I. Preface
Bronchiectasis is a common chronic septic inflammatory disease of the respiratory system. In recent years, the incidence of this disease has decreased significantly. However, with the application of HRCT, its detection rate has been increasing, and the incidence increases with age.
II. Definition
Bronchiectasis is the irreversible dilatation and deformation of one or more proximal bronchi or medium-sized bronchi due to the destruction of the bronchial wall muscles and elastic tissues by its own and surrounding inflammation. The clinical manifestations are mainly chronic cough, copious pus sputum and recurrent hemoptysis. Most of them are secondary to respiratory tract infections and bronchial obstruction, and mainly occur in children and young adults.
Etiology and pathogenesis
Bronchiectasis is divided into two types: congenital and secondary. Congenital is relatively rare, mainly due to congenital bronchial dysplasia. Secondary bronchiectasis is more common, and the key is the recurrence of inflammation, forming a vicious circle. Recurrent infections of bronchio-pulmonary tissues, bronchial obstruction and the involvement of the bronchial wall by negative pressure in the chest cavity interact with each other. All kinds of recurrent lung infections in childhood can lead to bronchial degeneration and dilatation. In adults, repeated lung infections and tumor compression of the bronchi narrow the lumen and cause poor drainage of sputum, resulting in distal bronchial dilatation; pulmonary fibrosis caused by tuberculosis also stretches the bronchi and causes bronchial dilatation and degeneration. Other respiratory diseases such as allergic bronchopulmonary aspergillosis, bronchial asthma, sinusitis, etc. are also important factors causing bronchial dilatation.
Bronchiectasis is mainly classified into cystic and columnar dilatation according to morphology, and often presents as mixed. Congenital dilatation is mostly cystic, while secondary dilatation is mostly columnar and mixed. It is most often seen in the lower lobe, with the left lower lobe, lingual lobe and right middle lobe being particularly common. In severe cases, chronic pulmonary heart disease may develop.
IV. Clinical manifestations
Most patients with bronchiectasis often have a history of measles, whooping cough, tuberculosis or bronchopneumonia that persists in childhood, and thereafter often have recurrent respiratory infections. The typical symptoms are chronic cough with large amount of pus sputum and repeated hemoptysis.
(A) Symptoms
1. Chronic cough and coughing up large amounts of purulent sputum are characteristic symptoms of the disease, often manifesting as large amounts of purulent sputum when the position changes, such as coughing up increased amounts of sputum when rising in the morning or lying in bed at night. In acute attacks of infection, yellow-green pus sputum increases significantly and can reach hundreds of ml per day in many cases. if there is anaerobic bacterial infection, the sputum has a foul odor. The sputum is collected in a glass bottle and separated into three layers: the upper layer is foam, the lower layer is suspended with purulent components, the middle layer is cloudy mucus, and the bottom layer is necrotic tissue. The sputum volume was used to estimate the severity: mild ＜10ml/d; moderate 10-150ml/d; severe ＞150ml/d.
2. Recurrent hemoptysis. Hemoptysis can occur repeatedly, and hemoptysis can be manifested as blood in sputum or even hemoptysis, and the amount of hemoptysis is sometimes not consistent with the severity of the disease. Some patients only show hemoptysis without cough and sputum, which is clinically called “dry bronchiectasis”. This kind of bronchial dilatation is mostly located in a well-drained area and is not easily infected, often due to tuberculosis.
3.Recurrent lung infections. Certain patients have concurrent chest pain and chest tightness. Inflammation extends to the lung tissue around the lesion, and symptoms such as high fever, poor nausea, night sweats, wasting and anemia may occur. Once the bronchial drainage is clear and a large amount of pus sputum is discharged, the patient’s symptoms may improve significantly.
(ii) Physical signs
Early stage of the disease or dry bronchiectasis often has no obvious pulmonary signs. When the lesion is severe or secondary infection is present, it is often possible to smell a coarse wet woven woven grass with a fixed site = min ship cormorant and a woven grass B disaster (18) and a woven grass (18) and a woven grass (18) and a woven grass with a fixed site.
