Bronchoectasies: symptoms, diagnosis, treatment
bronchiectasis - a pathology in which are formed in the bronchi irreversible expansion and deformation, and those in turn, provoke a chronic purulent inflammation of bronchial mucosa - purulent endobronchitis.With this disease, the bronchi become infertile both in anatomical and functional terms.
There are some clinical disputes: bronchiectasis is a particular disease or one of the signs of other diseases?Contents: Etiology Pathogenesis How are the bronchi and lungs under a microscope Classification Clinical symptoms of bronchiectasis bronchiectasis Diagnostics Current principles of treatment of bronchiectasis
At the moment, reached a compromise, and produce:
- bronchiectasis disease that occurs primarily;
- secondary bronchiectasis as symptomatic complexes that accompany other inflammatory-fibrotic diseases;
- bronchiectasis as a congenital anomaly.
immediate causes and the development of bronchiectasis has not been fully elucidated.Many factors regard as contributing factors, but they are not translated into the rank of direct causes of the disease.It:
- bronchopulmonary infection in the tree, which can cause acute respiratory process( pneumococci, staphylococci, Haemophilus influenzae).This factor does not "pull" the full etiological, because so many patients underwent a complete cure for the infection without consequences for bronchi . Infectious pathogens should be regarded as a push to exacerbate the inflammatory process in the bronchi, but not the cause of their deformation ;
- hereditary incompetence( inferiority) of the bronchial tree;It is manifested due to insufficient development of muscular, connective tissue and cartilage elements of the bronchial wall, as well as weak local mechanisms that should protect against infectious agents;
- weak general immunity.
Men are most often affected - they make up about 60-65% of patients with bronchiectasias . But the direct relationship between sex and the onset of the disease has not yet been detected, so at the moment this percentage ratio is regarded as only a statistic.
The association with age is more noticeable - in most cases the disease is diagnosed in patients aged 5 to 25 years.
in the development of bronchiectasis are three important pathogenetic moment :
- reduction in permeability of the large bronchi( equity and segmental), because of what the suffering of their drainage function - removal of secretions;
- in the accumulated, stagnant sputum, all conditions for the residence and reproduction of pathogenic microorganisms are created;
- obturation atelectasis is formed - a fall of the lung site, to which is the compromised bronchus.Atelectasis is characteristic for a number of pathological conditions, but with bronchoethasias it is most often isolated.
main reasons due to which the passage is broken bronchi:
- narrowing due to scarring( scarring within bronchus and outside);
- aspirated( that is, the one that inhaled) the foreign body;
- neoplasm( both inside the bronchus and externally);Basal lymph nodes compression;
- prolonged stay in the lumen of the bronchus of the mucous plug in any acute respiratory illness;
- Tuberculosis bronchoadenitis is a specific inflammation of the bronchial mucous glands caused by a stick of Koch.
The last three reasons are more typical for children.
Blockage of the bronchus and subsequent retention of the bronchial secretion in it gives an impetus to the development of a purulent process below the occlusion site. In turn, the purulent process triggers changes in the walls of the bronchi:
- complete or partial destruction of the ciliated epithelium( without its involvement, the bronchial secret can not go outside);
- thinning and destruction of the cartilage elements of the bronchus;
- degeneration of smooth muscle elements of the bronchial wall and replacement of their connective tissue( most often fibrous).
Because of such changes in the bronchial wall, it becomes more pliable and less resistant to the following factors:
- an increase in endobronchial pressure that occurs during coughing;
- dilated accumulated bronchial secretion;
- negative pressure in the pleural cavity - it is strengthened due to the fact that due to atelectasis the useful volume of some part of the lung decreases.
As a consequence, the expansion of the bronchus wall locally arises and increases locally.
Even if the bronchial patency is resumed( remove the slimy plug, eliminate the scars that press on the bronchus, and so on), the expansion of the bronchial wall does not disappear anywhere. If its muscular and connective tissue elements are somehow able to return to the original state, the cartilage elements after stretching to the previous state do not return, since they do not have the necessary elasticity.
