INTRODUCTION

Bronchiectasis is an abnormal, chronic enlargement of the bronchi, the passageways

from the trachea to the alveoli that are the air-exchanging parts of the lungs.
Bronchiectasis generally occurs as a result of infection, although noninfectious
factors may contribute to the development of this condition. Accompanying the
enlargement of the bronchi is their decreased ability to clear secretions.
Failure to clear secretions allows microbes and particles to collect in them, which
leads to more secretions and inflammation that further damage the airways, causing
more dilation in a vicious cycle.
Bronchiectasis can be categorized as a chronic obstructive pulmonary lung disease
manifested by airways that are inflamed and easily collapsible, resulting in air flow
obstruction with shortness of breath, impaired clearance of secretions often with
disabling cough, and occasionally hemoptysis. Severe cases can result in progressive
impairment with respiratory failure
Bronchiectasis most often presents as (1) a focal process involving a lobe, segment,
or subsegment of the lung or (2) a diffuse process involving both lungs. The former is
by far the most common presentation of bronchiectasis, while the latter is most often
associated with systemic illnesses, such as cystic fibrosis (CF), sinopulmonary
disease, or both.
Diagnosis is usually based on a compatible clinical history of chronic respiratory
symptoms, such as daily cough and viscid sputum production, and characteristic
radiographic findings on CT scans, such as bronchial wall thickening and luminal
dilatation.

Epidemiology

The prevalence of bronchiectasis is unknown largely because the

symptoms are variable and the diagnosis is often not made.

In the pre-antibiotic era, it was estimated to be as common as or more

common than tuberculosis and to be present in 92 percent of cases of
chronic bronchitis.

It occurs in every age group and, in the pre-antibiotic era, it most often
began in childhood .

Among all ages, it has been estimated that about 25 people per 100,000
have bronchiectasis,but this number increases to 272 per 100,000 for those
over 74 years old.

Cases of bronchiectasis are more common in women than men, especially

when it is of unknown cause.

A wide range of causes of bronchiectasis has been reported in adults, but

for more than half of the cases, there is no known cause or association.

It is estimated that between 30 and 35 percent of cases follow a lung

infection that damages the bronchi for the first time .

DEFINITION
o Bronchiectasis is a condition that is characterized by the permanent dilatation of
the bronchi associated with destruction of elastic and muscular components of
their walls, usually due to chronic infection.
o Bronchiectasis is chronic dilatation of bronchi with impaired drainage of
bronchial secretions leading to persistent infection of the affected segments or
lobes.
o Bronchiectasis is persistent and irreversible dilation and distortion of medium
sized bronchi (5th to 9th generation) by more than 2
o Bronchiectasis is a condition in which damage to the airways causes them to
widen and become flabby and scarred. The airways are tubes that carry air in and
out of your lungs.
o The anatomic distortion of a conducting bronchi, often with permanent dilation
due to elastic and muscular damage to the epithelium, results in bronchiectasis.

ANATOMY
The lungs are the essential organs of respiration they are two in number, placed one on
either side within the thorax, and separated from each other by the heart and other
contents of the mediastinum. The substance of the lung is of a light, porous, spongy
texture it floats in water, and crepitates when handled, owing to the presence of air
in the alveoli it is also highly elastic hence the retracted state of these organs when
they are removed from the closed cavity of the thorax. The surface is smooth,
shining, and marked out into numerous polyhedral areas, indicating the lobules of
the organ: each of these areas is crossed by numerous lighter lines.
The right lung usually weighs about 625 gm., the left 567 gm., but much variation is met
with according to the amount of blood or serous fluid they may contain. The lungs
are heavier in the male than in the female, their proportion to the body being, in the
former, as 1 to 37, in the latter as 1 to 43.
Each lung is conical in shape, and presents for apex, a base, three borders, and two
surfaces.
The apex (apex pulmonis) is rounded, and extends into the root of the neck, reaching
from 2.5 to 4 cm. above the level of the sternal end of the first rib. A sulcus
produced by the subclavian artery as it curves in front of the pleura runs upward
and lateralward immediately below the apex.

The base (basis pulmonis) is broad, concave, and rests upon the convex surface of the
diaphragm, which separates the right lung from the right lobe of the liver, and the
left lung from the left lobe of the liver, the stomach, and the spleen. Since the
diaphragm extends higher on the right than on the left side, the concavity on the
base of the right lung is deeper than that on the left. Laterally and behind, the base
is bounded by a thin, sharp margin which projects for some distance into the
phrenicocostal sinus of the pleura, between the lower ribs and the costal attachment
of the diaphragm. The base of the lung descends during inspiration and ascends
during expiration.

Surfaces.The costal surface (facies costalis external or thoracic surface) is smooth,

convex, of considerable extent, and corresponds to the form of the cavity of the
chest, being deeper behind than in front. It is in contact with the costal pleura, and
presents, in specimens which have been hardened in situ, slight grooves
corresponding with the overlying ribs.
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The mediastinal surface (facies mediastinalis; inner surface) is in contact with the
mediastinal pleura. It presents a deep concavity, the cardiac impression, which
accommodates the pericardium; this is larger and deeper on the left than on the
right lung, on account of the heart projecting farther to the left than to the right side
of the median plane. Above and behind this concavity is a triangular depression
named the hilum, where the structures which form the root of the lung enter and

leave the viscus.

Borders.The inferior border (margo inferior) is thin and sharp where it separates the
base from the costal surface and extends into the phrenicocostal sinus medially
where it divides the base from the mediastinal surface it is blunt and rounded.
The posterior border (margo posterior) is broad and rounded, and is received into the
deep concavity on either side of the vertebral column. It is much longer than the
anterior border, and projects, below, into the phrenicocostal sinus.
The anterior border (margo anterior) is thin and sharp, and overlaps the front of the
pericardium. The anterior border of the right lung is almost vertical, and projects
into the costomediastinal sinus; that of the left presents, below, an angular notch,
the cardiac notch, in which the pericardium is exposed. Opposite this notch the
anterior margin of the left lung is situated some little distance lateral to the line of
reflection of the corresponding part of the pleura.