V. Laboratory tests
(A) X-ray examination
Mild cases often have no abnormal findings. The typical X-ray bronchial columnar dilatation is shown as the “orbital sign”, which is a thickened bronchial wall shadow; cystic dilatation is shown as multiple irregular annular translucent shadows in the coarse and disorganized lung texture or curly hair shadows distributed along the bronchus, typically in the form of honeycomb or curly hair shadows, that is, the “curly hair sign In typical cases, the shadows appear as honeycomb or curly shadows, i.e., the “curly hair sign”. Some bronchiectasis without obvious changes require high-resolution CT of the chest (HRCT). In case of combined lung tissue infection, the X-ray shows patchy shadow.
(ii) CT examination
It can detect small bronchiectasis, which is characterized by bronchial dilatation with thickened walls and a diameter larger than the diameter of the accompanying vessels. HRCT occupies a very important position in the diagnosis of bronchiectasis and has basically replaced bronchography.
(iii) Bronchography
It can help to confirm the diagnosis of bronchial dilatation and clarify the site, nature and extent of bronchial dilatation, which can provide a basis for surgical decision on the scope of resection. However, it has been replaced by non-invasive HRCT in recent years.
(iv) Bronchoscopy
Fiberoptic bronchoscopy is generally not required for the diagnosis of bronchiectasis. This examination can be considered when there is bleeding, suspected foreign body or tumor obstruction, and more sputum. Local lavage can be performed to obtain smear Gram stain, bacterial culture and antacid stain, and cytological examination of the flushing fluid. For obstructed bronchus, fiberoptic bronchoscopy can be performed, which mainly involves local lavage and sputum aspiration to achieve the purpose of bronchus patency and sputum elimination.
(V) Sputum examination
Microbiological, cytological and pathological examinations of lower respiratory secretions should be performed in all patients to clarify the pathogenic bacteria species and to guide the use of antibiotics and other related diagnoses. Consistent isolation of S. aureus/Pseudomonas aeruginosa from lower respiratory secretions should be noted to exclude allergic bronchopulmonary aspergillosis and cystic fibrosis. To improve the detection rate, microbiological tests should be sent within 3 h of admission or before antibiotic treatment.
(F) Pulmonary function tests
Including ventilation, air exchange function and blood gas analysis examination. Patients treated with internal medicine, regular review can be compared to observe the effect of treatment and assess the prognosis. Pulmonary function tests should be performed at least once a year for general patients and at least four times a year for patients with immunodeficiency and primary cilia dysfunction.
(vii) Blood tests
Serum immunoglobulins (IgG,IgA,IgM) and serum electrophoresis to rule out antibody deficiency.
When the diagnosis of allergic bronchopulmonary aspergillosis is suspected, fumonisin allergen precipitation antibody, serum anti-trichomonas specific IgE, IgG antibody and serum total IgE level should be examined, and the above three tests are the serological diagnostic methods for the disease.
Six, the diagnosis routine
(A) Diagnostic basis
1. Medical history and symptoms: there may be a history of measles, whooping cough, bronchopneumonia, tuberculosis, etc. in early childhood; symptoms include chronic cough and sputum, with varying amounts and nature of sputum; some have hemoptysis, with varying amounts and causes; recurrent attackers may have intermittent fever, fatigue, poor appetite, panic, shortness of breath, etc.
2. Physical examination: there may be chronic infectious lesions in the oropharynx; early and mild cases have no abnormal signs.
3.Examination: imaging, pus sputum and 24-hour sputum volume, the number of infection exacerbations per year and the use of antibiotics should be evaluated during the stable phase.
The clinical manifestations of acute exacerbation of branched expansion are.
① changes in sputum volume and character.
② increase in dysphagia.
③ increase in cough.
④ fever (body temperature >38°C).
⑤ increased wheezing.