In the extensions of the bronchus, the secret begins to stagnate and stagnate, the infection joins. As a consequence, the inflammatory process begins to exacerbate periodically, which sooner or later becomes purulent-inflammatory.So there is a purulent endobronchitis.
This is not a complete explanation of the development of the disease, its pathological mechanisms continue to be studied.In addition, some parts of the pathogenesis require confirmation:
- the presence of obturation is difficult to prove - at the time of the patient's treatment to the doctor it is not observed, but hypothetically can develop, provoke changes and disappear;
- atelectasis is not found in all clinical cases.
In the development of bronchoectatic disease, a decrease in the patency of the bronchial spines is suspected, which are below the developing extensions of the . The expansion of smaller bronchi was diagnosed in all patients who were diagnosed with bronchiectasis. It is noted that the more the patency of these bronchi suffers, the more pronounced changes in lung tissue, namely:
- atelectasis( with complete bronchial blockage);
- emphysema( the opposite process to atelectasis is the "inflation" of the lung tissue with the use of the valve mechanism, that is, when the obstruction in the bronchus allows air to enter the lungs, but does not allow it to go back).
Based on the described pathogenesis, it becomes clear why bronchoectatic disease can be accompanied by diseases of the upper respiratory tract.Reasons for this:
- general failure of the respiratory protective mechanisms;
- enlarged bronchi are infected and "divide" by infection with upper respiratory tracts.The process in bronchiectasias subsides, but at that time the infection in the upper respiratory tract, which now "divide" it with the altered bronchial tubes, inflames.A vicious circle is formed, from which the patient can not get out.
Most often, with bronchoectatic disease, there are such diseases of the upper respiratory tract as:
- is a chronic inflammation of the tonsils( not only the palatines, but also others);
They are recorded in half of patients suffering from bronchiectasis, and are especially pronounced in children.
The described process in the bronchi causes a violation of pulmonary circulation. With bronchiectasies, the clearance of the bronchial arteries of the submucosal layer is increased 5-fold, in the lumen of arterio-arterial anastomoses - by 10-12 times.There is a pronounced discharge of arterial blood into the pulmonary arteries - because of this, retrograde blood flow starts in them( against the natural flow of blood through the vessels).It, in turn, causes local, and with further development and a general increase in blood pressure in the pulmonary arteries. This mechanism leads to the appearance of a pulmonary heart( an increase in the right heart because of increased blood pressure in a small circle of blood circulation).
How bronchi and lungs look under the microscope
When microscopic examination of the sections in the bronchial wall with bronchiectasias, chronic inflammation with perivascular sclerosis is observed - the proliferation of connective tissue around the vessels.Around the bronchi is determined lymphoid tissue - it surrounds them, like a coupling, especially this process is expressed in children.The walls of the bronchi themselves are thickened( sometimes thinned), the mucosa walls are folded, with characteristic irregularities.
In the bronchial extensions, the ciliated epithelium loses its cilia and degenerates into a multilayered or multilayered flat that is unable to "push out" the bronchial secret due to the lack of cilia.
Depending on how the modified bronchi are enlarged, the bronchiectasias are divided into:
- cylindrical - the bronchus is inflated evenly around the circumference, the changed area is similar to the cylinder;
- saccular - the wall of the bronchus is blown out in some weak place in the form of a hanging bag;
- spindle-shaped - the bronchial wall swells evenly, but not very wide in width, and more grips the bronchus along the length, which makes this site look like a spindle;
Due to the fact that bronchiectasias develop gradually, some intermediate forms may appear between the cylindrical, sacrospinous and spindle-shaped species.
By the presence of atelectasis bronchiectasis is divided into:
- without atelectasis.
The development of the clinical picture and the degree of severity are divided into 4 forms of the disease:
- light - fully compensated;
- expressed - the symptoms increase, but the compensatory mechanisms partially cope with the disease;
- heavy - compensatory mechanisms do not cope with the disease;
The prevalence of bronchiectasis is as follows:
- double sided.
