneumonia in chronic alcoholism, neurological disorders, inhalation of irritating substances (nitrogen oxides, hydrocarbons, silicates), as well as amyloidosis of the trachea and bronchi can cause the disease.    

Mostly medium-sized bronchi expand, less often – distal bronchi and bronchioles. Necrosis with subsequent partial replacement of fibrous tissue undergoes all layers of the bronchi. Depending on the degree of expansion of the bronchi, cylindrical, varicose and saccular bronchiectases are distinguished . Cylindrical bronchiectasis is characterized by moderate (sometimes reversible) expansion of the bronchi, which does not lead to significant deformation or impaired division of the bronchial tree. With varicose bronchiectasis (resembling varicose veins on bronchograms), moderate dilatation and deformation of the bronchi and a decrease in the number of divisions of the bronchial tree are observed. The most severe form is saccular bronchiectasis, which initially affects mainly the proximal (central) bronchi, and subsequently leads to the destruction and fibrosis of the distal bronchi and the formation of pus-filled “bags” on the periphery of the lung. Typically, bronchiectasis develops in the posterior basal segments of the lower lobes of both lungs and the middle lobe of the right lung. The occurrence of bronchiectasis in the upper parts of the lungs is possible with tuberculosis or an abscess. 

Clinic of bronchiectatic disease

The main manifestations are persistent cough with the separation of a large amount of purulent sputum, hemoptysis, repeated pneumonia, which are usually localized in the same segment or lobe of the lung. Coughing may intensify when the patient is lying down or when the body position changes, which is associated with leakage of secretion into large bronchi. Sometimes (especially after a course of antibiotic therapy) a cough becomes unproductive, sputum becomes a mucous membrane. In the period of exacerbation of sputum, as a rule, two to three layers. An admixture of blood is often found in sputum, which is caused by destructive processes in the bronchi and destruction of the walls of blood vessels. Sometimes pulmonary hemorrhages become the leading manifestation of the disease. With frequent exacerbations of the disease, anorexia, weight loss, fatigue, weakness, anemia are observed. A characteristic symptom of bronchiectasis is persistent voiced, small-bubbly moist rales over the affected area of ​​the lung. The auscultatory picture above the remaining parts of the lungs may reflect the presence of concomitant chronic bronchitis: breathing with prolonged expiration, dry rales. During an exacerbation of the disease, percussion is determined by a mildly expressed dullness of sound in the area of ​​inflammation, more often – a boxed shade of percussion sound in connection with the development of emphysema. Often there are drum fingers. Chronic obstructive bronchitis and pulmonary emphysema, which determine the progression of respiratory failure, should be considered complications; pulmonary heart; metastatic abscesses of the brain; amyloidosis; pulmonary hemorrhage.