⑥ discomfort, fatigue, lethargy or decreased exercise endurance.
(vii) Decreased lung function.
⑧ lung imaging changes consistent with changes in the condition.
⑨ change in lung auscultation. Diagnosis can be made by the presence of 4 of the above symptoms.
Possible bronchiectasis should be considered in the following cases.
(1) Long-term cough and sputum, especially if you have frequent “colds” or have been coughing and sputum since childhood.
(ii) Bronchial asthma that has been poorly treated with regular therapy.
③Patients with chronic inspiratory symptoms and positive sputum cultures for the following bacteria: Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa, Mycobacterium non-tuberculosis, Mycobacterium onychoplasma, etc.
(iv) Patients with severe pneumonia, especially those with incomplete improvement in symptoms, signs or imaging.
(v) Pertussis-like cough that persists for 6 months without improvement.
(vi) Recurrent pneumonia.
(vii) Unexplained hemoptysis or dry cough, or prolonged heavy coughing of pus sputum.
(viii) Long-term localized wet woven wool in the lungs on auscultation
For all patients with bronchiectasis, attention should be paid to exclude congenital defects of tracheobronchus, tracheobronchial hypertrophy, airway foreign bodies, long-term aspiration, tuberculosis and other diseases. Certain systemic diseases, such as rheumatoid arthritis, systemic lupus erythematosus, Crohn’s disease, ulcerative colitis, immunodeficiency (especially antibody deficiency), primary ciliary dyskinesia syndrome (which can be combined with bronchiectasis, sinusitis, otitis media, infertility, right-sided heart, etc., the so-called Kartagener syndrome), yellow nail syndrome, gastroesophageal reflux disease, etc. are often combined with bronchiectasis (b) Differential diagnosis
(B) Differential diagnosis
1. Chronic bronchitis: It occurs mostly in middle-aged patients and above, and the cough and sputum are obvious in the winter and spring seasons when the climate is changeable, mostly white mucus sputum and less purulent sputum. The amount of sputum is not much, no history of repeated hemoptysis, most of the two lung bottom with scattered fine dry and wet woven S tremor framedЪ frightened quercus stole curtain strife base 瘥抑粗芾拧
2, lung abscess: rapid onset, with high fever, chills, cough, large amount of purulent sputum; X-ray examination can be seen as a dense local inflammatory shadow, and may have gas-fluid flat. After acute lung abscess is treated with effective antibiotics, the inflammation can be completely subsided and absorbed. In case of chronic lung abscess, there is a past history of acute lung abscess.
3, pulmonary tuberculosis: there are often symptoms of tuberculosis systemic toxicity such as low fever, night sweats, malaise, wasting, etc. Dry and wet poopdeck waving admonition play the dune X-ray chest X-ray and sputum tuberculosis bacillus examination can help to make a clear diagnosis. It is worth mentioning that pulmonary tuberculosis is often combined with bronchiectasis.
4, pulmonary cysts: thin-walled cystic no pulmonary texture area, CT examination without inflammation.
5, diffuse panbronchitis: chronic cough and sputum, dyspnea, history of chronic sinusitis, small nodular shadows with diffuse distribution of poorly defined borders are seen on CT examination, and as the lesion progresses reticular shadows and images of cystic dilatation may appear in the lower lung fields. Positive rheumatoid factor, antinuclear antibody, and condensation set test. Pathological examination may confirm the diagnosis. Macrolide antibiotic treatment is effective for more than 2 months.
VII. Treatment routine
The aim of treatment is to maintain and improve pulmonary function, prevent disease progression, and reduce recurrent infections and acute exacerbations; pediatric patients should be treated on this basis to ensure good growth and development. The key is to keep the respiratory tract open for drainage and effective antibacterial drugs. Some patients can be treated at home; for patients with severe signs of infection, respiratory or circulatory failure, severe hypoxia, temperature greater than 38°C, respiratory rate greater than 25 breaths/min, and inability to take oral medication, they must be admitted to hospital. For patients with chronic respiratory failure due to bronchodilation, noninvasive ventilation can improve quality of life and reduce the frequency of acute exacerbations.