Depending on the condition of the patient, the disease phases of the are distinguished:
- aggravation - high temperature;
- remission - the morphological changes in the altered bronchi remain the same, but the clinical picture subsides.
Clinical symptoms of bronchiectasis
In many cases, it is difficult to record the exact onset of the disease, since the first signs are seen as a manifestation of colds of the .The patient may not attach importance to them, writing off that the common cold is an "ordinary phenomenon".
It is difficult to determine the onset of the disease in young children who may not show the same colds.To orientate, when the disease began, it is necessary to question parents very carefully, literally with the fixation of the slightest "sneeze" of the child.
Over the past few decades, there has been a decrease in the number of severe forms and the increase in lung capacity( also called small) forms.
Basic complaints of the patient:
- sputum discharge;
- rarely - hemoptysis;
- shortness of breath;
- aching pain in chest thoracic;
- increased body temperature;
- marked deterioration in the overall condition.
The most important clinical indicator of bronchiectasis is a cough with phlegm.
The amount allocated from the bronchi varies - from 20 to 500 ml.The most abundant sputum discharge is observed:
- in the mornings( very characteristic sign - "full mouth");
- if the patient is lying down and turns to the side of the unaffected bronchi( with unilateral disease);
- when trying to bend forward.
In sputum with the naked eye, you can detect the presence of purulent contents of , because of which it can acquire a faint specific smell. With severe disease, sputum is produced with an unpleasant, putrefactive shade, odor. In the period of process silencing, the process can not be separated at all, the patient will have a "dry" cough.
If you collect sputum in a jar, after a while it is divided into two distinctly different layers:
- top - a fluid of increased viscosity, with a trace of saliva in large quantities;
- lower - entirely consists of purulent sediment.
To assess the intensity of the process, it is more important not how much the patient has coughed up, but what percentage of purulent contents there are.
Hemoptysis is rare, but in some cases it can be the only sign of bronchiectasis if the patient has a so-called "dry" bronchiectasis without a purulent process in the bronchi. With severe cough and weakness of the vascular wall, pulmonary hemorrhage may occur.
Shortness of breath is one of the "popular" signs of bronchiectasis: it is observed in a third of patients.Disappears after the patient is operated.
A common symptom emerging at the height of the disease is chest pain.They are associated with changes in the pleura.
An increase in body temperature indicates the presence of a purulent-inflammatory process and is observed during periods of deterioration. The temperature rises to a low-grade figure( 37.1-37.4 degrees Celsius).In severe patients with a pronounced purulent process, it can rise to 38.5-39 degrees, sputum expectoration in large quantities decreases.
General condition worsening also occurs during exacerbation.In such patients, the following are observed:
- general poor health;
- lethargy both when trying to be active, or in a passive state;
- reduced performance;
- bad mood up to the depression of the psyche - due to the fact that the patient is psychologically disturbed by the presence of fetid sputum, an unpleasant odor when breathing and from the mouth, which is difficult to hide with the help of deodorizing devices( sweets, sprays).
The appearance of patients can only change in far-reaching cases, when due to pronounced changes in the bronchi, pulmonary ventilation worsens.At the same time, the skin and visible mucous membranes become pale.The pronounced cyanosis( blueing) of the integuments and the fingers in the form of tympanic sticks with a club-shaped thickening, which were previously a prognostic sign of bronchiectasias, are now very rare.
Of the common clinical manifestations in children and adolescents with severe disease,
- may have a slight delay in physical( sometimes mental) development;
- deceleration of puberty.
Diagnosis of bronchiectasis
When diagnosed as a bronchoectatic disease, a patient's complaint of a plentiful expectoration of a sputum is very characteristic.
Objective inspection data are less informative.Pallor of the patient is only an additional sign-stroke, as it can be observed with a large number of diseases.With percussion, there is sometimes a blunting of sound in the affected area. More informative auscultation - if there is sputum in the affected area, they are listened to:
- hard breathing;
- characteristic large and medium bubbling rales, they decrease or even disappear after asking the patient to clear his throat.