Fissures and Lobes of the Lungs .The left lung is divided into two lobes, an
upper and a lower, by an interlobular fissure, which extends from the costal to the
mediastinal surface of the lung both above and below the hilus. As seen on the
surface, this fissure begins on the mediastinal surface of the lung at the upper and
posterior part of the hilus, and runs backward and upward to the posterior border,
which it crosses at a point about 6 cm. below the apex. It then extends downward
and forward over the costal surface, and reaches the lower border a little behind its
anterior extremity, and its further course can be followed upward and backward
across the mediastinal surface as far as the lower part of the hilus. The superior lobe
lies above and in front of this fissure, and includes the apex, the anterior border,
and a considerable part of the costal surface and the greater part of the mediastinal
surface of the lung. The inferior lobe, the larger of the two, is situated below and
behind the fissure, and comprises almost the whole of the base, a large portion of
the costal surface, and the greater part of the posterior border other fissure separates
the superior from the middle lobe. It begins in the previous fissure near the
posterior border of the lung, and, running horizontally forward, cuts the anterior
border on a level with the sternal end of the fourth costal cartilage on the
mediastinal surface it may be traced backward to the hilus. The middle lobe, the
smallest lobe of the right lung, is wedge-shaped, and includes the lower part of the
anterior border and the The right lung, although shorter by 2.5 cm. than the left, in
consequence of the diaphragm rising higher on the right side to accommodate the
liver, is broader, owing to the inclination of the heart to the left side; its total
capacity is greater and it weighs more than the left lung.anterior part of the base of
the lung.

The Root of the Lung (radix pulmonis)A little above the middle of the
mediastinal surface of each lung, and nearer its posterior than its anterior border, is its
root, by which the lung is connected to the heart and the trachea. The root is formed by
the bronchus, the pulmonary artery, the pulmonary veins, the bronchial arteries and veins,
the pulmonary plexuses of nerves, lymphatic vessels, bronchial lymph glands, and areolar
tissue, all of which are enclosed by a reflection of the pleura. The root of the right lung
lies behind the superior vena cava and part of the right atrium, and below the azygos vein.
8

That of the left lung passes beneath the aortic arch and in front of the descending aorta;
the phrenic nerve, the pericardiacophrenic artery and vein, and the anterior pulmonary
plexus, lie in front of each, and the vagus and posterior pulmonary plexus behind each;
below each is the pulmonary ligament.
The chief structures composing the root of each lung are arranged in a similar manner
from before backward on both sides, viz., the upper of the two pulmonary veins in front
the pulmonary artery in the middle and the bronchus, together with the bronchial vessels,
behind. From above downward, on the two sides, their arrangement differs, thus:
On the right side their position iseparterial bronchus, pulmonary artery, hyparterial
bronchus, pulmonary veins, but on the left side their position ispulmonary artery,
bronchus, pulmonary veins. The lower of the two pulmonary veins, is situated below the
bronchus, at the apex or lowest part of the hilus .

Divisions of the Bronchi.

Just as the lungs differ from each other in the number of their lobes, so the bronchi differ
in their mode of subdivision.
The right bronchus gives off, about 2.5 cm. from the bifurcation of the trachea, a branch
for the superior lobe. This branch arises above the level of the pulmonary artery, and is
therefore named the eparterial bronchus.
All the other divisions of the main stem come off below the pulmonary artery, and
consequently are termed hyparterial bronchi. The first of these is distributed to the middle
lobe, and the main tube then passes downward and backward into the inferior lobe, giving
off in its course a series of large ventral and small dorsal branches. The ventral and dorsal
branches arise alternately, and are usually eight in numberfour of each kind. The
branch to the middle lobe is regarded as the first of the ventral series.
The left bronchus passes below the level of the pulmonary artery before it divides, and
hence all its branches are hyparterial it may therefore be looked upon as equivalent to that
portion of the right bronchus which lies on the distal side of its eparterial branch. The first
9

branch of the left bronchus arises about 5 cm. from the bifurcation of the trachea, and is
distributed to the superior lobe. The main stem then enters the inferior lobe, where it
divides into ventral and dorsal branches similar to those in the right lung. The branch to
the superior lobe of the left lung is regarded as the first of the ventral series.

Structure.The lungs are composed of an external serous coat, a subserous areolar

tissue and the pulmonary substance or parenchyma.
The serous coat is the pulmonary pleura it is thin, transparent, and invests the entire organ
as far as the root.
The subserous areolar tissue contains a large proportion of elastic fibers; it invests the
entire surface of the lung, and extends inward between the lobules.
The parenchyma is composed of secondary lobules which, although closely connected
together by an interlobular areolar tissue, are quite distinct from one another, and may be
teased without much difficulty in the fetus.
The secondary lobules vary in size those on the surface are large, of pyramidal form, the
base turned toward the surface those in the interior smaller, and of various forms. Each
secondary lobule is composed of several primary lobules, the anatomical units of the
lung. The primary lobule consists of an alveolar duct, the air spaces connected with it and
their bloodvessels, lymphatics and nerves.
The intrapulmonary bronchi divide and subdivide throughout the entire organ, the
smallest subdivisions constituting the lobular bronchioles. The larger divisions consist of:
(1) an outer coat of fibrous tissue in which are found at intervals irregular plates of
hyaline cartilage, most developed at the points of division;
(2) internal to the fibrous coat, a layer of circularly disposed smooth muscle fibers, the
bronchial muscle; and
(3) most internally, the mucous membrane, lined by columnar ciliated epithelium resting
on a basement membrane.
10

Each bronchiole divides into two or more respiratory bronchioles, with scattered alveoli,
and each of these again divides into several alveolar ducts, with a greater number of
alveoli connected with them.
Each alveolar duct is connected with a variable number of irregularly spherical spaces,
which also possess alveoli, the atria. With each atrium a variable number (25) of
alveolar sacs are connected which bear on all parts of their circumference alveoli or air
sacs.
The alveoli are lined by a delicate layer of simple squamous epithelium, the cells of
which are united at their edges by cement substance. Between the squames are here and
there smaller, polygonal, nucleated cells.
The pulmonary veins commence in the pulmonary capillaries, the radicles coalescing
into larger branches which run through the substance of the lung, independently of the
pulmonary arteries and bronchi. After freely communicating with other branches they
form large vessels, which ultimately come into relation with the arteries and bronchial
tubes, and accompany them to the hilus of the organ. Finally they open into the left
atrium of the heart, conveying oxygenated blood to be distributed to all parts of the body
by the aorta.
The bronchial arteries supply blood for the nutrition of the lung they are derived from
the thoracic aorta or from the upper aortic intercostal arteries, and, accompanying the
bronchial tubes, are distributed to the bronchial glands and upon the walls of the larger
bronchial tubes and pulmonary vessels. Those supplying the bronchial tubes form a
capillary plexus in the muscular coat, from which branches are given off to form a second
plexus in the mucous coat this plexus communicates with small venous trunks that empty
into the pulmonary veins. Others are distributed in the interlobular areolar tissue, and end
partly in the deep, partly in the superficial, bronchial veins. Lastly, some ramify upon the
surface of the lung, beneath the pleura, where they form a capillary network
The bronchial vein is formed at the root of the lung, receiving superficial and deep veins
corresponding to branches of the bronchial artery. It does not, however, receive all the
blood supplied by the artery, as some of it passes into the pulmonary veins. It ends on the
11

right side in the azygos vein, and on the left side in the highest intercostal or in the
accessory hemiazygos vein.

