Bronchiectasis

Classification according to ICD-10
J47	Bronchiectasis
Q33.4	Congenital bronchiectasis
A15 and A16	Respiratory tuberculosis - tuberculous bronchiectasis
ICD-10 online (WHO version 2019)

In medicine, bronchiectasis is the term used to describe irreversible sack-shaped or cylindrical expansions or widenings of the medium-sized airways ( bronchi ). This condition is also called bronchiectasis . These expansions are accompanied by a chronic necrotic festering bacterial infection of the bronchial wall.

etiology

There is a congenital and an acquired form of bronchiectasis.

Congenital bronchiectasis can occur in only one segment of the lung or one lobe of the lung. Unlimited incidence is also observed, mostly in connection with other defects (for example in Kartagener's syndrome , cystic fibrosis or necrotizing and festering pneumonia).
Bronchiectasis is acquired through early childhood damage, infectious diseases ( measles , whooping cough ), allergic bronchopulmonary aspergillosis , immunoglobulin deficiency , α-1-antitrypsin deficiency, ciliary dysfunction, cystic fibrosis , tracheoesophageal fistulas, foreign body aspiration or chronic inflammatory processes (for example, chronic bronchitis ).

morphology

The most noticeable changes occur in the lower lobes of the lungs. The bronchial extensions are

cylindrical
spindle-shaped
sack-shaped

The lumina are often filled with pus.

A light microscope shows an intensive accumulation of neutrophils, lymphocytes and mononuclear cells in the bronchial wall. Furthermore, extensive areas of ulceration can be seen in the bronchial mucosa; squamous cell metaplasia can also occur in the non-ulcer ( epithelium ). There is also peribronchial fibrosis.

clinic

The main symptoms are cough and large-volume sputum (called "mouthful expectoration"), which smells sweet, bland or putrid and typically settles in three layers in the glass ("three-layer sputum"): foamy top layer, slimy middle layer and tough sediment with pus . Drumstick fingers are typical .

Complications

When complications are pneumonia , fungal known settlements in the lungs and bacterial metastases in other organs. Coughing up blood ( hemoptysis ) can also occur. Cor pulmonale can develop in the long term . A vicious circle can also occur: as soon as the bronchi are widened, they tend to hold back part of the secretion, which then serves as a nidus for ongoing infection. If an extension is perforated, this may result in empyema of the chest lead.

diagnosis

Very pronounced bronchiectasis on both sides on computed tomography. Right (left in the picture) severe superinfection with accompanying pleural effusion .

The disease is diagnosed by its appearance and other diagnostic measures

Lung function : mostly mixed restrictive-obstructive ventilation disorder and sometimes already respiratory insufficiency .
Chest x-ray : first indications result from peribronchial stripes and cystic cavities with or without a mirror.
HR- CT : cystic lightening, expansion of the bronchial lumina; safest and most reliable bronchiectasis detection
Examination for allergic bronchopulmonary aspergillosis ( ABPA ), for this purpose an examination for sensitization and a determination of the total IgE , which is then almost always well above 500 ng / ml.
Determination of the differential blood count of IgA and IgM, of exhaled NO
Three-layer sputum : The sputum is often frothy-serous-purulent, Haemophilus influenzae , Streptococcus pneumoniae and Staphylococcus aureus are often found in the culture .
Bronchoscopy : to diagnose pathogens ( TBC and mycobacteria ) and to diagnose possible bronchial stenoses.
Lung scintigraphy : Examination of the lung perfusion / lung ventilation as a possible addition to the CT and to assess the functional situation of the entire lungs.

therapy

The focus is on physiotherapy to mobilize secretions, which is also carried out when there are symptom-free intervals. This also includes the daily "bronchial toilet" (coughing up the mucus in the knee-elbow position).

Medicinally, the following is possible:

Mucolytics that dilute the secretion and thus make it easier to expectorate
Bronchodilators , which widen the bronchi to make breathing easier
Antibiotics , for exacerbations and in severe cases as long-term therapy (here, for example, long-term macrolides prevent exacerbations; however, resistance does occur )
regular immunization ( vaccination ) against influenza and pneumococci .

In suitable cases, bronchiectasis can also be surgically removed (unilateral involvement, insufficient response to conservative therapy, threatening hemoptysis ).

swell

↑ Welte, T., Richtschnur bei Bronchiektasen, in Med. Tribune, 4, Sept. 2017, p. 4
^ Josje Altenburg: Effect of Azithromycin Maintenance Treatment on Infectious Exacerbations Among Patients With Non-Cystic Fibrosis Bronchiectasis. In: JAMA. 309, 2013, p. 1251, doi: 10.1001 / jama.2013.1937 .
↑ David J. Serisier: Effect of Long-term, Low-Dose Erythromycin on Pulmonary Exacerbations Among Patients With Non-Cystic Fibrosis Bronchiectasis. In: JAMA. 309, 2013, p. 1260, doi: 10.1001 / jama.2013.2290 .

Gerd Herold: Internal Medicine . Self-published, Cologne 1992 ff.
H. Greten, F. Rinninger, T. Greten: Internal medicine . Thieme, Stuttgart / New York 2010, ISBN 978-3-13-552213-5 .

literature

Jessica Rademacher, Tobias Welte: Bronchiectasis - Diagnosis and Therapy . In: Dtsch Arztebl Int . No. 108 (48) , 2011, pp. 809-815 ( review ).

[1] Welte, T., Richtschnur bei Bronchiektasen, in Med. Tribune, 4, Sept. 2017, p. 4

[DOI10.1001/jama.2013.1937-2] Josje Altenburg: Effect of Azithromycin Maintenance Treatment on Infectious Exacerbations Among Patients With Non-Cystic Fibrosis Bronchiectasis. In: JAMA. 309, 2013, p. 1251, doi: 10.1001 / jama.2013.1937 .

[DOI10.1001/jama.2013.2290-3] David J. Serisier: Effect of Long-term, Low-Dose Erythromycin on Pulmonary Exacerbations Among Patients With Non-Cystic Fibrosis Bronchiectasis. In: JAMA. 309, 2013, p. 1260, doi: 10.1001 / jama.2013.2290 .