These symptoms may be absent during remission.
Radiography shows changes in the lungs that have occurred due to changes in the bronchi.These are direct indications:
- cellularity against the background of intensification of pulmonary pattern;
- is a compaction in those parts of the lung whose bronchi have been affected;
- atelectasis zone.
There are also indirect radiographic signs that are no less important in diagnosing:
- the shadow of the mediastinum is biased towards the lesion;
- high placement and reduced mobility of the dome of the diaphragm from the side of the lesion;
- obliteration( overgrowing) of the sines( pockets) of the diaphragm;
- increased transparency of the unaffected parts of the lungs is explained by compensatory emphysema, since the lung from the lesion badly "breathes", its function is assumed by the "unaffected" lung, and there comes the vicarious( compensatory) emphysema.
When bronchoscopy, the bronchial tree is examined with the bronchoscope inserted into it.
With this method, you can:
- estimate the degree of suppuration;
- to sanitize( clear) the bronchi;
- to monitor the development of the process in dynamics.
The most informative method for the diagnosis of bronchiectasis is bronchography with contrasting. To fulfill it, the following conditions are necessary:
- maximum cleaning of the bronchial tree;
- maximum suppression of purulent process.
Bronchiectasis has the following signs of bronchiectasis:
- enlargement of affected bronchi;
- their convergence;
- lack of contrast agent in the small bronchi that are located further( below) behind the zone of bronchiectasias - because of the sharp difference between filled contrast and unfilled bronchi, the picture is similar to a bundle of twigs or a chopped broom.
With a qualitatively performed bronchography and the presence of a characteristic cough with a large amount of sputum, the diagnosis is not difficult.
In most cases, the disease affects the bronchi reaching the basal segments of the left lung, as well as the middle lobe on the right.
With bronchoectatic disease, periods of exacerbation( observed most often in the spring and autumn, with activation of infectious agents) alternate with periods of remission.
It happens that has suffered several exacerbations in childhood, patients can subjectively feel healthy for many years already until puberty. From the age of 14-17 the periods of exacerbation will occur more often and more or less regularly.
For many years the process can be limited, and with the correct medical tactics - docked. On the other hand, severe obstructive bronchitis may develop as a complication, which in turn can lead to the development of:
- respiratory failure;
- of the pulmonary heart.
Other complications may occur in such patients:
- focal nephritis;
- amyloidosis( primarily the kidney);
- aspiration abscess( from the side of the affected lung);
- pleural empyema( diffuse suppuration without clear boundaries).
At present, the occurrence of such complications began to be observed less often 5-6 times than 10-20 years ago.
Principles of treatment of bronchiectasis
Depending on the degree of development, bronchiectasis is treated with :
- by conservative methods;
- using surgical intervention.
With minor changes from the bronchial side, conservative therapy is indicated to:
- to prevent an exacerbation;
- remove the aggravation that has already developed;
- support clinical well-being;
- in a number of cases, when the disease is diagnosed at early stages, to achieve almost complete cure( this is observed mainly in children).
In cases with an extensive process where a radical operation is technically impossible, conservative methods are shown:
- as a palliative therapy, which facilitates the patient's condition;
- to prevent further progression of bronchiectasias;
- for the prevention of complications;
- as an auxiliary measure when preparing a patient for bronchoscopy.
In the intermediate version of the severity of the disease conservative therapy is important :
- in preparation for a radical operation with the removal of compromised bronchi.
Surgical treatment is prescribed in cases when conservative therapy does not cope with bronchiectasias:
- does not arrest exacerbations in compromised bronchi;
- can not stop further involvement in the bronchi process.
