Bronchiectasis: a case-based approach to investigation and management

Abstract

Bronchiectasis is a chronic respiratory disease characterised by a syndrome of productive cough and recurrent respiratory infections due to permanent dilatation of the bronchi. Bronchiectasis represents the final common pathway of different disorders, some of which may require specific treatment. Therefore, promptly identifying the aetiology of bronchiectasis is recommended by the European Respiratory Society guidelines. The clinical history and high-resolution computed tomography (HRCT) features can be useful to detect the underlying causes. Despite a strong focus on this aspect of treatment a high proportion of patients remain classified as "idiopathic". Important underlying conditions that are treatable are frequently not identified for prolonged periods of time.The European Respiratory Society guidelines for bronchiectasis recommend a minimal bundle of tests for diagnosing the cause of bronchiectasis, consisting of immunoglobulins, testing for allergic bronchopulmonary aspergillosis and full blood count. Other testing is recommended to be conducted based on the clinical history, radiological features and severity of disease. Therefore it is essential to teach clinicians how to recognise the "clinical phenotypes" of bronchiectasis that require specific testing.This article will present the initial investigation and management of bronchiectasis focussing particularly on the HRCT features and clinical features that allow recognition of specific causes.

FIGURE 1

Varicose and cystic bronchiectasis with mucus plugging in upper lobes.

FIGURE 2

Central tubular bronchiectasis in upper lobes.

FIGURE 3

a) Chest radiograph showing dextrocardia. b) High-resolution computed tomography showing cylindrical bronchiectasis in the lingula.

FIGURE 4

Cylindrical bronchiectasis and tree-in-bud pattern in lower lobes and middle lobe.

FIGURE 5

Different radiological “phenotypes” of bronchiectasis. a) Tubular bronchiectasis in lower lobes, b) varicose bronchiectasis in lower lobes, c) cystic bronchiectasis in right lower lobe, d) cystic bronchiectasis with tree-in-bud pattern and mucus plugging in lower lobes (cavitation in right lower lobe), e) mucus plugging and tree-in-bud pattern in lower lobes, f) varicose bronchiectasis in upper lobes and lingula.