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<div class="editorbox"> '''Original Editor '''- [[User:User Name|Kate Wright]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
'''Original Editors '''- [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project|Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.]]
== Introduction ==
[[File:Bronchiectasis vs normal.jpeg|thumb|406x406px|Bronchiectasis changes ]]
Bronchiectasis is a [[Chronic Disease|chronic]] [[Lung Anatomy|lung]] disease identified by persistent and lifelong widening of the bronchial airways and weakening of the function mucociliary transport mechanism due to repeated [[Infectious Disease|infection]]. These airway changes allow for easier [[Bacterial Infections|bacterial]] invasion and extra mucus pooling in the widened airways, making them prone to infection<ref name=":1">Bird K, Memon J. Bronchiectasis.2017 Available:https://www.ncbi.nlm.nih.gov/books/NBK430810/ (accessed 20.10.2022)</ref>.


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} 
The condition is characterised by a persistent cough with excess amounts of mucus and, frequently, airflow obstruction together with episodes of worsening symptoms.<ref name=":3">AIHW Bronchiectasis Available:https://www.aihw.gov.au/reports/chronic-respiratory-conditions/bronchiectasis/contents/bronchiectasis (accessed 20.10.2022)</ref>
</div>  
== Definition  ==


Bronchiectasis is an obstructive lung disease that results from the presence of chronic inflammatory secretions and microbes leading to the permanent dilation and distortion of airway walls, as well as recurrent infection&nbsp;<ref name="p1">Barker AF. Bronchiectasis. New England Journal of Medicine 2002; 346: 1383-93.</ref>.  It is associated with frequent acute exacerbations, which are an independent predictor of progressive decline in respiratory function and a poorer prognosis<ref name=":1">Martinez-Garcia M, Soler-Cataluna J, Perpina-Tordera M, Roman-Sanchez P, Soriano J: Factors associated with lung function decline in adult patients with stable non-cystic fibrosis bronchiectasis. Chest 2007, 132:1565–1572</ref>
Watch this informative 2 minute video on Bronchiectasis.{{#ev:youtube|uNeprw1rsgE|300}}<ref name=":2">salamhossein. Bronchiectasis Animation - What is Bronchiectasis? Video.mp4. Available from: https://www.youtube.com/watch?v=uNeprw1rsgE [last accessed 18/5/15]</ref>
== Etiology ==
The cause of bronchiectasis is not always known. Some conditions known to cause bronchiectasis that affect or damage airways are:


<br>  
* Conditions that damage the airways, raising the risk of lung infections. For example: Allergic bronchopulmonary aspergillosis; pneumonia; measles; inherited  disorders eg Primary Ciliary Dyskinesia, Cystic Fibrosis
* Immunodeficiency: predisposes the person to lung infections.
* Pulmonary Diseases eg asthma, COPD
* Lung infections: may cause damage to the walls of the airways, for example tuberculosis (TB), whooping cough, measles, pneumonia, or fungal infections, particularly in childhood.
* Conditions that cause an airway blockage, such as a growth or a noncancerous tumour, regurgitated stomach acid, or inhaled objects that become stuck and block an airway.<ref name=":1" /><ref name=":3" />


[[Image:Bronchiectasis.png]]
== Epidemiology ==
<br>
Bronchiectasis predominance is not clearly understood. The incidence of bronchiectasis has risen over the past few years. It can exist in any age group, but it generally occurred in childhood during the pre-[[Antibiotics|antibiotic]] period. New evidence shows that bronchiectasis disproportionately affects women and older individuals.<ref name=":1" />
 
== Mechanism of Injury / Pathological Process  ==
 
Bronchiectasis is chronic irreversible dilation of the bronchi on the lungs. It follows a severe lung infection or aspiration. It is more common in conditions such as [[Cystic Fibrosis]], [[Rheumatoid Arthritis]], Immunodeficiency, Young's syndrome and [[Allergic Bronchopulmonary Aspergillosis]], and after childhood diseases such as whooping cough, [[Tuberculosis|TB]] and measles. Bronchiectasis that is not associated with Cystic Fibrosis is known as non-CF Brochiectasis<ref name=":1" />
 
<br>
 
{{#ev:youtube|uNeprw1rsgE|300}}<ref>salamhossein. Bronchiectasis Animation - What is Bronchiectasis? Video.mp4. Available from: https://www.youtube.com/watch?v=uNeprw1rsgE [last accessed 18/5/15]</ref> <br>


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==
[[File:11287146_10152761139840952_221013016_n.jpg|335x335px|alt=|thumb|Respiratory Anatomy]]
Bronchiectasis involves [[Inflammation Acute and Chronic|inflammation]] of the airway walls, specifically the bronchial walls <ref name="p2">Hough A. Physiotherapy in Respiratory and Cardiac Care: an evidence-based approach. 4th ed. Hampshire: Cengage Learning EMEA, 2014.</ref>. The main area that is affected in bronchiectasis is the bronchi <ref name="p2" />. For more detailed anatomy see [[Lung Anatomy]]