Nerves. The lungs are supplied from the anterior and posterior pulmonary plexuses,
formed chiefly by branches from the sympathetic and vagus. The filaments from these
plexuses accompany the bronchial tubes, supplying efferent fibers to the bronchial
muscle and afferent fibers to the bronchial mucous membrane and probably to the alveoli
of the lung. Small ganglia are found upon these nerves.

12

13

14

PHYSIOLOGY
Pulmonary Mechanics
Successful exchange of gases in the lungs is predicated on efficient ventilation of the
lungs. Tidal respiration is based on cyclical expansion and contraction of the lungs.
During inhalation, active contraction of the diaphragm and external intercostal muscles
of the ribcage draw air into the lungs. Each of these muscle groups acts together to
expand the lungs.
During inhalation, intrathoracic pressures decrease and intraabdominal pressures
increase. Intercostal contraction results in visible expansion of the chest wall, whereas
diaphragmatic contraction pushes the abdominal contents downward and outward.
Expansion of the chest and abdominal walls should be well coordinated. If the abdomen
and chest move in opposite directions, one or the other of these systems is either weak or
paralyzed. Furthermore, the left and right diaphragms should move together.
Weakness of one or both diaphragms can reduce the ventilatory capacity of the lungs.
This can be tested with a "sniff test": the subject is asked to sniff while the movement of
the diaphragms is evaluated by fluoroscopy or ultrasound.
During inspiration, downward movement of the diaphragm on the intact side increases
intraabdominal pressures and decreases intrathoracic pressures, resulting in an upward
movement of the paralyzed side. The auxiliary muscles include the scalenus (which are
active during normal inspiration) and the sternocleidomastoid muscles (which are only
used with high levels of respiratory effort). The overall strength of the respiratory
apparatus can be easily evaluated by measuring the maximum inspiratory and expiratory
pressures (PImax and PEmax) that the patients can exert against a fixed obstruction of the
mouthpiece.
Although inhalation requires active muscle contraction, exhalation is normally a passive
process and is dependent on the elasticity of the pulmonary tissues. When the inward
15

force exerted by the elastic tissues of the lungs matches the outward force of the thorax,
the lung volume becomes stable at the "resting midposition" of the lungs
. This is equivalent to the functional residual capacity (FRC) of the lungs. The rate and
volume of exhalation can be increased by contracting the abdominal and internal
intercostal muscles. Loss of elastic tissues within the lungs due to emphysema reduces
the ability of patients with this disorder to exhale. Patients with severe intrathoracic
obstruction characteristically utilize abdominal muscles to force the diaphragms upward
during exhalation. However, this maneuver also reduces the diameter of the bronchi,
limiting the rate at which they can exhale. More time is consequently needed during the
expiratory phase and this must be kept in mind when adjusting the inspiratory/expiratory
time ratios during mechanical ventilation.
Breathing pattern;The term for the normal pattern of quite breathing is eupnea. Eu =

good. Easy or

normal. Pnea = breath.

Eupnea can consists of shallow, deep or combined shallow and deep breathing.
Costal breathing.
Diaphraqgmatic.
i.

Costal breathing;-

A pattern of shallow (chest)breathing called costal breathing. It consists of upward

and downward movement of the chest due to contraction of the intercostals muscles.
ii.

Diaphragmtic breathing;-

A pattern of deep (abdominal)breathing called diaphramtic breathing. It consists of

the upward movement of the abdomen due to contraction and descent of the diaphragm.

16

TERMS

SYMBOLS

Vital capacity

VC

DESCRIPTION

VALUE

Maximal volume of

4.5 litres

Air exhaled after forced inspiration.

Tidal volume

TV

Volume of air inhaled or exhaled during quiet

500 ml

breathing.
Inspiratory

reserve

IRV

After a quiet inspiration

2.3 3 lits

volume
Expiratory

reserve

ERV

Maximal air that can be breathed out after

1 ltr

volume

quiet expiration.

Residual volume

RV

Volume of air remaining in lungs after full

1.2 lits

expiration.
Inspiratory

vital

capacity
Forced
expiratory
volume
Functional residual

IVC

Maximal volume of air inhaled after full

FEV

expiration
Volume of air inhaled in a given period of

FRC

complete forced expiration.

Amount of air remained Iin the lungs at the

capacity
Total lung capacity

3.5 lits

2200 ml

residual expiration
TLC

Amount of air present in the lungs after a

6000ml

maximal deep inspiration

Respirsatory minute

RMV

volume

Amount of air breathed in and out of lungs at

every minute

BIO-MECHANICS:
17

6000 ml

1) Chest wall movements.

2) Muscles of respiration.
Chest wall movements;i.

Pump handle movement.

ii.

Bucket

handle

movement

Pump handle movement : During inspiration the ribs elevate in the

upper ribs

most of the movement occurs at the anterior aspect of the rib, given the

nearly coronal axis at the vertebrae.the costocartilage become more horizontal.the

movement of the ribs pushes the sternum ventrally and superiorly.the excursion of the
manubrium is less that of the body of the sternum.because of the first rib is shortest, with
the caudal ribs increasing in lengh until rib.the discrepancy in lengh causes movement of
the ms joint.the motion of the upper ribs and sternum has its greatest effect by increasing
the anteroposterior diameter of thorax.this combined rib and sternal motion that occurs in
a predominatetly saggital plane has been termed the pump handle motion.

Bucket handle movement : -

18

Elevation of the lower rib about the axis of motion lying nearly in the sagital plane. The
lower ribs have more angled shape ( obliquity increases from rib 1-10 ) and an indirect
attachment anteriorly to the sternum. These factors allow the lower ribs more motion at
the lateral aspect of the ribcage. The elevation of the lower ribs has its greatest effect by
increasing the transverse diameter of the lower thorax. This motion that occurs in a nearly
frontal plane has been termed the Bucket handle motion

Muscles of respiration :
The ventilatory muscles are most accurately classified as either primary or accesory
muscles,

19

Primary muscles :
These include the diaphragm, intercostal muscles and the scalene muscles. These
muscles all act on the ribcage to promote inspiration.

Diaphragm :
The diaphragm is the primary muscle of the ventilation accounting approximately
70-80% of inspiration force during quiet breathing, the diaphragm is a circular set of
muscle fibres that arises from the sternum, costocartilage, ribs and vertebral bodies the
fibres travels superiorly to insert insert into a central tendon.
Functionally the muscular portion of the diaphragm is divided into the costal
portion .

Which arises from the sternum, costo cartilage and ribs. The crural

portion which arises from the vertebral bodies.

