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      Anonymous
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      Bronchiectasis is defined as abnormal, irreversible or permanent dilation of the airways (bronchial tubes) due to various causes, which in turn predisposes to infection and inflammation.

      Anatomy of Airways
      Normally the air we breathe travels down the windpipe or trachea and through a series of tubes to reach the lungs. The trachea and the bronchial tree make up the anatomical and functional segment of the respiratory system. The tubes that branch off the windpipe are the bronchi; they further divide into bronchioles which are a bit smaller. The bronchioles end in even smaller tubes called alveoli. Normally, all these tubes are fairly small ranging from up to 2 cm in diameter at the windpipe, all the way down to just a few millimetres for the alveoli.

      Pathogenesis of Bronchiectasis
      The dilation and loss of elasticity of the airways makes it harder to bring out the normal secretions (mucus, phlegm) from the lower respiratory tract.
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      As a result these sticky secretions collect in the airways and form an ideal breeding ground for various microorganisms.
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      Overgrowth and infection by microorganisms leads to further inflammation and injury and more dilation with worsening of the condition

      Thus a vicious cycle is created with dilation leading to infection which causes further dilation

      How Common is Bronchiectasis?
      The overall prevalence of bronchiectasis was measured at 139 cases per 100,000 U.S. adults. The prevalence was greater in women than men, at 180 per 100,000 and 95 per 100,000, respectively. Prevalence also was found to rise with age, increasing from 7 per 100,000 in patients aged 18-34 to 812 per 100,000 in patients older than 75 years.

      In UK, in 2012, 379 females and 281 males for every 100,000 were found to have bronchiectasis.

      Causes of Bronchiectasis
      • Post-infectious – following necrotising bacterial, viral or fungal pneumonia, tuberculosis, whooping cough in childhood – leading to lung damage
      • Congenital diseases – cystic fibrosis, Kartagener’s syndrome, pulmonary sequestration – cause an inability to clear secretions
      • Bronchial obstruction – foreign body, tumor – accumulation of secretions
      • Immune system problem – HIV, inherited immunodeficiency
      • Pulmonary embolism – clot in the pulmonary artery or its branches
      • Chronic inflammatory conditions – allergic bronchopulmonary aspergillosis, rheumatoid arthritis, chronic graft versus host disease
      • Rare causes – Alpha-1 antitrypsin deficiency, yellow nail syndrome,
      • Idiopathic (about 40 percent) – No cause can be found

      Signs and Symptoms of Bronchiectasis
      • Productive cough daily, with lot of phlegm or sputum despite taking antibiotics
      • Associated fever, chills, night sweats and tiredness
      • Breathless on exertion and a reduced exercise tolerance
      • Coughing up blood (hemoptysis)
      • Unintentional weight loss
      • Frequent chest infections, particularly with Pseudomonas aeruginosa.
      • Chronic sinusitis
      • Recurrent chest or ear infections in children with congenital diseases (see above)
      • Poorly controlled asthma in childhood

      Diagnosis of Bronchiectasis
      Clinical picture of chronic cough and production of copious amounts of foul smelling sputum

      Routine baseline blood tests

      Bronchiectasis is diagnosed by imaging, often with a CT of the chest (CAT scan). The CT scan will demonstrate the location and severity of the bronchiectasis, and may identify any possible cause.

      Sputum may be sent up for culture to identify possible causes of infection and appropriate treatment

      Lung function tests to determine residual lung function

      A bronchoscopy procedure that allows the doctor to directly visualize the main airways of the lung using a very fine flexible tube, especially if a mechanical obstruction is suspected.

      Treatment of Bronchiectasis
      Although bronchiectasis is an irreversible condition, the symptoms and infections can be controlled. The main aim of therapy is

      1. Clearing the airway of secretions
      2. Treatment of infections

      Clearing Airways
      • Airways clearance techniques help to drain off excess mucus from the airways. This usually involves seeing a physiotherapist who is trained in treating lung conditions (termed a respiratory physiotherapist or ‘chest physio)’. The patient learns to use postural drainage techniques where the patient is taught to assume certain positions to drain the affected site, along with special breathing techniques and “chest clapping” to bring out the secretions. Although these require effort and perseverance, they are very effective.

      • Nebulized saline makes the sputum thinner and easier to bring out.

      • Similarly nebulized bronchodilators help to drain the excess mucus

      Management of Infections
      • Long-term prophylactic macrolide antibiotics such as azithromycin can help to prevent infections and reduce down inflammation in the lungs. Occasionally continuous therapy may be necessary in case of recurrent severe infections.

      • Acute exacerbations are treated appropriately

      • Usually antibiotics are prescribed in higher doses and for at least 10 days, compared to normal courses for chest infection. Occasionally a combination of two antibiotics will be considered.

      Treatment of any underlying condition – such as cystic fibrosis or tuberculosis

      Miscellaneous measures
      • Cessation of smoking
      • Avoiding exposure to pollution and other irritants
      • Regular exercise will also help in clearance of secretions
      • Periodic monitoring of lung function with spirometry and referral to specialist if there is any decline in lung function.
      • Being upto date with vaccinations such as the annual flu jab and pneumococcal vaccine

      Surgery
      This may be considered if the bronchiectasis is localised to one area of the lung, and if this area could be removed without impairing breathing. Surgery may not be a suitable option for many patients.

      Prognosis of Bronchiectasis
      The outcome is variable depending on the cause and severity.

      For most people (with no underlying disease), the outlook is favourable, and symptoms will not become too severe. Effective physiotherapy, and appropriate use of antibiotics, when an infection occurs, ensures optimal health and quality of life in these patients.

      Unfortunately, in some people, the condition becomes gradually worse, over time, with progression of the disease and involvement of more airways.

      For those who have developed bronchiectasis as part of another condition, the outcome largely depends on how the original disease is managed and effectively treated.

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