Orientation notes for study. Check local guidelines before prescribing.
Definition
Bronchiectasis is permanent, abnormal dilatation of the bronchi with chronic inflammation and infection, leading to a clinical syndrome of chronic productive cough, recurrent chest infections and sometimes haemoptysis.
Pathogenesis
- The "vicious cycle": an initial insult (infection, obstruction, or defective clearance) → impaired mucociliary clearance → mucus stasis and bacterial colonisation → chronic inflammation → destruction of the bronchial wall (elastin and muscle) → dilatation → worse clearance.
Causes
| Group | Examples |
|---|---|
| Post-infectious (commonest, especially in Kenya) | Tuberculosis, severe pneumonia, measles, whooping cough, adenovirus |
| Congenital and genetic | Cystic fibrosis, primary ciliary dyskinesia (Kartagener: bronchiectasis, sinusitis, dextrocardia), alpha-1 antitrypsin deficiency, Young's syndrome |
| Immune deficiency | HIV, hypogammaglobulinaemia (common variable immunodeficiency) |
| Obstruction | Foreign body, tumour, enlarged nodes (compressing a bronchus), mucus plug |
| Allergic | Allergic bronchopulmonary aspergillosis (ABPA) (central bronchiectasis in asthma) |
| Inflammatory and autoimmune | Rheumatoid arthritis, inflammatory bowel disease, Sjögren's |
| Aspiration | Recurrent aspiration, GORD |
| Idiopathic | A large fraction |
Clinical features
- Symptoms: chronic productive cough with copious purulent sputum (daily, may separate into three layers on standing), recurrent chest infections, haemoptysis (from bronchial artery bleeding), dyspnoea, wheeze, pleuritic pain, halitosis, fatigue and weight loss.
- Signs: finger clubbing, coarse crackles (often early to mid-inspiratory and moving with cough), wheeze, rhonchi; signs of cause (sinusitis, dextrocardia, joint disease); in advanced disease cyanosis and cor pulmonale.
Investigations
- HRCT chest (diagnostic): bronchial dilatation with internal diameter larger than the accompanying artery ("signet ring" sign), lack of tapering ("tram-track"), bronchial wall thickening, mucus plugging, "tree-in-bud".
- Chest X-ray: tram-track lines, ring shadows, cystic spaces (may be normal in early disease).
- Sputum: culture for Haemophilus influenzae, Pseudomonas aeruginosa, Staph aureus; AFB/GeneXpert for TB and non-tuberculous mycobacteria; fungal culture.
- Spirometry (obstructive, sometimes mixed).
- Cause-finding: HIV test, immunoglobulins, sweat chloride/CFTR (cystic fibrosis), ciliary function and nasal nitric oxide, Aspergillus IgE and precipitins, rheumatoid factor, alpha-1 antitrypsin.
- Bronchoscopy if focal disease or obstruction is suspected.
Management
- Treat the cause where possible (immunoglobulin replacement, treat ABPA with steroids and itraconazole, remove obstruction).
- Airway clearance: chest physiotherapy (active cycle of breathing, postural drainage, oscillating devices) daily; mucolytics or hypertonic saline in selected patients.
- Antibiotics for exacerbations: sputum culture first, treat for 10–14 days (amoxicillin or doxycycline for H. influenzae and S. pneumoniae; ciprofloxacin for Pseudomonas).
- Long-term prophylaxis in patients with 3 or more exacerbations a year: azithromycin (macrolide), or nebulised antibiotics (colistin, gentamicin) for Pseudomonas.
- Bronchodilators (and inhaled steroids if asthma or ABPA).
- Vaccination: influenza and pneumococcal; stop smoking; nutrition.
- Surgery: resection of a localised area, for massive haemoptysis or recurrent infections from a single lobe; bronchial artery embolisation for haemoptysis; lung transplant in end-stage disease.
Complications
- Recurrent infection, massive haemoptysis, empyema, lung abscess, pneumothorax, respiratory failure and cor pulmonale, amyloidosis, metastatic infection (brain abscess), sinusitis.
Exam points
- HRCT is the diagnostic test (signet ring sign).
- Post-TB and post-measles bronchiectasis are common in Kenya.
- Pseudomonas colonisation signals worse disease and needs targeted antibiotics.
- Daily airway clearance is the foundation of management.
- Kartagener syndrome: bronchiectasis + sinusitis + situs inversus.
Pharmacology at a glance
Tap a drug name for its full card (how it works, adverse effects, cautions, dose), then use Back to this note to return to this spot. Condition guide: bronchiectasis drugs.
| Drug | Class | Role here | Watch for |
|---|---|---|---|
| Amoxicillin | Penicillin | Exacerbation with Haemophilus or pneumococcus (14 days) | Rash, diarrhoea |
| Doxycycline | Tetracycline | Alternative for exacerbations | Photosensitivity, oesophagitis |
| Ciprofloxacin | Fluoroquinolone | Pseudomonas exacerbations | Tendon injury, QT prolongation |
| Azithromycin | Macrolide | Long-term prophylaxis if 3 or more exacerbations a year | QT prolongation, hearing loss; exclude non-tuberculous mycobacteria first |
| Gentamicin | Aminoglycoside | Nebulised or IV for resistant Pseudomonas | Kidney and hearing damage; level monitoring |
| Salbutamol | Short-acting β₂-agonist | Bronchodilator before airway clearance | Tremor, palpitations |
| Prednisolone | Systemic corticosteroid | Allergic bronchopulmonary aspergillosis | High glucose, infection risk |
Culture first, then treat: short courses relapse, so a full 14 days is the usual duration.
Practice questions
1. A 35-year-old man with daily large volumes of purulent sputum, clubbing and recurrent haemoptysis. The best diagnostic test is: A. Chest X-ray · B. Spirometry · C. High-resolution CT chest · D. Bronchoscopy · E. Sputum cytology Answer: C.
2. HRCT sign of bronchiectasis: A. Ground glass · B. Signet-ring sign (bronchus wider than its artery) · C. Honeycombing · D. Eggshell calcification · E. Cavity with air-fluid level Answer: B.
3. A man with bronchiectasis, chronic sinusitis and dextrocardia most likely has: A. Cystic fibrosis · B. Primary ciliary dyskinesia (Kartagener) · C. Sarcoidosis · D. Alpha-1 antitrypsin deficiency · E. ABPA Answer: B.