(I) General treatment
It includes strengthening nutrition, enhancing immunity, moderate exercise and pulmonary rehabilitation training to avoid recurrent infections. Vaccines and immunomodulators can be administered.
(B) Keep the respiratory tract unobstructed
1, postural drainage: the role of postural drainage is sometimes more important than antibiotic treatment, so that the affected lung is in a high position, drainage bronchial opening downward can make sputum drainage to the trachea and cough out with the body position. HRCT should be performed before postural drainage to clarify the lesion site, and drainage should be performed in different positions according to the lesion site. Currently, it is recommended to drain 1-2 times a day for no more than 20-30 minutes each time. During postural drainage, intermittent deep breathing followed by forceful coughing can be combined with patting the affected area with hands to improve the drainage effect. There is also the method of extrathoracic vibration for sputum drainage. For patients with more sputum drainage, attention should be paid to coughing out the sputum gradually to prevent choking due to excessive sputum gushing out; attention should also be paid to avoid accidents due to excessive increase in respiratory and circulatory physiological burden of patients. If the patient performs the body drainage outside the hospital, it is recommended to follow up at least once in 3 months.
2. Bronchoscopy can be used for local bronchial lavage and sputum aspiration. Most patients with bronchiectasis have poor ability to self-expectorate, especially those who are elderly and have poor lung function. Helping patients to expectorate with the help of bronchoscopy can achieve good therapeutic effect. Most patients have good improvement of dyspnea after bronchoscopy-assisted treatment. However, caution should be exercised for those with poor cardiopulmonary function.
3.Expectorants: There are more kinds of expectorants. Commonly used drugs include ambroxol, acetylcysteine, bromoxyn and so on. You can also use these expectorant solutions for nebulized inhalation, or saline or hypertonic saline for ultrasonic nebulized inhalation to reduce the viscosity of sputum. If necessary, nebulized inhalation of bronchodilators, such as β2 agonist salbutamol, anticholinergic ipratropium bromide, etc., to relieve bronchospasm, and then make postural drainage to improve the efficacy. At present, the routine use of glucocorticoids and theophyllines is not recommended. There is no evidence that leukotriene receptor antagonists and some other anti-inflammatory drugs such as indomethacin have value in bronchiectasis.
(iii) Control of infection
When patients have only mucus sputum or mucopurulent sputum with no significant change in sputum volume, long-term antibiotic use is not recommended. When patients have acute exacerbation and worsening symptoms, such as cough, increased sputum volume or significant change in sputum character, or change in consciousness, with or without shortness of breath, wheezing, or hemoptysis, they should be treated with antibiotics as early as possible. The aim of treatment is to control bacterial infection, reduce bacterial load, and interrupt the vicious cycle of inflammation in branched expansion, but not necessarily to clear the bacteria.
Antibacterial drug selection is mainly based on covering Haemophilus influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae, and oral or intravenous drugs are chosen according to the condition. Empirical treatment generally selects oral β-lactams, such as amoxicillin 0.5g 3 times a day, or clarithromycin 0.5g twice a day, or ceftriaxone 2g once a day. For penicillin-resistant bacteria that produce β-lactamase, high-dose amoxicillin 1g 3 times a day or 3g twice a day is used. Amoxicillin/clavulanic acid can also be used, as well as fluoroquinolones such as ciprofloxacin, levofloxacin or moxifloxacin; for severe infections or combined inflammation of the lung parenchyma, intravenous medication can be used, and antibiotics with anti-pseudomonas activity such as piperacillin, ceftazidime, cefepime, piperacillin/tazobactam, cefoperazone/sulbactam, ciprofloxacin, tobramycin, imipenem or meropenem should be used. If there is a positive sputum culture result, the medication should be adjusted according to the drug sensitivity result. In case of clear Pseudomonas aeruginosa infection, β-lactams with anti-Pseudomonas activity in combination with ciprofloxacin or aminoglycosides, or a combination of all three if necessary, are recommended. Because of impaired antibiotic penetration and secretion into the bronchial mucosa, the dose and duration of treatment should be greater than that for acute exacerbations of COPD, with a generally recommended duration of 7 to 14 d. Antibiotic inhalation therapy during acute exacerbations is inconclusive. The routine use of antiviral drugs in acute exacerbations is not recommended.
