Bronchiectasis | Clinical Medicine

foreign what's up Ninja nerds in this video today we're going to be talking about bronchiectasis this is a part of our clinical medicine section if you guys like this it helps you please support us and you can do that by hitting that like button commenting down the comment section and also subscribing also really urge you guys if you guys have the opportunity to go down in the description box below we get a link to our website we have a lot of cool stuff that I really urge you guys to become members of because there we have a lot of notes illustrations we're developing question Banks we're developing exam prep courses we got some merchandise that you guys can check out there so please do that if you have the opportunity all right let's start talking about bronchiectasis bronchiectasis is basically defined as you have this like massive bronchial dilation secondary to a lot of inflammation within the Airways so we have to ask ourselves the question when a patient comes in that we suspect may have bronchiectasis what really is the classic finding that really would cue you off to think that this is the cause because we talked about in other obstructive lung disease because this is one of them as they come in with potential findings of maybe some particular dyspnea maybe they come in with some wheezing whereas those with the COPD they come in with either a productive cough dyspnea they come in with wheezing as well what's really The Telltale sign to really break this one off of the obstructive lung diseases really the classic thing is they have so much mucus in their airways that whenever they expect to rate and they clear this mucus it is really intense it's super thick and it smells absolutely horrific so sometimes we say they have this thing called a foul smelling productive cough so it's this really nasty muco purulent type of sputum that they will expectorate and that's usually kind of this classic finding that we see in patients who have what's called bronchiectasis now the question is why do they have so much mucus that's within their airways and why is it so foul smelling it probably means that there's a lot of inflammation probably infected material there let's kind of explain that so here we have a patient who has a normal complete healthy Airway but then for whatever reason we decide to bring about a lot of inflammation all right so here we're going to talk about those causes in a second but here this thing right here is really taking this Airway and just turning it on hyperdrive and saying hey let's go either and increase a lot of inflammation Within These Airways and then lead to what when you inflame Airways you know one of the big things happens you stimulate these things called goblet cells in goblet cells they love they love to produce a ton of mucus and so one of the things that you'll start noticing is that these patients get a lot of mucus that builds up the narrow ways there could be other reasons why besides inflammation but we'll cover those now look I got this inflamed Airway with a ton of mucus the other thing that happens besides just the mucus is that this inflammation starts causing other particular processes to occur but for right now I want you to know that we're going to trigger this massive increase in mucus production now the next thing that happens is this mucus traps a lot of bacteria so imagine if we trap a lot of bacteria within this mucus and we also keep continuing to have inflammation what's going to potentially happen well the inflammation starts kind of destroying some of the bronchial walls and this leads to this process called bronchial dilation so then we start seeing dilation of the bronchioles and not only is this kind of dilation is occurring but you still have guess what else a lot of mucus lining this particular Airway so it's just this kind of vicious cycle of inflammation that propagates increasing mucus production the mucus will increase inflammation the inflammation will lead to the dilation of the bronchials due to a lot of destruction of the bronchial walls and again this is just kind of this vicious cycle I think one of the big things to remember is what's the end result of this well one of the things that happens is you build up mucus and inflamed Airways and then dilation is that these Airways become so filled that they become obstructed and so one of the primary themes that I think is important to remember in patients with bronchiectasis is they exhibit features of what's called Airway obstruction in other words these Airways are so filled with mucus and they're collapsed from because of these bronchial Airways being so weak and destroyed that it is almost impossible to get things like CO2 out and so these patients will potentially air trap and they can they potentially can develop features of hyperinflation but one of the classic classic features of these patients is they exhibit features of what's called Airway obstruction so bronchiectasis is a part of the category of diseases called obstructive pulmonary diseases and the reason why is there's mucus that builds up secondary inflammation dilation of the bronchials and then bronchial collapse and as well as mucus that are filling up the Airways they can't get air out and they obstruct their airways so the question that comes okay what in the heck is the cause of all of this bronchial inflammation that's propagating mucus production and dilation of the of the bronchioles let's come down and talk about them the first thing I want you guys to think about is that generally there could be dysfunction of What's called the mucosiliary apparatus so you know there's these particular cells and what they're supposed to do is they're supposed to take