ABSTRACT

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.

DEFINISION
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.
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CLINICAL MANIFESTATIONS
a. 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.
b. 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.
c. 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.
d. General ill-health:
Patients may suffer pyrexia, night sweats, anorexia, malaise, weight loss, lassitude
and oint pains.
e. 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
curvature of the nail, and an increase in the soft tissue of the ends of the fingers, forming
so- called drumstick fingers.
f. Thoracic Mobility
This gradually decreases, as do shoulder girdle movements.
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
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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.
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.
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.
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

INVESTIGATIONS
Diagnostic Tests and Procedures:
a. 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.
b. 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.
c. 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.
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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
deliver oxygen to your blood. Lung function tests help show how much lung
damage you have.

d. 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.
MANAGEMENT
A. 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
Bronchodilator therapy is as follows:
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a. 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.
b. 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.
B. 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.
a. 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.

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.

b. 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.
c. 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.
d. 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.
e. 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.
Active cycle of breathing techniques (ACBT)
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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 :
It is normal tidal breathing using the lower chest with relaxation of upper
extremities.
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.
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 is aerobic exercises, walking, swimming,
cycling, jogging, treadmill, gymnastics
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.
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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

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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.

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