Bronchiectasis involves inflammation of the airway walls, specifically the bronchial walls <ref name="p2" />. The airway walls are the ‘tubes’ that run from the mouth and nose and travel to the lung. The main area that is affected in bronchiectasis is the bronchi <ref name="p2" />. The trachea bifurcates into the right and left main bronchi, which then further divide into secondary bronchi; one for each lobe of the lung <ref name="p3" />. They then divide into tertiary bronchi; one for each bronchopulmonary segment <ref name="p3">Palastanga N, Soames R. Anatomy and human movement: structure and function. 6th ed. New York: Churchill Livingstone; 2012.</ref>.  For more detailed anatomy see [[Lung Anatomy]]<br>
The cilia are also damaged in bronchiectasis and the mucociliary clearance of mucus is adversely affected. NB. Cilia line the airway and are attached to the epithelium. They are hair-like with tiny hooks on the tip to grab the mucous and help move the mucus up to the throat <ref name="p2" />.  
 
== Pathophysiology ==
<br>
The three most significant mechanisms that contribute to the pathogenesis of bronchiectasis are recurrent infections, airway obstruction, and peribronchial [[fibrosis]].<ref name=":1" />  
 
[[Image:11287146 10152761139840952 221013016 n.jpg]]<br>
 
<br>
 
The cilia are also damaged in bronchiectasis. Cilia line the airway and are attached to the epithelium. They are hair-like with tiny hooks on the tip to grab the mucous and help move the mucous up to the throat <ref name="p2" />. <br>
 
== Epidemiology  ==
 
It is underestimated in prevalence, incidence, and morbidity because symptoms are often ascribed to smoking. A study by Hill <ref name="p4">Hill AT, Welham S, Reid K, Bucknall CE. British Thoracic Society national bronchiectasis audit 2010 and 2011. Thorax 2012; 1:1-3.</ref>found that one in 1000 people in the UK have bronchiectasis, with associated deaths increasing at a rate of approximately 3% per year in England and Wales <ref name="p5" />. Though the overall mortality rate is increasing in these countries, rates in older groups are rising whereas rates in younger groups are falling &nbsp;<ref name="p5">Roberts HJ, Hubbard R. Trends in bronchiectasis mortality in England and Wales. Respiratory Medicine 2010; 104: 981-5.</ref>. A disproportionate amount of cases found in developing countries and in Aboriginal populations in affluent communities <ref name="p6" />. In some populations, an improvement in socio-economic status, housing, and education can improve overall health and reduce the incidence of respiratory infection and development of bronchiectasis <ref name="p6">Chang AB, Marsh RL, Vaughan-Smith HC, Hoffman LR. Emerging drugs for bronchiectasis. Informa healthcare 2012; 17: 361-378.</ref>. <br>  


== Aetiology  ==
# The process begins with [[Inflammation Acute and Chronic|inflammatory]] damage to the bronchial walls, which then stimulates the formation of excess thick mucus <ref name="p2" />.
# The warm and moist environment of the lungs combines with the mucus to cause further inflammation and obstruction, creating an excellent environment for infection <ref name="p2" />.
# The thick mucus crushes the cilia and causes further damage. The immune response releases toxic inflammatory chemicals (i.e. neutrophils), as well as leads to fibrosis and bronchospasm if persistent<ref name="p2" />.
== Diagnostic Procedures ==
[[File:Bronchiectasis.png|400x400px|alt=|right]]Bronchiectasis relies on both a clinical and radiological diagnosis.


The cause is unknown for 50% of cases, but it has been linked to inflammatory bowel disease, rheumatoid arthritis, and in 29-50% of patients, COPD <ref name="p7">Goeminne P, Dupont L. Non-cystic fibrosis bronchiectasis: Diagnosis and management in the 21st century. Postgrad Med J 2010; 86: 493-501.</ref>. There are several associated conditions with bronchiectasis including; cystic fibrosis, primary ciliary dyskinesia, lung tuberculosis, allergic bronchopulmonary aspergilosis, rheumatoid diseases, symptomatic lupus erythematosus, immune deficiency, severe childhood respiratory infection and exposure to foreign body or corrosive substance <ref name="p2" />. It has also been linked to an x1-antitrypsin deficiency <ref name="p2" />. Bronchiectasis tends to predispose patients to acquired and congenital lung infections&nbsp;<ref name="p2" />.<br>
Currently, a high-resolution CT scan is the gold standard for diagnosing bronchiectasis <ref name="p2" />. Findings are: bronchial wall dilation; failure of the bronchi to taper; visualisation of bronchi in the outer 1-2cm of the lung fields.<ref name=":4">Bronchiectasis.com Bronchiectasis Dx Available: https://bronchiectasis.com.au/bronchiectasis/diagnosis-2/how-is-it-diagnosed (accessed 20.10.2022)</ref><br>Microbiology can also be used to identify the bacteria present during an exacerbation <ref name="p2" />. A sputum sample is sent off and the results are returned with the incidence of bacterial colonization measured <ref name="p2" />.