things like and push chloride out right these are these transmembrane ions and in patients who have diseases such as what's called a cystic fibrosis so let's say that you have this disease called cystic fibrosis they have the inability for the cystic fibrosis transmembrane receptor protein to be able to produce chloride so they have this defect in these Transporters where chloride will not be excreted why is that important well whenever goblet cells make mucus so let's say here it makes a clump of mucus this mucus that's produced by the goblet cells can be thinned out by the chloride but if under the circumstances that you don't have chloride what's going to happen to this mucus it's not going to be able to get thinned out and what is the result they develop a massively thick kind of mucus that obstructs the Airways there's one way that we get a lot of mucus and if mucus gets caught up within those Airways what can it entrap bacteria what can bacteria do to the actual bronchial tissue inflame it and then with inflammation that chronic inflammation will also lead to dilation and then over time lead to Airway obstruction so again big big problem here is very very thick mucus because you lose the ability for these chloride molecules to get taken up into this actual mucous kind of molecule right here a mucous Clump here and to thin it out all right that's one reason patients will develop this so think about the cystic fibrosis it's actually in a younger patient with other history um maybe they have a potential history of exocrine pancreatic insufficiency or other diseases particularly like recurrent pulmonary infections and lots of mucopril and sputums particular thing that you want to think about is a cause here is a very interesting one and this is when the Cilia stop working so let's say that these cilia normally what they're supposed to do is they're supposed to beat up mucus and particles and things to that effect all the way up like kind of this escalator right so if there's a chunk of mucus let's say right here which has some bacteria in it it's going to move it a little bit up here via the Cilia it'll move it a little bit up here via the Cilia and remove it up here via the Cilia but now you've destroyed this process so now you lose the ability to move and mobilize this mucus upwards that you can spit it out or swallow it and so what happens to the mucus it builds up and builds up and builds up and so as a result these patients will build up mucus and if you build up a lot of this mucus guess what's going to happen you end up with the process that we've just talked about so the question is what so there's a Inc there's a build up there's an increased buildup of mucus what is the cause of this where the Cilia aren't working this is called primary ciliary dyskinesia another uh term which is thrown around sometimes is called cardigan or syndrome but primary ciliary dyskinesia is one particular thing to think about here what happens here is also you need to remember that in primary cellular dyskinesia or cardigan the syndrome they may also have other diseases usually you think about cytus and versus and you think about chronic sinusitis in combination with bronchiectasis and a patient with cystic fibrosis you think about bronchiectasis frequent pulmonary infections as well as maybe even extra pancreatic insufficiency and other organs are usually involved as well in cystic fibrosis the last one that causes mucociliary dysfunction is when you have an airway obstruction this could literally be anything I'm not kidding let's see I'm just going to use this as this one thing here that there is an obstructed like substance of some sort there's a substrate here and it's blocking the movement it's similar to like not having cilia if you want to think about it here silly is intact but here we have some mucus let's say that we want to move along kind of clear but if we can't clear that mucus what is it going to do it's going to build up and so it's the same kind of concept here that as these goblet cells produce mucus you want to be able to clear that mucus but you have something that's obstructing the movement of the mucus there's a lot of different things that can do that but it's the same concept you're going to build up mucus so over time this will definitely lead to the same concept here but you want to know what are those things this could be a tumor I'd say that's a big one because that's going to be more of a chronic process or chronic obstructive pulmonary diseases particularly chronic bronchitis think about COPD or maybe some type of foreign body this is another one I would definitely potentially consider as well but these are something that would lead to mucociliary dysfunction the next question that you have to ask is okay these things make sense as to why there's a ton of mucus the mucus will do what again carry with it and keep within a bacteria bacteria can cause tissue damage tissue damage and propagates more inflammation more inflammation leads to dilation of the bronchials and then again with a combination of mucous buildup inflamed bronchials and then dilation you lead to potentially Airway obstruction the last thing is what if I have recurrent infections that can cause inflammation right so recurrent infections are really important you got to think about it two ways one is you have a lot of bacteria that you're being exposed to one is called pseudomonas and there is a particular disease that has lots and lots and lots of pseudomonas that colonizes the Airways do you guys know what it is I want you to remember on abbreviate it's called cystic fibrosis so you see how that's a big one there pseudomonas will definitely lead to lots of bacteria that then destroy or inflame the Airways