Bronchiectasis in acute pneumonia ... Pseudobronchiectasis

Cystic fibrosis modulator therapy can reverse cystic bronchiectasis

Bronchiectasis is often considered progressive and irreversible, so cases of regression or reversal are an important step in understanding the underlying pathophysiological mechanisms. Cystic fibrosis, (CF) caused by pathogenic variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene has been a success story in personalized medicine. The recent development of CFTR modulator therapies has revolutionized care. Dramatic improvements in lung function, sputum production, daytime functioning, and quality of life are seen within weeks. However, the effect of long-term exposure to elexacaftor + tezacaftor + ivacaftor (ETI) on the structural abnormalities is at present unknown. This case series outlines three adults with CF who have demonstrated progressive improvement in the cylindrical, varicose and importantly cystic changes of bronchiectasis with prolonged ETI treatment. This raises the exciting question of reversibility of bronchiectasis as well as the mechanisms involved in the maintenance and progression of bronchiectasis as it relates to CF.

Imaging in non-cystic fibrosis bronchiectasis and current limitations

Non-cystic fibrosis bronchiectasis represents a heterogenous spectrum of disorders characterised by an abnormal and permanent dilatation of the bronchial tree associated with respiratory symptoms. To date, diagnosis relies on computed tomography (CT) evidence of dilated airways. Nevertheless, definite radiological criteria and standardised CT protocols are still to be defined. Although largely used, current radiological scoring systems have shown substantial drawbacks, mostly failing to correlate morphological abnormalities with clinical and prognostic data. In limited cases, bronchiectasis morphology and distribution, along with associated CT features, enable radiologists to confidently suggest an underlying cause. Quantitative imaging analyses have shown a potential to overcome the limitations of the current radiological criteria, but their application is still limited to a research setting.

In the present review, we discuss the role of imaging and its current limitations in non-cystic fibrosis bronchiectasis. The potential of automatic quantitative approaches and artificial intelligence in such a context will be also mentioned.

Diagnosis and Initial Investigation of Bronchiectasis

Bronchiectasis refers to both the name of a disease and a single radiological appearance that may, or may not, be associated with disease. As chronic respiratory disease, bronchiectasis is characterized by a variable range of signs and symptoms that may overlap with other chronic respiratory conditions. The proper identification of bronchiectasis as a disease in both primary and secondary care is of paramount importance. However, a standardized definition of radiologically and clinically significant bronchiectasis is still missing. Disease heterogeneity is a hallmark of bronchiectasis and applies not only to radiological features and clinical manifestations but also to other aspects of the disease, including the etiological and microbiological diagnosis as well as the evaluation of pulmonary function. Although the guidelines suggest a "minimum bundle" of tests, the diagnostic approach to bronchiectasis is challenging and may be driven by the "treatable traits" approach based on endotypes and biological characteristics. A broad spectrum of diagnostic tests could be used to investigate the etiology of bronchiectasis as well as other pulmonary, extrapulmonary, and environmental traits. Individualizing bronchiectasis workup according to the site of care (e.g., primary, secondary, and tertiary care) could help optimize patients' management and reduce healthcare costs.

Reversible bronchial dilatation in adults

Bronchiectasis is characterized by the destruction of bronchial wall and persistent irreversible bronchiectasis due to respiratory infection and bronchial obstruction. Reversible bronchiectasis is rarely reported in adults. The study aims to evaluate dynamic changes in chest computed tomography (CT) findings and relevant factors affecting improvement or reversal of bronchiectasis. A total of 239 patients with bronchiectasis admitted to our hospital from January 2009 to December 2019 were retrospectively analyzed. 23 patients (group A) with bronchiectasis reversion or improvement confirmed by chest CT were matched with patients in group B according to gender and age (difference <5 years). 23 patients (group B) with bronchiectasis progression or no obvious improvement confirmed by chest CT were selected from the remaining patients. The clinical features and imaging findings of the two groups were compared. The duration of disease in group A was less than that in group B, and the stable period was longer (p < 0.05). There was no significant difference in other clinical features between the two groups. In contrast to the traditional concept of "Bronchiectasis", our results suggested that some adult bronchiectasis can be improved and completely radiologically reversed.

Surgical treatment of bronchiectasis: Our 23 years of experience

Background

In this study, we aimed to evaluate the success of surgery and a complete resection for bronchiectasis treatment and to present our 23 years of surgical experience.

Methods

Between January 1991 and December 2013, a total of 1,357 patients (667 males, 690 females; mean age 30.5±14.3 years; range, 3 to 73 years) with the diagnosis of bronchiectasis who underwent pulmonary resection in our clinic were retrospectively analyzed. Demographic and clinical characteristics of the patients, etiologies, symptoms, localizations, surgical procedures, and long-term follow-up results were evaluated.

Results

There were 1,394 surgeries, as 37 (2.7%) patients had bilateral disease. The surgical procedures included lobectomy (n=702, 50.3%), pneumonectomy (n=183, 13.1%), segmental resections (n=114, 8.2%), bilobectomy (n=83, 6.0%), and lobectomy + segmentectomy (n=312, 22.4%). During the postoperative period, 1,269 (93.5%) patients were followed at a mean duration of 51.6 (range, 1 to 120) months. After surgery, 774 (61%) patients were asymptomatic, 456 (35.9%) showed an improvement, and 39 (3.1%) had no response or deterioration.