Intercostal muscles :
The external and internal intercostal muscles are categorized as Ventilatory
muscles. The parasternal muscles are considered as primary muscles of ventilation.
The internal intercostal and external intercostal and the subcostales muscles
connect adjacent ribs to one another.
The external intercostal muscles are activated during inspiration and the internal
intercostal muscles are active during exhalation.
Scalene muscles :
The scalene muscles are also primary muscles of quiet ventilation. The scalene
muscles attached on the transverse process of c3 c7 and descend to the upper borders of
1st and 2nd rib, their action lifts the sternum and the 1st to ribs in the pump handle motion
of the upper rib cage.
The scalene muscles also function as stabilizers of ribcage.
Accessory muscles :
These muscles assesd with inspiration or expiration in situations of stress such
as increased activity or disease.
When the trunk is stabilized the accessory muscles of ventilation move the
vertebral column, arm, head or pelvis on the trunk.

20

The accessory muscles of inspiration increases the thoracic diameter by

moving the rib cage upward and downward.
The accessory muscles of expiration move the diaphragm upward and the
thorax downward and inward.
The most common accessory muscles are sternocleidomastoid, trapezius,
pectoralis major, pectoralis minor, subclavius.
The abdominal muscles are trasversus, abdominalis, internal oblique
abdominalis, external oblique abdominalis, rectus abdominalis,are expiratory
muscles.

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TYPES OF BRONCHIECTAISIS:
Types of bronchiectasis include:
1-Cylindric/Fusiform/Tubular:

Cylindrical

bronchiectasis

produces

"tram-lines"

because the distal bronchus has the same lumen size as parent and extends to the lung
periphery. This is the most common form of bronchiectasis. It may occur secondary to
infection, ciliary dyskinesia, or cystic fibrosis. Patients may have only mild symptoms
such as a cough, with small amounts of sputum production. On HRCT there are thick
walled (smooth, not irregular) bronchi which extend into the peripheral 3 cm of the lung.

Cylindrical bronchiectasis with signet-ring appearance.The luminal airway diameter is

greater than the diameter of the adjacent vessel.
2- Saccular/Cystic: This is the most severe form of bronchiectasis. It is characterized by
progressive dilatation of the bronchi toward the periphery which terminate in cytic
cavities resembling balloons. The findings may resemble a cluster of cysts. Air-fluid
levels within the massively dilated bronchi are seen frequently due to retained secretions,
and are usually not seen in uncomplicated lung cysts. Remember, that in contrast to
bronchiectasis, emphysematous bullae have no discernible walls.

22

3. Traction/ Varicose: Unlike most other causes of bronchiectasis, the airway changes
are not caused by a primary insult to the airways themselves, but rather as a result of
adjacent parenchymal fibrosis. In this form of bronchiectasis the bronchial walls are
characteristically more irregular and may assume a beaded appearance when in the plane
of section (resembling a "varicose" vein). Differentiation from cylindrical bronchiectasis
is difficult when viewed in cross section.

Varicose bronchiectasis with alternating areas of bronchial dilatation and constriction.

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AETIOLOGY
Bronchiectasis is caused by recurrent inflammation or infection of the airways. It may be
present at birth, but most often begins in childhood as a complication from infection or
inhaling a foreign object. Prior to the widespread use of immunizations, bronchiectasis
was often the result of a serious infection with either measles or whooping cough. Now,
viruses that cause influenza (flu) or influenza-like syndromes, may lead to development
of bronchiectasis.
Some other Causes of Bronchiectasis may be:

Respiratory syncytial virus can cause bronchiectasis in some

Childs.

Some inherited conditions. For example, a condition called

primary ciliary dyskinesia affects the cilia so they do not 'beat'
Correctly to clear the mucus. Cystic fibrosis is another condition
that affects the lungs and causes 'bronchiectatic' airways.

Inhaled objects, such as peanuts, can become stuck and block an

airway. This may lead to local damage to that airway. Acid from
the stomach that is regurgitated and inhaled can also damage
airways. Inhaling poisonous gases may also cause damage.

Some rare immune problems can also cause lung infections and
damage to airways thereby causing bronchiectasis.

Severe lung infections such as tuberculosis (TB), whooping cough,

pneumonia or measles can damage the airways at the time of
infection. Ongoing bronchiectasis may then develop.

Less commonly, bronchiectasis may be caused by cystic fibrosis,

an inhaled foreign body such as a peanut, following tuberculosis,
or lung infection in Aids.

Other causes include inhalation of damaging gases, dust or smoke. The

condition is worsened by smoking.

It is also seen in later life after severe lung infections such as pneumonia
in childhood, and it is sometimes
24

Some other Symptoms of Bronchiectasis may be:

o Cough worsened by lying on one side
o Shortness of breath worsened by exercise
o Weight loss.
o Coughing up of blood is also common.
o Fatigue.
o Wheezing.
o There may be frequent bouts of pneumonia or hemoptysis.
o Recurrent fever, chills,
o Skin discoloration, bluish.
o Paleness.
o Abnormal chest sounds.

25

Pathology

Bronchial obstruction may be localized (due perhaps to an inhaled foreign

body such as a pea nut or broken tooth or obstruction due to a tumor or
enlarged gland) or generalized (eg .pneumonia that is slow to resolve
owing to whooping cough or measles).

The bronchial obstruction will cause absorption of air from the lung tissue
distal to the obstruction and this area will therefore shrink and collapse.
This causes traction forces to be exerted upon the more proximal air
ways, which will distort and dilate them.

If the obstruction can be cleared and the lung re-expanded quickly then
the dilatation is reversible. Secretions may collect distal to the obstruction
if it is not relieved quickly and these easily become infected.

This causes inflammation of the bronchial wall with destruction of the

elastic and muscular tissue.

These infections occur repeatedly, with walls becoming weaker and

weaker. They will eventually dilate owing to the negative intrapleural
pressure.

As the disease advances, the bronchi become grossly dilated and pockets
containing pus are formed.

The elastic and muscle tissue is destroyed and the mucus lining is
replaced by granulation tissue with loss of cilia. Therefore the
mucociliary transport mechanism is disrupted and the of mucus out of the
lungs is thus hindered.

Several types of obstructions are recognized pathologically: tubular,

fusiform, or saccular. The arterial vessels within the bronchial walls
anastomose with the pulmonary capillaries and this results in the common
feature of haemoptysis.

26

Clinical manifestations
Cough and sputum:
Patients complains of persistent cough with purulent sputum since childhood.
Initially, it is present only following colds or influenza, but if the disease is allowed to
progress in severity the effected segments continually accumulate purulent secretions,
resulting in cough and sputum production. The sputum is usually in green, often foulsmelling and present fairly large volume.
The cough is particularly troublesome on a change of position and on raising
first thing in the morning.