The main links of conservative treatment for bronchiectasias:
- sanation of the bronchial tree with the maximum possible removal of the purulent discharge;
- local effects of antimicrobial and antiseptic drugs on pyogenic infectious agent( carried out after sanation);
- effect on the bronchial mucosa of mucolytics, which facilitate sputum discharge( carried out after sanitation);
- parenteral antibiotic therapy( it is important to know that the introduction of drugs intramuscularly and intravenously is not an alternative to endobronchial drug administration - and vice versa);
- restorative procedures - walks, nutrition, and in the remission stage - also swimming in the pool and natural water sources, hardening.
Among the conservative procedures are activities that contribute to the sputum:
- respiratory gymnastics;
- chest massage with vibrators;
- postural massage.
Sanitation of the bronchial tree is carried out:
- through a trans-tracheal catheter;
- with diagnostic laparoscopy.
Postural drainage is the draining of the bronchial tree by a natural method( cough), when the patient is in a certain position. The most common methods of postural drainage:
- patient is in bed, whose head end is raised, and the pillow is removed, the patient is asked to turn on his side, then on his stomach, back on his side, while coughing up phlegm - and so with repetitions;After 15-20 minutes the procedure is suspended, the head end is set to the normal position, the procedure is repeated after 2-3 hours( depending on the patient's condition);
- the patient lies across the bed, the upper part of his body should hang so that he leans on the floor with his elbows;The patient, turning from side to side, coughs up phlegm for 10-15 minutes, then takes a break and repeats the procedure.
In some clinics, for postural drainage, there are tables in which the angle of slope of their parts can be adjusted.
Many clinicians describe cases that it was after postural drainage that the patients experienced intoxication phenomena that had not previously been stopped by other methods.
For bronchiectasias, a sparing resection of the lung area with altered bronchi is performed.Intervention is carried out in the event that it is possible to establish the limits of the lesion and its volume.
Resection of the lung is a disabling operation. In "small forms" the decision to perform such an operation is taken with caution, after a number of bronchographic studies in dynamics that confirm the negative dynamics, and in the event that conservative therapy does not help.
If bronchiectasias are observed only in one lung, resection of the lung can be more radical, up to removal of the lung with its extensive lesion.But at the same time it is necessary to take into account the theoretical possibility of bronchiectasis on the other hand.
If bronchiectasias are observed on both sides, but one side is affected more, resection of the compromised site on this side is allowed. At the same time continue to perform therapeutic appointments.Thanks to this combination of conservative and operative treatment, the patient's condition improves or, at least, stabilizes.
In approximately symmetrical lesions, a bilateral resection is performed on both sides - as a rule, it is carried out in stages, with a time difference of 6 to 12 months.
Operation is not performed if the upper lung segments are affected in bilateral bronchiectasias. Also for the decision on a radical operation, the presence of complications of bronchoectatic lesion is taken into account - most often it is:
- obstructive bronchitis;
- severe respiratory failure;
- pulmonary heart.
To prevent the development of bronchiectasias:
- to avoid factors that cause diseases of the bronchi and lungs - they, in turn, lead to the development of bronchiectasias;
- with already arisen airway diseases scrupulously fulfill the doctor's prescriptions( for example, do not arbitrarily abolish antibiotics prescribed for pneumonia, even if the clinical picture has significantly improved).
For severe and complicated forms of bronchiectasis, the prognosis is serious.Among those who were sick from 5 to 10 years, lethal outcome was observed in 24%, progression of the disease deterioration was recorded in 45.2% of patients who did not undergo timely operative treatment.
Mortality after surgery in these patients is up to 1%.Surgical treatment does not always improve the prognosis. Statistical data indicate that:
- , an improvement in the condition occurs in approximately 50% of the operated;
- unsatisfactory results were recorded in 12% of cases.
The deterioration of the postoperative condition depends primarily on:
- incorrect determination of the lesion volume, which causes a part of the lesions to be left in the resection;
- postoperative complications.
In a number of cases, relapse of the disease occurs - they are associated with the movement of the bronchi after resection, which worsens their drainage function.
Kovtonyuk Oksana Vladimirovna, medical reviewer, surgeon, medical consultant