== Pathophysiology  ==
== Medical History ==


The process begins with inflammatory damage to the bronchial walls, which then stimulates the formation of excess thick mucus <ref name="p2" />. The warm and moist environment of the lungs combines with the mucus to cause further inflammation and obstruction, creating an excellent environment for infection <ref name="p2" />. The thick mucus crushes the cilia and causes further damage. The immune response releases toxic inflammatory chemicals (i.e. neutrophils), as well as leads to fibrosis and bronchospasm if persistent<ref name="p2" />.<br>
* History of childhood infection or childhood respiratory symptoms
* Family history of bronchiectasis, especially cystic fibrosis
* Smoking history
* Presence of symptoms to suggest a systemic inflammatory disorder (joint problems, skin rash, muscle pain)
* Duration and severity of symptoms
* Frequency of infective exacerbations


== Diagnostic Procedures  ==
== Objective Examination ==


Currently, a high-resolution CT scan is the gold standard for diagnosis of bronchiectasis <ref name="p2" />. Parallel tramlines and ring shadows may be present on the scan, indicating thickened airway walls and dilated airways, respectively<ref name="p2" />. There may also be ‘glove finger shadows’, which are finger –like projections that represent the dilated bronchi filled with solidified secretions<ref name="p2" />.<br>Spirometry will simply identify if there is an airway obstruction, but this can be indicative of many other diseases<ref name="p2" />.<br>Microbiology can also be used to identify the bacteria present during an exacerbation <ref name="p2" />. A sputum sample is sent off and the results are returned with the incidence of bacterial colonization measured <ref name="p2" />. <br>
# Peripheral examination for signs of chronic lung disease e.g nail changes (clubbing) occur in some forms of bronchiectasis
# Cough quality, strength and sputum production
# Auscultation: Bronchiectasis is characterised by focal or generalised noises (crepitations, crackles, wheeze,) heard with the stethoscope.<ref name=":4" />
# Dyspnoea on exertion seems to be a major clinical manifestation as it is experienced by three out of four patients.
# Stress [[Urinary Incontinence|incontinence]] can also be a result of excess coughing. <ref name="p2" />.
# Exacerbations can occur several times a year and are identified by four or more of the following signs and/or symptoms: change in sputum, increased dyspnoea, increased cough, fever of greater than 38°, increased wheeze, decreased exercise tolerance, fatigue, lethargy, and radiographic signs of a new infection<ref name="p2" />.


== Clinical Manifestations  ==
== Management ==
The treatment of bronchiectasis involves promoting sputum clearance, using positional physiotherapy, and early and aggressive treatment of pulmonary infections. Some clients require chronic prophylactic administration of antibiotics.


As delicate cilia are often damaged due to the presence of thick mucus, the voluminous quantities of sputum formed cannot be efficiently cleared<ref name="p2" />. These secretions will lead to the production of wheezes, coarse crackles and squeaks on auscultation. Often times, patients will also present with muscular dysfunction due to inflammation, gas exchange abnormalities, inactivity, malnutrition, hypoxia and medications <ref name="p8">Ozalp O, Inal-Ince D, Calik E, Vardar-Yagli N, Saglam M, Savci S, et al. Extrapulmonary features of bronchiectasis: muscle function, exercise capacity, fatigue, and health status. Multidisciplinary Respiratory Medicine 2012; 7: 1-6.</ref>. Dyspnoea on exertion seems to be a major clinical manifestation as it is experienced by three out of four patients. Other physical manifestations include chest pain, snoring, finger clubbing, fatigue, persistent cough, recurrent infection, and loss of appetite<ref name="p2" />. Stress incontinence can also be a result of excess coughing. Bronchiectasis tends to also have psychological manifestations, such as anxiety, depression, reduced confidence, altered relationships and time off work<ref name="p2" />.<br>Exacerbations can occur several times a year and are identified by four or more of the following signs and/or symptoms: change in sputum, increased dyspnoea, increased cough, fever of greater than 38°, increased wheeze, decreased exercise tolerance, fatigue, lethargy, and radiographic signs of a new infection<ref name="p2" />.<br>
In cases where bronchiectasis is severe and causes significant morbidity, surgical resection of the affected lobe may be of the benefit provided sufficient respiratory reserve exists.