Dyspnoea:
Shortness of breath is noticeable only if disease is particularly severe and
widespread. If the bronchiectasis is localized, other well-ventilated and perfused alveoli
should maintain blood gases at a reasonable level, although bronchospasm may be a
Feature, particularly during an exacerbation.

Haemoptysis:
This occurs quite commonly, usually in association with an acute infection. It can
be life-threatening if severe and may require surgical resection of the affected lung tissue.

Recurrent pneumonia:
Characteristically this will affect the same site and is a common feature.

Chronic sinusitis:
.

This occur in approximately 70per cent of patients

General ill-health:
Patients may suffer pyrexia, night sweats, anorexia, malaise, weight loss, lassitude
and oint pains.

Clubbing:
In about 50per cent of patients fingers and toes become clubbed. The first sign of
clubbing is loss of the angle between the nail and the nail bed. This is followed by
27

curvature of the nail, and an increase in the soft tissue of the ends of the fingers, forming
so- called drumstick fingers.

Thoracic Mobility
This gradually decreases, as do shoulder girdle movements.

28

DIFFERENTIAL DIAGNOSIS:
The typical history that suggests bronchiectasis is chronic cough with mucopurulent
secretions. Bronchiectasis can be confirmed with chest radiographs and HRCT. The
differential diagnosis of bronchiectasis is one of the most challenging in pulmonary
medicine. Bronchiectasis occurs in several suppurative lung diseases. One useful
distinction is that of focal versus diffuse disease. Bronchiectasis involving a single lobe
or segment of the lung typically results from focal bronchial obstruction or severe lobar
pneumonia. Patients present with a history of recurrent or persistent lobar pneumonia.
Bronchial obstruction proximal to the region of bronchiectasis may be secondary to a
foreign body, carcinoma, broncholith, or lymph nodes (as occurs in middle lobe
syndrome). Multilobar disease is usually secondary to diffuse infections such as
influenza, S aureus, P aeruginosa, or Klebsiella species, to toxic inhalation, or to defects
in host defense. The latter occurs in chronic granulomatous infections, immunodeficiency
disorders, autoimmune diseases, and congenital diseases

29

INVESTIGATIONS
Diagnostic Tests and Procedures:

Chest Computed Tomography Scan:

The most commonly used test to diagnose bronchiectasis is a chest computed tomography
scan, or chest CT scan.
This painless test creates precise images of your airways and other structures in your
chest. It can show how much your airways are damaged and where the damage is. A chest
CT scan gives more detailed pictures than a regular chest x ray.

This CT scan shows areas of both cystic bronchiectasis and varicose bronchiectasis.

30

Chest X Ray:
You also may have a chest x ray. This painless test creates pictures of the structures in
your chest, such as your heart and lungs. A chest x ray may show areas of abnormal lung
and thickened, irregular airway walls.

Cystic and cylindrical bronchiectasis of the right lower lobe on a posterior-anterior chest
radiograph.

Other Tests:
You also may have other tests, such as:

Blood tests: These tests can show whether you have an underlying condition that
can lead to bronchiectasis. They also can show whether you have an infection or
low levels of certain infection-fighting blood cells.

A sputum culture: Lab tests of a sample of your sputum can show whether you
have bacteria (such as the bacteria that cause tuberculosis) and fungi.

Lung function tests: These tests measure the size of lungs, how much air you can
breathe in and out, how fast you can breathe air out, and how well your lungs
31

deliver oxygen to your blood. Lung function tests help show how much lung
damage you have.

A sweat test or other tests for cystic fibrosis.

Bronchoscopy:
If bronchiectasis doesn't respond to treatment, Bronchoscopy is a procedure used to look
at the insides of the airways.
During this procedure, a long, narrow, flexible tube with a light on the end is inserted
through your nose or mouth into your airways. This tube is called a bronchoscope. It
provides a video image of your airways. You'll be given medicines to numb the upper
airway and to help you relax during the procedure.
Bronchoscopy can show whether something is blocking your airways. If there is
bleeding, this procedure can show where the bleeding is coming from.
Ciliary function test:
A screening test can be performed in patients suspected of having a cilary dysfunction
syndrome by assessing the time taken for a small pellet of saccharin placed in the anterior
chamber of nose to reach pharynx, when the patient can taste it. This time should not
exceed 20minutes and is greatly prolonged in patients with ciliary dysfunction.
It is also possible to assess ciliary function by measuring ciliary beat frequency using
biopsies taken from nose.
If ciliary function is thought to be impaired, the ciliary ultrastructure should also be
determined by electron microscopy.

32

MANAGEMENT
1. CONSERVATIVE
2. SURGICAL
3. PHYSIOTHERAPY

CONSERVATIVE MANAGEMENT
Antibiotics and chest physiotherapy are the mainstay modalities. Other modalities
(beyond those for specific associated conditions) may include bronchodilators,
corticosteroid therapy, dietary supplementation
Antibiotic therapy is as follows:
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.

-Oral- ciprofloxacin (250-750mg twice daily).

o Intravenous treatment is indicated for severe infections.
-Ceftazidime by intravenous injection or infusion (100150mg/kgdaily in divided dose).
o Inhaled nebuliser or continuous oral therapy may be used for
chronic

sepsis

and

more

resistant

pathogens.(e.g-

staphylococcus aureus )
- In acute exacerbation, broad-spectrum antibacterial agents are generally preferred.

Acceptable choices for the outpatient who is mild to moderately ill

include amoxicillin,

tetracycline,

trimethoprim-sulfamethoxazole,

a newer macrolide e.g., azithromycin85 or c larithromycin86

a second-generation cephalosporin,

one of the fluoroquinolones.

In general, the duration is 7-10 days.

33

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.

Additionally, some patients with chronic bronchial infections may need regular antibiotic
treatment to control the infectious process.
-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
Bronchodilator therapy is as follows:

Bronchodilators, including

-beta-agonists and anti-cholinergic- may help some patients with bronchiectasis,

presumably reversing bronchospasm associated with airway hyperreactivity and
improving mucociliary clearance.
-Treatment with inhaled bronchodilators may be appropriate.

Anti-inflammatory medication therapy is as follows:

The rationale is to modify the inflammatory response caused by the
microorganisms associated with bronchiectasis and subsequently reduce the amount of
tissue damage.
o Inhaled corticosteroids,
o Oral corticosteroids,
o Leukotriene inhibitors and nonsteroidal anti-inflammatory
agents have all been examined.
34

Although evidence tends to support some benefit from the use of these agents, findings
are not universally definitive.
On inhaled corticosteroids are beneficial to patients with bronchiectasis compared
with a placebo, particularly patients with associated P.aeruginosa infections, while
another study showed improvement in quality-of-life scores.
Azithromycin has known anti-inflammatory properties and long-term use has been
studied in patients with both CF and non-CF bronchiectasis.
In non-CF patients, azithromycin has been shown to decrease exacerbations and improve
spirometry and microbiologic profiles.
In CF patients a meta-analysis suggests that it improves lung function, especially in those
patients colonized with Pseudomonas.

