Approach to bronchiectasis Kyle Perrin. Overview Risk factors Diagnosis –History –Examination...
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Transcript of Approach to bronchiectasis Kyle Perrin. Overview Risk factors Diagnosis –History –Examination...
![Page 1: Approach to bronchiectasis Kyle Perrin. Overview Risk factors Diagnosis –History –Examination –Investigations Approach to management.](https://reader034.fdocuments.in/reader034/viewer/2022051316/56649dd95503460f94ace2c1/html5/thumbnails/1.jpg)
Approach to bronchiectasis
Kyle Perrin
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Overview
• Risk factors
• Diagnosis– History– Examination– Investigations
• Approach to management
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What is bronchiectasis?
• Bronchiectasis is a disease defined by localized, irreversible dilation of part of the bronchial tree caused by destruction of the muscle and elastic tissue
• It is classified as an obstructive lung disease
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Pathogenesis
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Prevalence
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Prevalence
• An overall incidence of 3.7 per 100 000 under 15 years– NZ European1.5– Maori children 4.8 – Pacific children 17.8
• 7 times higher than Finland
• The median age at diagnosis was 5.2 years; the majority had symptoms for more than two years
• Mean FEV1 of 77% predicted
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Risk factors
• Severe or recurrent chest infections– Whooping cough
• Foreign body
• Congenital or acquired immune deficiency
• Congenital problems of cilia function
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History
• Previous– Frequent childhood infections?– Foreign body?– Other infections? (sinus, skin etc)
• Current– Recurrent chest infections– Chronic production of purulent sputum– Haemoptysis– Wheeze– Breathlessness
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Examination
• Sometimes finger clubbing
• Thick/coarse crackles usually in the lung bases
• Occasional wheeze
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Investigations
• Spirometry– Obstructive, but may be normal
• CXR and CT scan
• Blood tests (immune deficiency?)
• Sputum test
• Test for CF?
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Goals of treatment
• The treatment aims in adult care are to – Control symptoms– Enhance quality of life– Reduce exacerbations– Maintain pulmonary function
• There is clear evidence that patients with bronchiectasis who have more frequent exacerbations have worse quality of life
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Treatment
1. Treatment of the specific underlying cause
2. Education
3. Airway clearance– Physiotherapy and exercise
– Mucolytic and hyperosmolar therapies
4. Airway drug therapy– Bronchodilation
– Anti-inflammatory
5. Antibiotic therapy
6. Surgical management
7. Management of complications
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Airway clearance
• All patients with a productive cough should be taught airway clearance by a physiotherapist
– Active cycle of breathing techniques– Postural drainage– Positive expiratory pressure (PEP)– Acapella
• Duration?• Frequency?
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Inhaled drug therapy
• Mucolytics– Pulmozyme (not effective)– Mannitol
• Bronchodilators?
• Inhaled corticosteroids?
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Long term antibiotics
• Nebulised tobramycin
• Oral azithromycin
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Exacerbations
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Need for admission
• Unable to cope at home.• Development of cyanosis or confusion.• Breathlessness with respiratory rate ≥25/min.• Circulatory failure.• Respiratory failure.• Temperature ≥38°C.• Unable to take oral therapy.
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Antibiotics for exacerbations
• If possible guided by previous sputum results
• Common bacteria include– H influenzae, M catarrhalis, S aureus and S pneumoniae– Some patients become colonised by pseudomonas
• If no sputum available– Augmentin is a reasonable first choice– Send a sputum and modify if necessary
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Other treatments
• Vaccinations
• Pulmonary rehab
• Surgery
• Lung transplant
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A case
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Hannah age 16
• Asthma and eczema since age 3
• Whooping cough infection age 6
• Last 3-4 years had recurrent chest infection and always coughs up green sputum
• CT scan confirmed bronchiectasis
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Current medications
• Seretide 2 puffs bd• Lotatadine 10mg od• Montelucast 10mg od• Flixonase 2 puffs bd• Theophyline 250mg od
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Social history
• Lives in a private rental house with mum, aunty and 5 other kids– No insulation– Damp– A bit of mold around
• Mum works as a cleaner for minimum wage
• Cant afford to heat the house very often
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Why is this important?
• Bronchiectasis is a disease of poverty
• Like rheumatic fever, it is a “ticking time bomb”
• It often starts in childhood but the worst effects are seen in adulthood
– Frequent hospital admissions– Poor quality of life– Early death
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Priorities…
• The current approach to treatment of existing bronchiectasis patients has not changed a great deal in recent years
• There may be new developments in antibiotic therapy and mechanisms of sputum clearance
• We must take steps to reduce the incidence of this condition by addressing the social determinants of health particularly among Maori and Pacifica