BRONCHIACTESIS COULD BE CONGENITAL OR ACQUIRED
CONGENITAL BONCHIACTESIS RESULTS FROM DEVELOPMENTAL ARREST OF THE BRONCHIAL TREE AFFECTING INFANTS & CHILDREN.
BRONCHIACTESIS COULD BE OF FOLLOWING TYPES:
* - CYLINDRICAL BRONCHIACTESIS
* - CYSTIC OR SACCULAR BRONCHIACTESIS
* - VARICOSE BRONCHIACTESIS
Medical Care: The goals of therapy are to improve symptoms, to reduce complications, to control exacerbations, and to reduce morbidity and mortality. Early recognition is essential in bronchiectasis and associated conditions. Additionally, management of underlying conditions, which may include the use of intravenous immunoglobulin or intravenous alpha1-antitrypsin therapy, is essential to the overall treatment.
Antibiotics and chest physiotherapy are the mainstay modalities. Other modalities (beyond those for specific associated conditions) may include bronchodilators, corticosteroid therapy, dietary supplementation, and oxygen or surgical therapies. Admitting patients with severe exacerbations of bronchiectasis to the hospital and treating them with intravenous antibiotics, bronchodilators, aggressive physiotherapy, and supplemental nutrition is not uncommon.
" General therapy
o Patients should stop smoking.
o Patients should avoid second-hand smoke.
o Patients should have adequate nutritional intake with supplementation, if necessary.
o Immunizations for influenza and pneumococcal pneumonia are recommended.
o Immunizations for measles, rubeola, and pertussis should be confirmed.
o Oxygen therapy is reserved for patients who are hypoxemic with severe disease and end-stage complications, such as cor pulmonale.
o Patients with CF should be cared for at specialized CF treatment centers that address all aspects of the disease, including nutritional and psychologic aspects.
" Antibiotics
o Antibiotics have been the mainstay of treatment for more than 40 years.
o Oral, parenteral, and aerosolized antibiotics are used, depending on the clinical situation.
o In acute exacerbation, broad-spectrum antibacterial agents are preferred.
o Acceptable choices for the outpatient who is mild to moderately ill include amoxicillin; tetracycline; trimethoprim-sulfamethoxazole; a newer macrolide, such as azithromycin; a second-generation cephalosporin; or one of the quinolones. In general, the duration is 7-10 days.
o For patients with moderate-to-severe symptoms, parenteral antibiotics, such as an aminoglycoside (gentamicin, tobramycin) and an antipseudomonal synthetic penicillin, a third-generation cephalosporin, or a fluoroquinolone, may be indicated.
o Patients with bronchiectasis from CF are often infected with mucoid Pseudomonas species, and as such, tobramycin is often the drug of choice for acute exacerbation.
o Infection with MAC provides special treatment challenges. For the treatment of MAC in the setting of bronchiectasis, the American Thoracic Society recommends a 3- to 4-drug treatment regimen with clarithromycin, rifampin, ethambutol, and possibly streptomycin that is continued until the patient's culture results are negative for 1 year. The typical duration of therapy may be 18-24 months.
o Additionally, some patients with chronic bronchial infections may need regular antibiotic treatment to control the infectious process. Some clinicians prefer to prescribe antibiotics on a regular basis or for a set number of weeks each month. The oral antibiotics of choice are the same as those mentioned previously. Potential regimens include daily antibiotics for 7-14 days of each month, alternating antibiotics for 7-10 days with antibiotic-free periods of 7-10 days, or a long-term daily dose of antibiotics. For patients with severe CF and bronchiectasis, intermittent courses of intravenous antibiotics are sometimes used.
o Recently, the nebulized route of antibiotic administration has received more attention because it is capable of delivering relatively high concentrations of drugs locally with relatively few systemic adverse effects. Currently, inhaled tobramycin is used widely in the treatment of patients with CF, and recent studies suggest efficacy in patients with non-CF bronchiectasis and chronic infection with P aeruginosa.
" Bronchial hygiene
o With its tenacious sputum and defects in clearance of mucous, good bronchial hygiene is paramount in the treatment of bronchiectasis. Postural drainage with percussion and vibration is used to loosen and mobilize secretions. Other devices available to assist with mucous clearance include flutter devices, intrapulmonic percussive ventilation devices, and incentive spirometry. However, consistent benefits from these techniques are lacking and vary with patient motivation and knowledge. A new device called the Vest system is a pneumatic compression device worn by the patient periodically throughout the day and is relatively technique independent.
o Nebulization with sodium chloride solutions and mucolytics, such as acetylcysteine, are often tried. While some patients seem to benefit from these techniques, a universal benefit does not exist. However, maintaining adequate general hydration, which may improve the viscidity of secretions, is important.
o Aerosolized recombinant DNase, which breaks down by-product DNA from neutrophils, has been shown to benefit patients with CF. However, improvement has not been shown in patients with bronchiectasis from other causes.
" Bronchodilators
o Bronchodilators may help some patients with bronchiectasis, presumably reversing bronchospasm associated with airway hyperreactivity and improving mucociliary clearance.
o Treatment with inhaled bronchodilators may be appropriate, although good, large, randomized clinical trials looking at their use in bronchiectasis have not been performed.
" Anti-inflammatory medication
o The rationale is to modify the inflammatory response caused by the microorganisms associated with bronchiectasis and subsequently reduce the amount of tissue damage. Inhaled corticosteroids, oral corticosteroids, and nonsteroidal anti-inflammatory agents have all been examined. Although evidence tends to support some benefit from the use of these agents, findings are not universally definitive. One recent study did find inhaled corticosteroids beneficial to patients with bronchiectasis when compared with a placebo, particularly those with associated P aeruginosa infections.
o A practical approach is to use tapering oral corticosteroids and antibiotics in the acute exacerbation and to consider inhaled corticosteroids for daily use in patients with significant obstructive physiology on pulmonary function testing and evidence of reversibility suggesting airway hyperreactivity.
Surgical Care:
" Surgery is an important adjunct to therapy in some patients with advanced or complicated disease. Surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality at any age. In general, surgery should be reserved for patients who have focal disease that is poorly controlled by antibiotics. The involved bronchiectatic sites should be completely resected for optimal symptom control. Other indications for surgical intervention may include the following:
o Reduction of acute infective episodes
o Reduction of excessive sputum production
o Massive hemoptysis (Alternatively, bronchial artery embolization may be attempted for the control of hemoptysis.)
o Foreign body or tumor removal
o Consideration in the treatment of MAC or Aspergillus species infections
" Complications of surgical intervention include empyema, hemorrhage, prolonged air leak, and persistent atelectasis.
" Patient selection plays an important role in perioperative mortality, which may be as low as 1% in the surgical treatment of segmental or even multisegmental bronchiectasis.
" Single or double lung transplantation has been used as treatment of severe bronchiectasis, predominantly when related to CF. In general, consider patients with CF and bronchiectasis for lung transplantation when forced expiratory volume in 1 second (FEV1) falls below 30% of the predicted value. Female patients and younger patients may need to be considered even sooner.
DRUG TREATMENT :
1. ANTIBIOTICS
2. INHALED BETA AGONISTS LIKE ALBUTEROL
3. EXPECTORANTS