35

SURGICAL MANAGEMENT:
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 in patients of 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.
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.
Other indications for surgical intervention may include the following:
* Reduction of acute infective episodes
* Reduction of excessive sputum production
* Massive hemoptysis (Alternatively, bronchial artery embolization may be
attempted for the control of hemoptysis.)
* Foreign body or tumor removal
* Consideration in the treatment of Aspergillus species infections.
Although there is conflicting evidence regarding the efficacy of surgery when compared
to conservative treatment.

36

Complications of surgical intervention include empyema, hemorrhage, prolonged air

leak, and persistent atelectasis.
Patient selection plays an important role in preoperative mortality rates, which may be as
low as 1% in the surgical treatment of segmental or even multisegmental bronchiectasis.
Female patients and younger patients may need to be considered even sooner.

37

PHSYIOTHERAPY ASSESSMENT :
I. SUBJECTIVE ASSESSMENT :
Name
Age
Gender
Occupation
Chief complaints

HISTORY OF PATIENT:
Past history
Present history
Medical history
Personal history
Family history
Socio economic history
Environmental history
II. OBJECTIVE ASSESSMENT:
Observation:
Breathlessness
Dyspnea
Cough
Sputum
Wheeze
Other symptoms:
1.Fever
2. High fever with sweating
3. Head ache- early morning
4. Peripheral edema

38

General observation:
vital signs:
1. Temperature:98.4
2. Heart rate: 60-100/min
3. Pulse rate: 12-16/min
4. Blood pressure: 128/80mm of hg
Pulse deficit:
Pulse paradox:
Body weight: body mass index-kg/m2
Observation of chest:
Land marks of heart and lung shape
Shape
Chest deformities:
Chest movements:
Breathing patterns:

ON PALPATION;
-

Pain

Tenderness

Warmth

Swelling

ON PERCUSSION:
-

Dull sounds

Hyper resonant

ON AUSCULTATION:
Sounds
Breath sounds
I. Normal
II. Abnormal
III. Add ( or ) Adventious
39

Normal :
a. Bronchial.
b. Bronchovesicular.
c. Vesicular.
Abnormal breath sounds :
a. Bronchial sounds.
b. Decreased sounds.
c. Absence of sound
Added or adventitious sound :
a. Cracked rales / crepitus sounds
b. Ronchi
c. Wheeze
1. Extra pulmonary sounds
2. voice sounds
3. heart sounds
a. S1 sounds
b. S2 sounds
INVESTIGATIONS:
a. X-rays
b. Sputum examination
c. E.C.G
d. A.B.G. Analysis
e. Stress test
f. Pulmonary function test
g. ciliary function test
Differential daignosis :
40

Provisional diagnosis :
Management:
Short term Goal
Plan
Long term --- Goal
Plan
Progress note :
Discharge summary:

PHYSIOTHERAPY AIMS:
The principal aims of physiotherapy in bronchiectasis are:
To remove secretions and clear lung fields.
To teach an appropriate sputum clearance regimen.
To educate the patient in the pathology and management of the condition.
To promote good general health and maintain or improve exercise tolerance.
To teach the patient how to fit in home treatment within his or her llifestyle.

41

PHYSIOTHERAPY MANAGEMENT:
In early stage :

Postural drainage

Coughing

Humidification

Relax position

Breathing exercises
Segmental
Diaphragmatic

In later stage :

Inspiratory muscle traing

Exercise tolerance

Home program

Postural Drainage and Chest Physiotherapy:

Postural drainage therapy (PDT) is a component of bronchial hygiene therapy. It consists

of postural drainage, positioning, and turning and is sometimes accompanied by chest
percussion and/or vibration.
Cough or airway clearance techniques are essential components of therapy when postural
drainage is intended to mobilize secretions. Postural drainage therapy is often used in
conjunction with aerosol administration and other respiratory care procedures.

Chest physiotherapy,

Postural drainage and percussion,

Percussion and vibration.

42

Postural drainage therapy is designed to improve the mobilization of bronchial secretions

and the matching of ventilation and perfusion, and to normalize functional residual
capacity based on the effects of gravity and external manipulation of the thorax.
Turning
Turning is the rotation of the body around the longitudinal axis to promote
unilateral or bilateral lung expansion and improve arterial oxygenation.
Regular turning can be to either side or the prone position, with the bed at any
degree of inclination (as indicated and tolerated). Patients may turn
themselves or they may turned by the caregiver or by a special bed or device.
Postural Drainage
Postural drainage is the drainage of secretions, by the effect of gravity, from one
or more lung segments to the central airways (where they can be removed by
cough or mechanical aspiration). Each position consists of placing the target lung
segment(s) superior to the carina. Positions should generally be held for 3 to 15
minutes (longer in special situations). Standard positions are modified as the
patient's condition and tolerance warrant.
Percussion
Percussion is also referred to as cupping, clapping, and tapotement. The purpose
of percussion is to intermittently apply kinetic energy to the chest wall and lung.
This is accomplished by rhythmically striking the thorax with cupped hand or
mechanical device directly over the lung segment(s) being drained. No
convincing evidence demonstrates the superiority of one method over the other.
Vibration
Vibration involves the application of a fine tremorous action (manually performed
by pressing in the direction that the ribs and soft tissue of the chest move during
expiration) over the draining area. No conclusive evidence supports the efficacy
of vibration, the superiority of either manual or mechanical methods, or an
optimum frequency.

43

Postural drainage positions :

Upper lobe;-

Apical
Anterior
Posterior

Apical ;1) Anterior segment;

Position;

half lying

Techniques apply ; directly under clavicle

Posterior segment;
Position;

forward lean sitting

Techniques apply; directly above the scapula

Anterior segment;
Position;

supine lying

Techniques apply; directly over the nipple

Posterior segment;
Right side
Position;

patient lies flat and quarter turn from prone

Techniques apply; right scapula

Left side
Position;

one quartern turn from prone

44

45

Middle lobe;
Medial and lateral broncho pulmonary segmen
position;

patient lies one-quarter turn from supine on left

side supporting placing a pillow from shoulder.

Techniques apply; under the right breast

Lingular segments;
Position;

patients lies one-quarter turn from supine on

Right side supported with pillow and in 30
degrees head down position

Techniques apply; under the left breast

Lower lobe;
Apical broncho pulmonary segments;
Position;

patient lies prone placing pillow under the

Abdomen.

Techniques apply; directly below the scapula

Anterior segments :
Position;

patient lies on supine pillow under the knees

in a 30-40 degrees head down

Techniques apply;

over the lower portion of the ribs.