Conclusion

The surgical treatment plays an important role in the clinical and symptomatic improvement of patients with bronchiectasis. Surgery reduces the morbidity and mortality rates with careful preoperative preparation and appropriately selected cases.

A case report of reversible bronchiectasis in an adult: Pseudobronchiectasis

Bronchiectasis is a sequel to permanent chronic airway inflammation and defined as ‘irreversible bronchial dilatation’. It is increasingly being recognized with the wider availability of high-resolution computed tomography. Children with noncystic fibrosis can be seen with improvement in bronchiectasis even resolution, as opposed to adults. We report a case of reversible bronchial dilatation in an adult as evidenced by high-resolution computed tomography, which demonstrates that, although quite rare in adults, spontaneous resolution may occur.

Rapid resolution of reversible bronchiectasis after Mycoplasma pneumoniae pneumonia in an adult: A case report

RATIONALE

Bronchiectasis results when inflammatory and infectious damage to the bronchial and bronchiolar walls leads to a vicious cycle of airway injury. On the basis of the classic characteristic, that is, permanent bronchial dilatation, bronchiectasis is generally considered irreversible in the adult population.

PATIENT CONCERNS

A 21-year-old woman presented to our hospital with a 9-day history of productive cough and fever.

DIAGNOSIS

Bronchiectasis after Mycoplasma pneumoniae pneumonia.

INTERVENTIONS

The patient was treated with azithromycin for 7 days.

OUTCOMES

The bronchial dilatation resolved as evidenced by sequential chest high-resolution computed tomography 7 days and 1 month later, respectively.

LESSONS

Although complete disappearance is quite rare in adult, this case demonstrated that bronchial dilatation might resolve completely in such a fascinating short period of time if receiving adequate and timely regimens.

A woman with breathlessness: a practical approach to diagnosis and management

Worsening breathless in a patient with severe chronic obstructive pulmonary disease (COPD) is a common diagnostic and management challenge in primary care. A systematic approach to history-taking and examination combined with targeted investigation of pulmonary, cardiovascular, thromboembolic and systemic causes is essential if co-morbidities are to be identified and managed. Distinguishing between heart failure and COPD is a particular challenge as symptoms and signs overlap. In low and middle income countries additional priorities are the detection of infections such as tuberculosis and human immunodeficiency virus (HIV). Clinicians need to be alert to the possibility of atypical presentations (such as pain-free variants of angina) and less common conditions (including chronic thromboembolic pulmonary hypertension) in order not to overlook important potentially treatable conditions.

Clinical, radiologic, and functional evaluation of 304 patients with bronchiectasis

BACKGROUND

Bronchiectasis continues to be one of the major causes of morbidity and mortality in developing countries, with a probably underestimated higher prevalence than in developed countries.

OBJECTIVE

To assess the clinical profile of adult patients with bronchiectasis.

METHODS

We retrospectively reviewed the clinical, radiologic, and physiologic findings of 304 patients with bronchiectasis confirmed by high-resolution computed tomography.

RESULTS

Mean age of participants (45.7% males, 54.3% females) was 56 ± 25 years and 65.8% of them were lifetime non-smokers. Most common identified causes of bronchiectasis were childhood disease (22.7%), tuberculosis (15.5%), and pneumonia (11.5%). The predominant symptoms were productive cough (83.6%), dyspnea (72%), and hemoptysis (21.1%). The most common findings on chest examination were crackles (71.1%) and rhonchi (28.3%). Types of bronchiectasis were cylindrical in 47%, varicose in 9.9%, cystic in 45.1%, and multiple types in 24.3%. Involvement was multilobar in 75.3% and bilateral in 62.5%. Of 274 patients, 20.8% displayed normal pulmonary function test results, whereas 47.4%, 8% and 23.7% showed obstructive, restrictive, and mixed pattern, respectively. Patients with cystic disease had a higher frequency of hemoptysis (42%) and a greater degree of functional impairment, compared to other types.

CONCLUSION

In patients with bronchiectasis from southern Turkey, generally presenting with recurrent productive cough, hemoptysis, dyspnea, and persistent bibasilar rales, the etiology remains mainly idiopathic. Post-infectious bronchial destruction is one of the major identified underlying pathological processes. The clinical picture and the deterioration of the pulmonary function test might be more severe in patients with cystic type bronchiectasis.

Bronchiectasis

Bronchiectasis, which was once thought to be an orphan disease, is now being recognized with increasing frequency around the world. Patients with bronchiectasis have chronic cough and sputum production, and bacterial infections develop in them that result in the loss of lung function. Bronchiectasis occurs in patients across the spectrum of age and gender, but the highest prevalence is in older women. The diagnosis of bronchiectasis is made by high-resolution CT scans. Bronchiectasis, which can be focal or diffuse, may occur without antecedent disease but is often a complication of previous lung infection or injury or is due to underlying systemic illnesses. Patients with bronchiectasis may have predisposing congenital disease, immune disorders, or inflammatory disease. The treatment of bronchiectasis is multimodality, and includes therapy with antibiotics, antiinflammatory agents, and airway clearance. Resectional surgery and lung transplantation are rarely required. The prognosis for patients with bronchiectasis is variable given the heterogeneous nature of the disease. A tailored, patient-focused approach is needed to optimally evaluate and treat individuals with bronchiectasis.