== Physiotherapy and Other Management  ==
When both lungs are extensively involved (e.g. cystic fibrosis) lung transplantation can be considered.<ref>Radiopedia Brochiectasis Available:https://radiopaedia.org/articles/bronchiectasis (accessed 20.10.2022)</ref>


The key to management of bronchiectasis is through education and systemic management. Currently, antibiotics are used at the first sign of change in sputum colour<ref name="p2" /> and longterm use of antibiotics is recommended for people who experience 3 or more exacerbations a year<ref name=":0">Hill AT, Sullivan AL, Chalmers JD, De Soyza A, Elborn JS, Floto RA, Grillo L, Gruffydd-Jones K, Harvey A, Haworth CS, Hiscocks E. British Thoracic Society Guideline for bronchiectasis in adults. Thorax. 2019 Jan 1;74(Suppl 1):1-69.</ref>. Since antibiotics do not help with the persistent inflammation in the airways, inhaled steroids are taken as an anti-inflammatory and to decrease sputum production<ref name="p2" />. Brochodilators tend to help patients who also have co-existing COPD and asthma<ref name=":0" />.  A review and a controlled study found that many people with bronchiectasis also have a Vitamin D deficiency and prescribing Vitamin D may have an anti-inflammatory and anti-infective role<ref>Bartley J, Garrett J, Grant CC, Camargo CA. Could vitamin D have a potential anti-inflammatory and anti-infective role in bronchiectasis?. Current infectious disease reports. 2013 Apr 1;15(2):148-57.</ref><ref>Chalmers JD, McHugh BJ, Docherty C, Govan JR, Hill AT. Vitamin-D deficiency is associated with chronic bacterial colonisation and disease severity in bronchiectasis. Thorax. 2013 Jan 1;68(1):39-47.</ref>. 
== Physiotherapy ==


<br>Physiotherapy has a very valuable role in aiding with symptoms of bronchiectasis. Since mucociliary clearance is reduced to about 15% of normal, patients tend to cough more<ref name="p2" />. Physiotherapy treatments are aimed at aiding secretion clearance, managing fatigue induced by the effort of ineffective clearance and increased coughing. The most common and effective treatments are:
Physiotherapy has a very valuable role in aiding with symptoms of bronchiectasis. Since mucociliary clearance is reduced to about 15% of normal, patients tend to cough more<ref name="p2" />. Physiotherapy treatments are aimed at aiding secretion clearance, managing fatigue induced by the effort of ineffective clearance and increased coughing.
* [[Active cycle of breathing technique|Active Cycle of Breathing Technique]] (ACBT) is a commonly taught technique and is often used with Postural drainage and manual drainage<ref>O’Neill B, Bradley JM, McArdle N, et al. The current physiotherapy management of patients with bronchiectasis: a UK survey. Int J Clin Pract 2002;56:34–5.</ref>.  Its purpose is to loosen and clear excess pulmonary secretions, improve the effectiveness of a cough and to improve lung ventilation and function. It consists of 3 main stages:
[[File:The Active Cycle of Breathing Technique.png|thumb|385x385px|Active Cycle of Breathing Technique.]]
** Breathing Control
[[File:Percussion and vibration.jpeg|thumb|399x399px|Percussion and vibration]]
** Deep Breathing Exercises or Thoracic Expansion Exercises
See [[Chest Physiotherapy]] for a comprehensive look at the most effective techniques.   [[File:Postural drainage examples.png|thumb|353x353px|Postural drainage examples]]The most common treatments are:
** Huffing or Forced Expiratory Technique (FET)<ref>Larner E, Galey P. [http://www.nnuh.nhs.uk/publication/active-cycle-of-breathing-technique-v3/ Active cycle of breathing technique]. Available from: http://www.nnuh.nhs.uk/publication/download/active-cycle-of-breathing-technique-v3 (accessed 24 March 2019)</ref>


* [[Active Cycle of Breathing Technique]] see link
* Forced expiration technique, sometimes referred to as a huff.  It is part of the ACBT but can be used alone.  A huff is very effective at clearing secretions especially when combined with other airway clearance techniques.<ref>Van der Schans CP. Forced expiratory manoeuvres to increase transport of bronchial mucus: a mechanistic approach. Monaldi archives for chest disease= Archivio Monaldi per le malattie del torace. 1997 Aug;52(4):367.</ref>
* Forced expiration technique, sometimes referred to as a huff.  It is part of the ACBT but can be used alone.  A huff is very effective at clearing secretions especially when combined with other airway clearance techniques.<ref>Van der Schans CP. Forced expiratory manoeuvres to increase transport of bronchial mucus: a mechanistic approach. Monaldi archives for chest disease= Archivio Monaldi per le malattie del torace. 1997 Aug;52(4):367.</ref>
* Manual Therapy is a popular treatment technique and is often used when the patient is fatigue or experiencing an exacerbation of symptoms.  It describes techniques that involve external forces to the chest wall to loosen mucus and includes any combination of [[percussion]], shaking, rib springing, vibrations and over pressure<ref>Syed N, Maiya AG, Siva Kumar T. Active Cycles of Breathing Technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis–a crossover trial. Advances in Physiotherapy. 2009 Jan 1;11(4):193-8.</ref>.  Because of the nature of the technique it is contraindicated in patients that are taking anticoagulants or that have osteoporosis<ref>Diehl N, Johnson MM. Prevalence of Osteopenia and Osteoporosis in Patients with Noncystic Fibrosis Bronchiectasis. South Med J. 2016;109(12):779-83</ref>.  The aim of treatment is to:
* Manual Therapy is a popular treatment technique and is often used when the patient is fatigue or experiencing an exacerbation of symptoms.  It describes techniques that involve external forces to the chest wall to loosen mucus and includes any combination of [[percussion]], shaking, rib springing, vibrations and over pressure<ref>Syed N, Maiya AG, Siva Kumar T. Active Cycles of Breathing Technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis–a crossover trial. Advances in Physiotherapy. 2009 Jan 1;11(4):193-8.</ref>.  Because of the nature of the technique, it is contraindicated in patients that are taking anticoagulants or that have osteoporosis<ref>Diehl N, Johnson MM. Prevalence of Osteopenia and Osteoporosis in Patients with Noncystic Fibrosis Bronchiectasis. South Med J. 2016;109(12):779-83</ref>.   
** Loosen secretions
* [[Postural Drainage]] is an effective treatment that incorporates gravity-assisted techniques to help clear secretions from specific segments of the lungs, and often requires tilting the head down to clear secretions from the middle and lower lobes. See link
** Reduce fatigue
* [[Autogenic Drainage]] is a technique that utilises breathing control to clear secretions from the airways.  The aim is to vary the depth, rate and location of lung volumes during respiration to move secretions from the smaller airways to the larger airways for easier expectoration.   
** Increase the effectiveness of other treatment techniques
* [[Positive Expiratory Pressure (PEP) Devices|Positive Expiratory Pressure (PEP)]] is a technique that describes breathing against resistance and can be performed either through a device or against pursed lips.
 