46

Posterior segments;
Position;

patient lies prone position 45 degrees down

Position

Techniques apply;

lower portion of the ribs.

Lateral segments(right);
Position;

on the left side in a30-45 degrees head

down position

techniques apply;

over the lateral aspect of the rib cage.

Lateral segment ( left ) :

Position -

on the right side in a 30-40 degrees head

down position
Technique apply -

over the lateral aspect of the rib cage.

INDICATIONS:

Turning

Inability or reluctance of patient to change body position. (eg,

mechanical

ventilation,

neuromuscular

disease, drug-induced

paralysis)

Poor oxygenation associated with position(eg, unilateral lung

disease)

Potential for or presence of atelectasis

Presence of artificial airway

Postural Drainage
47

Evidence or suggestion of difficulty with secretion clearance

Difficulty clearing secretions with expectorated sputum production

greater than 25-30 mL/day (adult)

Evidence or suggestion of re-tained secretions in the presence of an

artificial airway.

Presence of atelectasis caused by or suspected of being caused by

mucus plugging.

Diagnosis of diseases such as cystic fibrosis, bronchiectasis, or

cavitating lung disease

Presence of foreign body in airway.

External Manipulation of the Thorax

Sputum volume or consistency suggesting a need for additional

manipulation (eg, percussion and/or vibration) to assist movement
of secretions by gravity, in a patient receiving postural drainage

CONTRAINDICATIONS:
The decision to use postural drainage therapy requires assessment of potential benefits
versus potential risks. Therapy should be provided for no longer than necessary to obtain
the desired therapeutic results. Listed contraindications are relative unless marked as
absolute.
Positioning
All positions are contraindicated for:

Intracranial pressure (ICP) > 20 mm Hg(59,60)

Head and neck injury until stabilized

Active hemorrhage with hemodynamic instability

Recent spinal surgery (eg, laminectomy) or acute spinal injury

Acute spinal injury or active hemoptysis

Empyema

Bronchopleural fistula

Pulmonary edema associated with congestive heart failure

48

Large pleural effusions

pulmonary embolism

Aged, confused, or anxious patients who do not tolerate position changes

Rib fracture, with or without flail chest

Surgical wound or healing tissue

patients in whom increased intracranial pressure is to be avoided (eg,

neurosurgery, aneurysms, eye surgery)

Uncontrolled hypertension

Distended abdomen

ASSESSMENT OF NEED:
The following should be assessed together to establish a need for postural drainage
therapy
o Excessive sputum production,
o Effectiveness of cough,
o Decreased breath sounds or crackles or rhonchi suggesting
secretions in the airway
o Change in vital signs
o Abnormal chest x-ray consistent with atelectasis, mucus plugging,
or infiltrates
o Deterioration in arterial blood gas values or oxygen saturation
Pulmonary problems treated successfully with PDT (eg, bronchiectasis, cystic
fibrosis, lung abscess)

49

Active cycle of breathing techniques (ACBT)

It is the cycle of breathing control thoracic expansion exercise and force expiration
technique.
ACBT used to mobilize and clear excess bronchial secretions.
it has been effective in clearance of bronchial secretions improve lung function

Breathing control

Thoracic expansion exercises

Breathing control

Thoracic expansion exercises

Forced expiration technique

Breathing control :
It is normal tidal breathing using the lower chest with
relaxation of upper extremities.
50

Forced expiratory technique :

Combination of forced expiration a period of breathing control.
Huff from high lung volume will clear secretions that have reach more proximal airway.
Huffing:
Open expectoration against open glottis
Types :
High volume huffing dislodge secretions from proximal airways.
Mid lung volume huffing dislodge secretions from mid airways of
zone ll
Low lung volume huffing dislodge secretions from tertiary airways.
Techniques:

Ask the patient to take 3-4 deep breaths. Then diaphragmatic

breathing exercise are carried out and then 3-4 huff from mid lung
volume to low volume.

Then again diaphragmatic breathing exercises are carries out.

If the secretions reach the proximal airways there the patient to

made to cough or huff with high lung volume in order to clear the
secretions in proximal airways.
Coughing technique actually the cuff coughing is contraindicated
when the secretions is stable the technique coughing are using.

Closed expectoration against closed glottis.

For a cough to be effective, there shall be

High pressure during expiration.

High expiratory flow rate.

Expiration has to be at higher volumes.

51

Techniques of cough :
An inspiratory gulp of about 90% of total lung capacity.
Closure of glottis and trapping of air inside at a power positive
pressure of about 30 mmhg
Ask the patient to mimis swallowing in order to increase in the
intra thoracic pressure.
For abdominal contraction and internal intercostal muscle
contraction.
Ask the patient to pronounce the alphabet K to increase the intra
abdominal pressure.
Forcibly expire against the open glottis costal expansion is crried
out to improve ventilation and optimize gaseous exchange.

52

Relaxation position for breathless patient :

These relaxation position will assist relaxation of upper chest while
encouraging diaphragmatic breathing control during an attack of breath less.

High side lying :

Position :

5 or 6 pillows are used to rise the patienst shoulder

while lying on his shoulder

Pillow placement :

One pillow placed between the waist and axills to

keep the spine straight.
One pillow must be above the shoulder so thst only
the head and neck are supplied.
One pillow- the underneath the forearm.
53

One pillow underneath the pillow in the waist.

One pillow if the knees are bent on top leg place in
front of the one beneath.
These patients who are suffering from acute breathlessness during the night :

Forward lean sitting :

Position;

patient sits on the table leaning forward from the hips

with head and upper chest supported on several
pillows.

Pillow placement : The back must be kept straight, so diaphragmatic movement is not
inhibited.children can sit or kneel with the head and upper chest resting against pillows.
Relaxed sitting :
This is an obstructive position can be taken up easily. the back should be
kept straight , the forearms resting on the thighs and the wrists relaxed.
Forward lean standing :
The patient should lean forward with the forearm resting on an object of
suitable height such as the windows, banisters.
Relaxed standing :
The patient can lean back against a wall with the fet placed slightly
apart and approximately 30 cms away from it. The shoulder and arm should be relaxed.
Improve the breathing pattern :
Breathing exercises :

These are fundamentals interventions for

the

prevention

management

of

or

comprehensive

acute

pulmonary disorder.

54

Diaphragmatic breathing.

Segmental breathing.

Pursed breathing.

Low frequency breathing.

or

chronic

Sustained maximal breathing.

Diaphragmatic breathing :
Uses :
1. To induced relaxed pattern of breathing.
2. To have a controlled pattern of breathing.
3. To improve the efficiency of ventilation.
4. To mobilize lung secretions during postural drainage.