that's one particular thing you know as you cause Airway inflammation what do you then do you stimulate goblet cells to produce mucus and as you increase that mucus and propagate more of the actual inflammation of the Airways you'll lead to this Upstream effect that we talked or the downstream effect that we talked about up here what's another bug another one would be what's called haemophilus influenza this is a really big one you know what disease carries this one a lot COPD so patients with COPD carry or colonize this bug a lot other ones I think that are important to remember here is what's called allergic Broncho pulmonary aspergillosis these bugs right here so this is usually bacteria this is more of like a fungus I think one of the big things to remember about allergic bronchopulmonary aspergillus is they have these crazy high ige levels and they have lots and lots of eosinophils this is like the only type of like air you know airway disease where there's tons and tons of inflammation and mucus that's not due to neutrophilia usually asthma and things like bronchiectasis can have lots of eosinophils if it's due to this disease so there's lots of bugs what if there's not enough immune function to clear these bacteria other types of infections so they don't have a good immune system so I think patients who have very diminished T cells or very reduced numbers of ige antibodies what if you have decreased number of T cells or decrease IG antibodies are you going to be able to fight off particular bacteria so let's say here's a bacteria and this bacteria is going to induce damage an injure these actual respiratory cells which propagates more mucus production so you get a lot of mucus if you don't have the proper immune system to fight that bacteria off right this will not be able to be inhibited right and so this will continue this bacteria will continue to destroy the airway tissue what are diseases that cause a reduction in T cells HIV what's a disease where you have reduction in IG antibodies various types of amino deficiencies these could be a hereditary Amino deficiencies we can call this like hypogammoglobulinemia but you get the point there's destruction of the actual tissue that leads to an increase in mucus production as well as more inflammation of the Airways which propagates this process the last one is when a patient has chronic inflammation that's systemic that maybe damages the lung tissue as a result it's not localized it's systemic and then as an adverse effect it hits the lungs as a result this could definitely be due to a lot of nasty antibodies right so usually this is autoimmune diseases so autoimmune diseases that carry lots of particular things like anas or maybe rheumatoid factor which you'll see this in diseases like SLE or you'll see this in diseases like rheumatoid arthritis things to that effect these will really go in attack this lung tissue and as it injures and inflames the lung tissue there's other diseases like Scleroderma as well it'll do what increase rev up the production of mucus by the goblet cells and so these will start making lots of mucus it'll propagate increased inflammation and then dilation of the Airways and then Airway obstruction so you guys get the point and a patient develops wrong cactuses think about that nasty foul smelling productive cough and a patient who has very dilated but inflamed filled Airways with mucus due to mucociliary dysfunction such as in thick mucus or a problem being able to move the mucus or recurrent infections or chronic inflammation and again this is a part of your obstructive lung diseases what's the potential complications of bronchiectasis let's talk about that now all right my friend so now we're going to talk about the complications potentially associated with bronchiectasis when a patient comes in a bronchiectasis we already know they get a lot of foul smelling productive cough filled with mucopril and sputum we know the particular pathophysiology we know the cause is now well we then have to watch out for is what are the downstream negative consequences of this disease one of the big ones that I'd say one of the most common things that you really want to watch out for on your exam is hemoptysis and the reason why is this is a chronic disease and so that chronic inflammation what will happen is the inflammation over time will erode and eat away at the vessel wall and so it'll cause mucosal erosions and you know what's right here supplying the bronchioles there's a beautiful artery called the bronchial artery 90 95 of the time bronchial arteries are the most common cause of the bleeding that rushes into the actual bronchial tree so it leads to bronchial artery ulceration let's say and as you ulcerate that puppy then you get hemoptysis so then what happens is let's kind of like see how this kind of all occurs in sequence chronic inflammation mucosal erosions bronchial artery ulceration hemoptysis let's flush this look here's all this inflammation where all the mucus and bacteria and all that stuff are chronic dilation this starts eating away at these tiny little bronchial arteries and then as that happens blood easily enters into the bronchial tree and when this enters into the bronchial tree it's nice and irritating to the actual mucosa what would you then do and this will then lead to them coughing up a lot of this type of bloody types of material Sometimes some of this Blood could get stuck down here into the Airways that's not a good thing that can definitely lead to respiratory failure but that is a possibility but oftentimes they'll cough up some of that actual material there and that's something that you really want to watch out for if a patient has hemoptysis think about bronchiectasis is a very