* High-Frequency Chest Wall Oscillation is achieved by wearing a vest that emulates chest physiotherapy.  The vest applies positive pressure air pulses to the chest which causes vibrations that loosen and thin mucus, This along with an intermittent cough or huff assists with the clearance of secretions.  Allows people to perform therapy in their own time.
* Postural Drainage (or modified postural drainage) is an effective treatment that incorporates gravity-assisted techniques to help clear secretions from specific segments of the lungs, and often requires tilting the head down to clear secretions from the middle and lower lobes. PD is commonly used in conjunction with other techniques like ACBT, percussion, coughing or huffing and studies have found using PD with these techniques produced a greater amount of sputum<ref>Ramos EM, Ramos D, Moreira GL, Macchione M, Guimarães ET, Rodrigues FM, de Souza AA, Saldiva PH, Jardim JR. Viscoelastic properties of bronchial mucus after respiratory physiotherapy in subjects with bronchiectasis. Respiratory care. 2015 May 1;60(5):724-30.</ref><ref name=":2">Flude LJ, Agent P, Bilton D. Chest physiotherapy techniques in bronchiectasis. Clinics in chest medicine. 2012 Jun 1;33(2):351-61.</ref>.  Although  PD is effective in secretion clearance it is time consuming and often found to be less tolerated than techniques that are performed in sitting<ref name=":2" />.  Where tilting the head down is contraindicated or not tolerated then modified postural drainage (mPD) positions can be used instead and in cases where gastroesophageal reflux disease GORD) is present and exacerbated even when using modified PD then it is suggested to use a technique that can be performed in sitting. 
* Intrapulmonary Percussive Ventilation. Intrapulmonary percussive ventilator (IPV) is a machine that delivers short bursts of air through a mouthpiece that vibrates the airway walls<ref>Paneroni M, Clini E, Simonelli C, et al. Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis. Respir Care 2011;56:984–8.</ref>.  It is indicated for short-term use when other techniques are contraindicated or have proved ineffective.
 
* [[Intermittent positive pressure breathing|Intermittent Positive Pressure Breathing]] (IPPB). A technique used to provide short term or intermittent mechanical ventilation via mouthpiece or mask for the purpose of augmenting lung expansion and delivering aerosol medication. IPPB may be applied to intubated as well as nonintubated patients
* [[Autogenic Drainage]] is a technique that utilises breathing control to clear secretions from the airways.  The aim is to vary the depth, rate and location of lung volumes during respiration to move secretions from the smaller airways to the larger airways for easier expectoration.  It consists of three phases:
* [[Physical Activity and Respiratory Conditions|Physical Exercise]] is recommended for respiratory conditions, including bronchiectasis with the aim of improving aerobic capacity and, fitness and endurance.  A study by Lee et al concluded that exercise resulted in short term improvements and had an impact on dyspnoea and fatigue, and resulted in fewer exacerbations over a 12 month period<ref>Lee AL, Hill CJ, Cecins N, et al. The short and long term effects of exercise training in non-cystic fibrosis bronchiectasis--a randomised controlled trial. Respir Res
## Mobilising (unstick) phase - involves breathing as much air out of the lungs as possible and resisting the urge to cough.  During this phase crackles may be heard.
## Collecting phase - as the secretions get louder the rate and depth of the breaths change, the speed of breathing out is faster (but not too fast to stimulate a cough) and are felt more in the middle of the chest.  This assists the movement of secretions from the smaller airways to the larger airways.
## Clearing phase - as the secretions get louder the aim is now to take full, slow deep breaths in, followed by a fast breath out.  Suppress the urge to cough and after three deep breaths huff to expel the secretions.  Often the huff is enough to clear secretions but if they are ineffective this is the stage where a cough may be effective in clearing secretions.
* [[Positive Expiratory Pressure (PEP) Devices|Positive Expiratory Pressure (PEP)]] is a technique that describes breathing against resistance, and can be performed either through a device or against pursed lips. It is a technique which is recommended when other techniques have not been effective or are contraindicated; it has been found to have no adverse effect of GORD.<ref>Lee AL, Denehy L, Wilson JW, et al. Upright positive expiratory pressure therapy and exercise: effects on gastroesophageal reflux in COPD and bronchiectasis. Respir Care 2012;57:1460–7.</ref>  The increase in pressure creates back pressure in the airways during expiration.  This may cause a build up of gas behind the mucus, temporarily increasing functional capacity, and improving mucus clearance.<ref>McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews. 2015(6).</ref>
 