55

56

Diaphragmatic breathing exercise gives :

1. Concentrates on forward movement of whole abdominal wall.
2. Concentrates on upper abdominal wall and lower lateral ribs.
1st method :
Concentrates on upper abdominal wall and lateral ribs.
Position : semi- fowlers position.
Procedure :
Patient places hands on anterior central margin or upper
abdominal wall and ask the patient to breath out gently as he
does.
The lower ribs are sinking down and in towards the mid
line.
During the technique the patient should relax shoulder and
upper chest quiet the abdominal rise.
Then the patient to slowly tell all the air our using control
expiration.
2nd method :
Position :

Half lying

Procedure :
Therapist places both hands on anterior abdominal valve then
the patient to breath out gently.
He felt abdomen is sinking down and ask him to breath in
through his nose.
The air is concentrated and directed to abdomen and it bulges
achieve the therapist places hands.
Segmental breathing : In this expansion exercises are includes.
In COPD costal expansions exercise are gives :
1. To improve ventilation to the lung after relieving
bronchospasm.
2. To mobilize the secretions.
3. To improve the thoracic cage movements.
57

58

Lateral costal expansion :

It is done unilaterally, bilaterally emphasing deep breathing with a focus of
movements of this position of the lower rib cage on thoughts to facilitate diaphragmatic
excursion.
Position :
Technique :

Relaxed half lying ( or ) sitting position.

The therapist placed the pattern of hand over the mid axillary
line of 7th and 8th rib.

Procedure :

Ask the patient to breath out gently and the therapist applies a
firm pressure against chest wall and ask the patient to breath
air through nose the pressure maintained during inspiration.
Before inspiration give up stretch and pressure is relaxed at
the end of inspiration.

Apical expansion exercise :

Position :
Technique :

Relaxed half lying ( or ) sitting position.

Pressure in applied below the clavicle using the tips of
fingers.

Procedure :

The patient is instruction to breathe to breathe in expand

the upper chest against pressure.
Maximal inspiration holds for 3 to 5 second and expiration
slowly.

Thoracic mobility exercises :

Chest mobilization exercises are any exercises that they
are designed to maintained ( or ) improve mobility of chest
wall trunk, and shoulder girdle when it effect ventilation or
postural alignment.
Exercises that combine stretching of these muscle with
deep breathing ventilation on that side of the chest and
control the expiration.

59

Specific technique :
To mobilize one side of the chest :
Postion :

Sitting position

Procedure :

Patient bend away from the right side lengthen

hypomobile stricter expands that side of the chest during

inspiration.
Patient push the fisted hand into lateral aspect of chest and
patient bend towards the right side and breath out.
Progress by having the patient rise the arm on the right
side.
To mobilize the upper chest stretch the pectoralis muscle :
Position :
Procedure :

Sitting position in a chair

The patient hands closed behind the head ; patients
horizontally abducts the arms during a deep inspiration.
Then instruct the patient to bring the elbow together
and bend forwards during expiration.

To mobilize the upper chest and shoulders :

Position :
Procedure :

sitting position in a chair

Patient reach with both arms over head during inspiration.
Patient bend forward and the hip and reach for the floor
during expiration.
In addition to exercises therapist may also instruct the
patient in posture correction.

To enhance expiration ;
It is a process of moisturing of the air for gases we breath.
Function :
Normally one of the functions of upper respiration tract, the air way add
heat and water to the inspired gas and extract heat and water from expired gas.

60

If the secretions are very thick and tenacious the patient may be given
humidification through nebulizer inhalation with penio oil added to near be oiling water
may also be given prior to treatment to remove excess brochial secretions.
Inspiratory muscles training :
Inspiratory muscles training is used in pulmonary rehabilitation to
increase and endurance of the inspiratory muscles, general and specific training program
are used ininspiratory muscle training.
General :
Aerobic exercises
Walking
Swimming
Cycling
Jogging
Treadmill
Gymnastics
Specific:
Inspective spirometry :Types :
Volume oriented incentive spirometry
Flow oriented incentive spirometry
It is use to encourage the patient to take long slow deep breath and
thus prevent athlectasis. It may be most commonly use respiratory therapy in post
operative patient.
Gardon - Barach Belt :
Gardon barach belt and diaphragmatic breathing with active abdominal contraction
during expiration in design to cause a cephalic displacement of diaphragm.
Before inspiration give quick stretch is apply and pressure is maintained
during inspiration at the end of inspiration pressure is relieved.
Posterior basal expansion exercise :
Position : patient sit and lean forward on pillow slightly bending the rib.
61

Technique : Pressure is given unilaterally over the posterior aspect of the lower
rip and pressure is relieved at end of inspiration.

Pursed-lip breathing :
Increased the tidal volume
Improve exercise tolerance
Develop this pattern of breathing
Procedure :

patient assumes a comfortable position and relax as much as possible.

Explain to the patient that expiration must be relaxed on that contract of abdomen must
be avoided.
Place your hand over the patient abdominal muscle to detect breath in
slowly and deeply then have the patient loosely pure the lips and in able.

62

PREVENTION:

Early identification and treatment of conditions that tend to cause

bronchiectasis may prevent its development or reduce its severity.

More than half the cases of bronchiectasis in children can be accurately

diagnosed and promptly treated.

Childhood immunizations against measles and whooping cough,

improved living conditions, and good nutrition have markedly reduced
the number of people who develop bronchiectasis.

Influenza vaccines, pneumococcal vaccine, and use of appropriate

antibiotics early in the course of lung infections help to prevent
bronchiectasis or reduce its severity.

Receiving immunoglobulin for an immunoglobulin deficiency syndrome

may prevent recurring infections.

Avoiding toxic fumes, gases, smoke, and injurious dusts also helps
prevent bronchiectasis or reduce its severity.

Inhalation of foreign objects into the airways by children may be

prevented by watching what they put in their mouth.

Avoiding over-sedation from drugs or alcohol and seeking medical care

for neurologic symptoms (such as impaired consciousness) or
gastrointestinal symptoms (such as difficulty in swallowing and
regurgitation or coughing after eating) may help to prevent aspiration.

Also, drops of mineral oil or petroleum jelly should never be placed in

the nose because they can be inhaled into the lungs
63

CONCLUSION
According to the treatment i have conclude that prevention is always better than
cure. Hence the patient is advice to stop smoking, if he is chronic smoker. Patient is also
advice to take care of personal and environment hygine, health and good diet.
Physiotherapist has main role in treating the bronchiectasis patients, to prevent the
condition becoming worse.
The patient is given chest physiotherapy in the early stages itself to improve
the condition. Chest physiotherapy techniques include breath exercises, coughing,
huffing, manual techniques, postural drainage, mobility exercises, relaxation positions
ect.
Hence physiotherapy plays a major role in bringing out a good prognosis.

64