common cause okay what about respiratory failure this is another really big one because it's a chronic disease it leads to chronic inflammation mucous development within the Airways now because of that think think of this if you have this problem you got this big mucus plug so mucus plug that's actually developing Within These Airways what is that going to do to the actual ventilation to the salveoli the ventilation will be impaired so it's going to be really really difficult to get good ventilation into this alveoli and good ventilation into this alveoli so you'll have a reduction in ventilation here but your perfusion may be normal what is this called this could be a VQ mismatch right but here's something really interesting yes you may have reduction in ventilation but here's another concept when these patients plug up their airways it is not only a difficult time getting air in you know what else happens they have Airway obstruction and so from this Airway obstruction two things happen they have a kind of a mixture of the respiratory failure one of the things that's really really interesting is as you develop Airway obstruction what do you do to your lungs you cause hyperinflation if you obstruct along can you get Co2 out no the lungs build up to get big as a result they develop hyperinflation if you hyperinflate your lungs how difficult is it going to be to get air in take a deep breath in hold it don't exhale try to take a deep breath on top of that that's what it's like for these patients so as a result they developed something called hypoventilation and when they develop this hypoventilation the consequences is that they don't actually bring in enough oxygen but the other problem here is that they don't clear enough CO2 and as a result these patients have two particular problems that ensue as a result of this one is they have very low o2s but they also have very high co2s and so this is another particular thing that you want to watch out for is they'll develop features of what's called hypoxemia and potentially hypercapnia what kind of respiratory failure is this this is example of what's called a type two respiratory failure so this is something to potentially watch out for with these patients all right what's another thing that can happen in patients with respiratory failure due to Airway obstruction and hypoventilation what could they look like they could look terrible some of these patients May exhibit increased respiratory rate increase work of breathing dyspnea so other things that you want to watch out for is what do they look like and if they're working hard to breathe that they're breathing at 50 a minute that is also a potential sign of respiratory distress and therefore respiratory failure not just the low O2 again something to watch out for last potential feature here is usually because of the respiratory failure so patients who have bronchiectasis this is usually chronic they're living with hypoventilation VQ mismatch every single day so because of that they have difficulty again getting air in and getting air out so what's the chronic result here in these patients they build up oxygen they build up CO2 and then they drop their oxygen so they usually exhibit chronic hypoxemia that chronic hypoxemia as a result of this hypoventilation of EQ mismatch leads to hypoxic vasoconstriction these vessels clamp down like a son of a gun so then you get this intense Vaso constriction when this vessel vasoconstricts what it does is it makes the pressure and the resistance I'm sorry resistance in the vessel really high so as a result here peripheral vascular resistance goes up and then the pressure in the arteries go up so these patients develop something called pulmonary hypertension and then what happens is if your pressures in the actual pulmonary arteries get really really high what happens is the right heart has to develop such a very strong stroke volume of cardiac output against the high afterload and what happens over time is this will cause the right heart to really become strained and begin to fail and there's all features of right heart failure now if the right heart fails they have difficulty getting blood into the heart and difficulty getting blood out of the heart right maybe because of hypertrophy or dilation or just High afterload because of that they can't get blood out of the heart the pressure inside of the right heart increases and it starts backing up into the vena cava and this leads to elevated central venous pressures this will back up and go down and develop many different features such as it'll help drag the venous extension via the supravena Cava it'll go down the inferior vena cava and cause hepatomegaly it could even cause ascites and last but not least it may go into the lower extremities and cause pedal edema so these are the potential findings that could develop as a result of core pulmonale which is usually defined as pulmonary hypertension due to an underlying lung disease you know what type of pulmonary hypertension this is this is example of type three so here let's write that down this is an example of type 3. all right the last thing that I want to say here but it actually should be relatively common understanding is that most patients who develop bronchiectasis the common causes of recurrent infections when patients who develop bronchiectasis guess what else happens they build up mucus and they can't clear the actual mucus from their airways mucus is an area where bacteria love to colonize and stay so because of that they have lots of bacteria developing within the Airways and in high amounts that can cause infections so patients with bronchiectasis are not only can develop but because of chronic infections but they can develop very