High Frequency Chest Wall Oscillation is achieved by wearing a vest that emulates chest physiotherapy.  The vest applies positive pressure air pulses to the chest which causes vibrations that loosen and thin mucus, This along with an intermittent cough or huff assists with the clearance of secretions.  This device allows people to perform therapy in their own time, allowing them some control and less dependence on other people.  
 
Intrapulmonary Percussive Ventilation is another technique that relies on a device to assist with the clearance of secretions. An intrapulmonary percussive ventilator (IPV) is a machine that delivers short bursts of air through a mouthpiece that vibrates the airway walls<ref>Paneroni M, Clini E, Simonelli C, et al. Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis. Respir Care 2011;56:984–8.</ref>.  It is indicated for short-term use when other techniques are contraindicated or have proved ineffective.
 
[[Intermittent positive pressure breathing|Intermittent Positive Pressure Breathing]]<nowiki/>i(IPPB), it is an expensive piece of equipment<ref>Eggertsen SC. Intermittent positive pressure breathing and the treatment of acute asthma. The Journal of family practice. 1983 May;16(5):909-13.</ref> ands usesually only ud when all other clearance techniques have proved to be ineffective<ref name=":0" />.  It is commonly seen in Intensive Care and gives positive pressure as the patient breathes in, and during expiration it creates negative pressure making the cough stronger and more effective
 
[[Physical Activity and Respiratory Conditions|Physical Exercise]] is recommended for respiratory conditions, including bronchiectasis with the aim of improving aerobic capacity and, fitness and endurance.  A study by Lee et al concluded that exercise resulted in short term improvements and had an impact on dyspnoea and fatigue, and resulted in less exacerbations over a 12 month period<ref>Lee AL, Hill CJ, Cecins N, et al. The short and long term effects of exercise training in non-cystic fibrosis bronchiectasis--a randomised controlled trial. Respir Res


2014;15:44.
2014;15:44.
</ref>.
</ref>.
==  Outcome Measures  ==


In order to assess the effectiveness of treatment and changes in quality of life, patients can complete a St. George’s Respiratory Questionnaire (SGRQ) <ref name="p2">Hough A. Physiotherapy in Respiratory and Cardiac Care: an evidence-based approach. 4th ed. Hampshire: Cengage Learning EMEA, 2014.</ref>. The SGRQ is a commonly used questionnaire to measures health related quality of life in patients with respiratory conditions <ref name="p9">Ferrer M, Miravitlles M, Villasante C, Alonso J, Sobradillo V, Gabriel R, et al. Interpretation of quality of life scores from the St George's Respiratory Questionnaire. Eur Respir J 2002;19(3):405-13.</ref>.<br>
== Outcome Measures ==
The following could be used, many exist:
* [[Dyspnoea Management Questionnaire]]
* [[Incentive Spirometry]]
* [[Borg Rating Of Perceived Exertion]]
* [[Leicester Cough Questionnaire]]<ref>Birring SS, Prudon B, Carr AJ, Singh SJ, Morgan MD, Pavord ID. Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ). Thorax. 2003 Apr 1;58(4):339-43.</ref>
* [[2 Minute Walk Test]]


== References  ==
== References  ==
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[[Category:Acute Care]]
[[Category:Acute Care]]
[[Category:Medical]]
[[Category:Medical]]
[[Category:Chronic Respiratory Disease - Conditions]]
[[Category:Genetic Disorders]]

Latest revision as of 02:49, 21 October 2022

Original Editor - Kate Wright Top Contributors - Kim Jackson, Lucinda hampton, Jordan Tremblay, Remy Valiaveettil, Admin, Kate Wright, WikiSysop, 127.0.0.1, Laura Ritchie, Evan Thomas, Michelle Lee, Karen Wilson, Vidya Acharya and Manisha Shrestha

Introduction[edit | edit source]

Bronchiectasis changes

Bronchiectasis is a chronic lung disease identified by persistent and lifelong widening of the bronchial airways and weakening of the function mucociliary transport mechanism due to repeated infection. These airway changes allow for easier bacterial invasion and extra mucus pooling in the widened airways, making them prone to infection[1].