(iv) Surgical treatment
In patients with recurrent acute respiratory tract infection or (and) hemoptysis, whose lesions do not extend beyond the bilobar lung, especially with localized lesions with recurrent hemoptysis, who are poorly treated with medication, who are under 40 years of age, and who are in good general condition, a lung segment or lobectomy may be performed depending on the extent of the lesion. If the lesion is rare and the symptoms are not obvious, or if the lesion is more extensive involving both lungs and accompanied by severe impairment of respiratory function, surgical treatment is not indicated.
(E) Treatment of hemoptysis
Patients with hemoptysis should first be evaluated urgently, including the amount of bleeding, respiratory rate, pulse rate, circulation, and mental status. Patients with small hemoptysis, defined as hemoptysis of less than 100 ml in 24 hours, can be given vitamin K6 4 mg three times a day and Carbapenem 5-10 mg three times a day and closely observed. For large hemoptysis, defined as hemoptysis of more than 500ml in 24 hours or hemoptysis of more than 100ml at a time, absolute bed rest, lateral position, oxygenation, etc. should be given, and blood pressure, pulse rate, heart rate, oxygen saturation should be monitored. Attention should be paid to fluid replacement and blood transfusion to replenish blood volume.
1.Commonly used hemostatic drugs: (1) posterior pituitary hormone: 5-10U added to saline 20ml for 10 minutes by slow intravenous injection (can be repeated if invalid), or can be added directly to the infusion drip pot, followed by 0.2-0.4U per minute by static drip. A total amount of <40u>70mmHg is appropriate. It is optional for those who are contraindicated to posterior pituitary hormone. (3) In patients with coagulation disorders or hepatic insufficiency: 50-100mg of fisetin injection is added to 40ml of saline intravenously once or twice daily. Generally, it is injected at the rate of 0.5ml per minute, and the amount injected in 10 minutes should not exceed 50mg. Because of the anticoagulant effect of this product, the dose should not exceed 100mg in 2 hours (i.e. within the effective duration of the product) and should not be used continuously for more than 72 hours. (4) Others: Phenolsulfonylamine (hemostatic), Tenoxin (Aniloxin). Vitamin K3 (4mg intramuscularly), Carbachol (5-10mg intramuscularly), Yunnan Baiyao: 0.3-0.5g, 3 times daily orally. (5) Corticosteroids: hydrocortisone sodium succinate 100-200mg/d, or hydrocortisone 100-200mg/d, methylprednisolone sodium succinate 20-40mg/d, dexamethasone 10-20mg/d, intravenously.
2.Stop bleeding by tracheoscopy: Those who have failed to get rid of the accumulated blood and stop bleeding through tracheoscopy. 500 ml of cold saline at 4℃ with epinephrine 5 mg, 10-15 ml each time injected into the bleeding lung segment, followed by repeated aspiration until the recovered fluid becomes light or basically clarified, then look for the active bleeding site, local reperfusion, and withdraw the tube after the bleeding stops.
3.Bronchial artery embolization.
4.Surgical treatment is performed when the above methods cannot achieve the purpose of hemostasis.
VIII. Prevention
Prevention and treatment of acute and chronic respiratory infections such as measles, whooping cough, bronchopneumonia and tuberculosis, strengthening the immune function and resistance to disease, treating chronic sinusitis and tonsillitis, and paying attention to preventing foreign bodies from entering the trachea by mistake are important to prevent bronchiectasis.