frequent pulmonary infections that's something else to watch out for is a potential complication of bronchiatasis let's talk about how to diagnose it when a patient comes in I'd say one of the biggest things is look for that productive foul smelling cough frequent pulmonary infections and on top of that hemoptysis those are the big things getting a chest x-ray chest x-ray is going to be kind of helpful because anytime someone has a nasty cough or hemoptysis and you know potential signs that they could have like COPD or bronchiectasis it's good to get a chest x-ray to just get a look so in COPD you see that conic classic hyperinflation increased lucency AP diameter all that stuff a flat diaphragm in bronchiectasis you see something very specific you see kind of like these like bronchial cuffing and tram track signs but that's not always the best off your chest x-ray so one of the things I like to do is get the pfts to say okay I still think it could be an obstructive lung disease I don't know if it's chronic bronchitis or if it is bronchiectasis get the pfts because that can be helpful if it shows a low fev1 a low FEC and an fev1 over FEC ratio that's less than 70 percent that's definitely supportive of obstructive lung disease even if they have this increased total lung capacity residual volume functional residual capacity we definitely know it's obstructive lung disease particularly maybe in this case bronchiectasis if they have chest x-ray findings that are supportive of it will be the real good test though to really help me if I'm confused between COPD and this particular case of bronchiectasis a high resolution CT is really good the reason why is radiographically bronchiectasis is oftentimes diagnosed and what you look for is you look for this massive bronchial dilation look how dilated in cystic appearing these Airways look on top of that there's also another one which we use like the ratio between the bronchial wall here's your bronchial kind of like wall here and here's an Associated like vessel usually when the wall bronchial wall diameter in comparison to the vascular diameter is like greater than 1 or 1.5 it's super suggestive of bronchiectasis so if I have chest x-ray findings that may be supportive of a bronchiectasis obstructive lung disease findings and a high resolution CT that shows these findings I can pretty much with confidence say I have bronchiectasis so then you got to figure out the cause so oftentimes that kind of means going back and looking okay do they have any things that would suggest what cystic fibrosis test the you know sweat chloride test or the cftr test uh check for immuno immunodeficiencies check the IG levels check for HIV look to see do they have any kind of like massive like tumor or form body that's present within the Airways on their CT scan or their Bronx shows that okay maybe it's an airway obstruction do they have autoimmune factors maybe it's ra or SLE do they have a sputum culture that suggests that they have age flu or pseudomonas or mycobacterium or aspergillosis maybe it's recurrent infections and so those are the ways that we can kind of go about looking at bronchiectasis how do we treat these patients well one of the biggest things is finding the cause and treating underlying cause because that'll reduce the chronic inflammation whether it's reducing the mucus production reducing the um kind of like bacteria accumulation reducing the chronic inflammation autoimmune diseases you got to treat that but one of the things that you can kind of do while you're treating the underlying cause is really clear that mucus man because that stuff can really kind of cause problems as you saw the downward Cascade of it so usually this is via chest physiotherapy you can do this like with this little child probably has cystic fibrosis so they have on this like vest and it kind of like hits and kind of percusses the chest and helps them to kind of cough and clear their secretions you can also kind of lay them in certain postural positions where you can help to drain some of the secretions and clap and hit on their back sometimes you can do nebulizing therapies that are kind of like thin up the mucus like hypertonic saline or muco in acetyl cysteine therapies and that kind of thins out the mucus making it easier to cough but anything to kind of clear that mucus is really important so that you don't trap bacteria and cause chronic inflammation the other thing is in these patients you're doing mucous clearance but you're also going to have a lot of bacteria that are colonizing so I think it's important to reduce bacterial growth to knock down the risk of recurrent exacerbations and infections and so you have to ask yourself the question as the patient had three plus exacerbations where they've had to be treated with antibiotics per year then they probably need to be on antibiotic therapy until determined otherwise and you should probably try to tailor it towards the pathogen from their sputum culture because if it's pseudomonas fluoroquinolones are going to be preferable outpatient and if it's not pseudomonas azithromycin may be the preferred measurement there the last thing I think is really important for bronchiectasis is reducing the risk of hemoptysis these patients may require bronchial artery embolization at some point in time in their life and if they have recurrent events of hemoptysis it may even require surgical resection of the disease lug segments well my friends that covers bronchiectasis I hope it made sense I hope that you guys enjoyed it and as always until next time [Music] foreign foreign

Channel: Ninja Nerd

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Id: zI0A2rF8gbg

Length: 27min 51sec (1671 seconds)

Published: Mon Mar 11 2024