The condition is characterised by a persistent cough with excess amounts of mucus and, frequently, airflow obstruction together with episodes of worsening symptoms.[2]

Watch this informative 2 minute video on Bronchiectasis.

[3]

Etiology[edit | edit source]

The cause of bronchiectasis is not always known. Some conditions known to cause bronchiectasis that affect or damage airways are:

  • Conditions that damage the airways, raising the risk of lung infections. For example: Allergic bronchopulmonary aspergillosis; pneumonia; measles; inherited disorders eg Primary Ciliary Dyskinesia, Cystic Fibrosis
  • Immunodeficiency: predisposes the person to lung infections.
  • Pulmonary Diseases eg asthma, COPD
  • Lung infections: may cause damage to the walls of the airways, for example tuberculosis (TB), whooping cough, measles, pneumonia, or fungal infections, particularly in childhood.
  • Conditions that cause an airway blockage, such as a growth or a noncancerous tumour, regurgitated stomach acid, or inhaled objects that become stuck and block an airway.[1][2]

Epidemiology[edit | edit source]

Bronchiectasis predominance is not clearly understood. The incidence of bronchiectasis has risen over the past few years. It can exist in any age group, but it generally occurred in childhood during the pre-antibiotic period. New evidence shows that bronchiectasis disproportionately affects women and older individuals.[1]

Clinically Relevant Anatomy[edit | edit source]

Respiratory Anatomy

Bronchiectasis involves inflammation of the airway walls, specifically the bronchial walls [4]. The main area that is affected in bronchiectasis is the bronchi [4]. For more detailed anatomy see Lung Anatomy

The cilia are also damaged in bronchiectasis and the mucociliary clearance of mucus is adversely affected. NB. Cilia line the airway and are attached to the epithelium. They are hair-like with tiny hooks on the tip to grab the mucous and help move the mucus up to the throat [4].

Pathophysiology[edit | edit source]

The three most significant mechanisms that contribute to the pathogenesis of bronchiectasis are recurrent infections, airway obstruction, and peribronchial fibrosis.[1]

  1. The process begins with inflammatory damage to the bronchial walls, which then stimulates the formation of excess thick mucus [4].
  2. The warm and moist environment of the lungs combines with the mucus to cause further inflammation and obstruction, creating an excellent environment for infection [4].
  3. The thick mucus crushes the cilia and causes further damage. The immune response releases toxic inflammatory chemicals (i.e. neutrophils), as well as leads to fibrosis and bronchospasm if persistent[4].

Diagnostic Procedures[edit | edit source]

Bronchiectasis relies on both a clinical and radiological diagnosis.

Currently, a high-resolution CT scan is the gold standard for diagnosing bronchiectasis [4]. Findings are: bronchial wall dilation; failure of the bronchi to taper; visualisation of bronchi in the outer 1-2cm of the lung fields.[5]
Microbiology can also be used to identify the bacteria present during an exacerbation [4]. A sputum sample is sent off and the results are returned with the incidence of bacterial colonization measured [4].

Medical History[edit | edit source]

  • History of childhood infection or childhood respiratory symptoms
  • Family history of bronchiectasis, especially cystic fibrosis
  • Smoking history
  • Presence of symptoms to suggest a systemic inflammatory disorder (joint problems, skin rash, muscle pain)
  • Duration and severity of symptoms
  • Frequency of infective exacerbations

Objective Examination[edit | edit source]

  1. Peripheral examination for signs of chronic lung disease e.g nail changes (clubbing) occur in some forms of bronchiectasis
  2. Cough quality, strength and sputum production
  3. Auscultation: Bronchiectasis is characterised by focal or generalised noises (crepitations, crackles, wheeze,) heard with the stethoscope.[5]
  4. Dyspnoea on exertion seems to be a major clinical manifestation as it is experienced by three out of four patients.
  5. Stress incontinence can also be a result of excess coughing. [4].
  6. Exacerbations can occur several times a year and are identified by four or more of the following signs and/or symptoms: change in sputum, increased dyspnoea, increased cough, fever of greater than 38°, increased wheeze, decreased exercise tolerance, fatigue, lethargy, and radiographic signs of a new infection[4].

Management[edit | edit source]

The treatment of bronchiectasis involves promoting sputum clearance, using positional physiotherapy, and early and aggressive treatment of pulmonary infections. Some clients require chronic prophylactic administration of antibiotics.

In cases where bronchiectasis is severe and causes significant morbidity, surgical resection of the affected lobe may be of the benefit provided sufficient respiratory reserve exists.

When both lungs are extensively involved (e.g. cystic fibrosis) lung transplantation can be considered.[6]

Physiotherapy[edit | edit source]

Physiotherapy has a very valuable role in aiding with symptoms of bronchiectasis. Since mucociliary clearance is reduced to about 15% of normal, patients tend to cough more[4]. Physiotherapy treatments are aimed at aiding secretion clearance, managing fatigue induced by the effort of ineffective clearance and increased coughing.

Active Cycle of Breathing Technique.
Percussion and vibration

See Chest Physiotherapy for a comprehensive look at the most effective techniques.

Postural drainage examples

The most common treatments are:

  • Active Cycle of Breathing Technique see link
  • Forced expiration technique, sometimes referred to as a huff. It is part of the ACBT but can be used alone. A huff is very effective at clearing secretions especially when combined with other airway clearance techniques.[7]
  • Manual Therapy is a popular treatment technique and is often used when the patient is fatigue or experiencing an exacerbation of symptoms. It describes techniques that involve external forces to the chest wall to loosen mucus and includes any combination of percussion, shaking, rib springing, vibrations and over pressure[8]. Because of the nature of the technique, it is contraindicated in patients that are taking anticoagulants or that have osteoporosis[9].
  • Postural Drainage is an effective treatment that incorporates gravity-assisted techniques to help clear secretions from specific segments of the lungs, and often requires tilting the head down to clear secretions from the middle and lower lobes. See link
  • Autogenic Drainage is a technique that utilises breathing control to clear secretions from the airways. The aim is to vary the depth, rate and location of lung volumes during respiration to move secretions from the smaller airways to the larger airways for easier expectoration.
  • Positive Expiratory Pressure (PEP) is a technique that describes breathing against resistance and can be performed either through a device or against pursed lips.
  • High-Frequency Chest Wall Oscillation is achieved by wearing a vest that emulates chest physiotherapy. The vest applies positive pressure air pulses to the chest which causes vibrations that loosen and thin mucus, This along with an intermittent cough or huff assists with the clearance of secretions. Allows people to perform therapy in their own time.
  • Intrapulmonary Percussive Ventilation. Intrapulmonary percussive ventilator (IPV) is a machine that delivers short bursts of air through a mouthpiece that vibrates the airway walls[10]. It is indicated for short-term use when other techniques are contraindicated or have proved ineffective.
  • Intermittent Positive Pressure Breathing (IPPB). A technique used to provide short term or intermittent mechanical ventilation via mouthpiece or mask for the purpose of augmenting lung expansion and delivering aerosol medication. IPPB may be applied to intubated as well as nonintubated patients
  • Physical Exercise is recommended for respiratory conditions, including bronchiectasis with the aim of improving aerobic capacity and, fitness and endurance. A study by Lee et al concluded that exercise resulted in short term improvements and had an impact on dyspnoea and fatigue, and resulted in fewer exacerbations over a 12 month period[11].

Outcome Measures[edit | edit source]

The following could be used, many exist:

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Bird K, Memon J. Bronchiectasis.2017 Available:https://www.ncbi.nlm.nih.gov/books/NBK430810/ (accessed 20.10.2022)
  2. ↑ 2.0 2.1 AIHW Bronchiectasis Available:https://www.aihw.gov.au/reports/chronic-respiratory-conditions/bronchiectasis/contents/bronchiectasis (accessed 20.10.2022)
  3. ↑ salamhossein. Bronchiectasis Animation - What is Bronchiectasis? Video.mp4. Available from: https://www.youtube.com/watch?v=uNeprw1rsgE [last accessed 18/5/15]
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Hough A. Physiotherapy in Respiratory and Cardiac Care: an evidence-based approach. 4th ed. Hampshire: Cengage Learning EMEA, 2014.
  5. ↑ 5.0 5.1 Bronchiectasis.com Bronchiectasis Dx Available: https://bronchiectasis.com.au/bronchiectasis/diagnosis-2/how-is-it-diagnosed (accessed 20.10.2022)
  6. ↑ Radiopedia Brochiectasis Available:https://radiopaedia.org/articles/bronchiectasis (accessed 20.10.2022)
  7. ↑ Van der Schans CP. Forced expiratory manoeuvres to increase transport of bronchial mucus: a mechanistic approach. Monaldi archives for chest disease= Archivio Monaldi per le malattie del torace. 1997 Aug;52(4):367.
  8. ↑ Syed N, Maiya AG, Siva Kumar T. Active Cycles of Breathing Technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis–a crossover trial. Advances in Physiotherapy. 2009 Jan 1;11(4):193-8.
  9. ↑ Diehl N, Johnson MM. Prevalence of Osteopenia and Osteoporosis in Patients with Noncystic Fibrosis Bronchiectasis. South Med J. 2016;109(12):779-83
  10. ↑ Paneroni M, Clini E, Simonelli C, et al. Safety and efficacy of short-term intrapulmonary percussive ventilation in patients with bronchiectasis. Respir Care 2011;56:984–8.
  11. ↑ Lee AL, Hill CJ, Cecins N, et al. The short and long term effects of exercise training in non-cystic fibrosis bronchiectasis--a randomised controlled trial. Respir Res 2014;15:44.
  12. ↑ Birring SS, Prudon B, Carr AJ, Singh SJ, Morgan MD, Pavord ID. Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ). Thorax. 2003 Apr 1;58(4):339-43.
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