2. DEFINICIÓN
«Dilatación anormal irreversible y el engrosamiento
de las paredes de los bronquios»
Fase final de procesos patológicos
Destrucción de la pared bronquial
Tejidos de soporte
Tos Crónica - meses a años
Expectoración mucopurulenta copiosa
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
3. PREVALENCIA
52/100 000 – US
>
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
5. Inflamación
transmural
Edema de la
mucosa
Erosión y
ulceración del
epitelio
neo
vascularización
Infección
Bacteriana
Crónica
+
Obstrucción de la
vía aérea
Impedimento del
drenaje
Respuesta
inmunitaria
inapropiada
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
6. Granulomas
submucosos
Hipertrofia del
músculo liso
Perdida del
epitelio
Arteriolas
tortuosas –
Anastomosis
broncopulmonares
Perdida de ciliios
Metaplasia
escamosa
Hipertrofia de las
glándulas
bronquiales
Intenso infiltrado:
neutrófilos,
linfocitos,
monocitos
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
7. INFECCIONES
Infecciones en la
infancia:
• Neumonía severa
• Pertusis
• Sarampión
• tuberculosis
Infecciones:
• Adenovirus,
herpesvirus
• S. Aureus
• K. pneumoniae
• P. aeruginosa
Infección por
Mycobacterium
• Bronquitis
• Estenosis de la
pared bronquial
Mycobacterium
avium complejo
• Caucásicos
• Mujeres 50 a 70
años
• Inmunocompromiso
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
8. OBSTRUCCIÓN BRONQUIAL
Obstrucción Colapso Inflamación
Bronquiectasia
local
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
Obstrucciones internas
• Adenomas, Fibromas,
Condromas, Papilomatosis
Obstrucciones externa Estenosis bronquial
9. ASPIRACIÓN Y LESIÓN POR
INHALANTES
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
10. FIBROSIS QUÍSTICA
Una de las causas más
comunes
Autosómico recesivo
>200 mutaciones
1-3 % Diagnóstico tardío
Lobo superior + Cultivo
para Pseudomonas
aeruginosa
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
11. OTRAS CAUSAS
• Azoospermia obstructiva + infecciones sinopulmonares crónicas (sin anormalidades
ciliares)
Síndrome de Young
• Autosómico recesivo
• Genes: DHA1, 5 y 11- dineinas
• Defectos del movimiento de cilios
Dicinesia ciliar primaria
• Aspergillus fumigatus
• Pacientes con asma y fibrosis quística – millieu
• Eosinofilia sistemica y local, Ig G y E especificos
• Criterios de Rosemberg Patterson (sin F.Q.)
Alergia broncopulmonar al Aspergillus
• Inmunodeficiencias primarias
• Colagenopatias
Desordenes inflamatorios
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
12. ¿A QUIENES DEBERÍA INVESTIGASE
UNA BRONQUIECTASIA?
Tos productiva persistente con al menos uno de los
siguientes factores proclives
Inicio de presentación a edad joven
Historia de síntomas relacionados muchos años
Ausencia de historial de tabaquismo
Expectoración diaria en gran cantidad de características
purulenta
Hemoptisis
Colonización de esputo por P. aeruginosa.
Pasteur M. C. «British Thoracic Society guideline for non-CF bronchiectasis” BTS.
13. CUADRO CLÍNICO
Tos podría ser el único síntoma durante años
Expectoración:
Empeora por la mañana,
Intermitente
Infecciones frecuentes,
Taponamiento bronquial
Terapia antimicrobiana
Bronquiectasia «seca»
Tos mínimamente productiva
Hemoptisis
Historia de infecciones recurrentes o secundario a
Infección por pertusis, neumonía severa y tuberculosis
Tos Crónica Expectoración mucopurulenta
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
14. EXACERBACIÓN
Aumento en la frecuencia e
intensidad de la tos
Disnea
Producción de esputo
fiebre,
Hemoptisis
Dolor de pecho
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
15. EXPLORACIÓN FÍSICA
Estertores crepitantes
inspiratorios tempranos y
mesoinspiratorios
Roncus difusos
Expiración prolongada
Paquioniquia
Osteoartropatía hipertrófica
pulmonar
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
18. Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
ESTUDIOS
RADIOLÓGICOS
RADIOGRAFÍA DE
TÓRAX
Signo del anillo
Líneas en «rieles»
Radiopacidad en «
dedo en guante»
Datos de atelectasia
20. CLASIFICACIÓN RADIOLÓGICA
Reid 1950 – Tomografía
computada
Cilíndrica:
Contorno regular, diámetro
aumentado, Paredes lisas
Varicosa
Dilataciones irregulares,
saculaciones o trayectos
tortuosos que asemejan una
vena
Quisticas o saculares
Distorsión quística en las vías
aéreas distales, podría ser focal
o diseminado. Resultando en
sáculos que aparecen como
racimos de uvas.
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
21. Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
22. MANEJO Identificar la
causa primaria
Control de
infecciones
Higiene
Bronquial
Aclaramiento
de moco
Mejorar la
función
pulmonar
Reducir las
exacerbaciones
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
23. CONTROL DE INFECCIONES
Resolver la perpetuación del a bronquiectasia
Antibioticoterapia - exacerbaciones
H. Influenzae
Pseudomonas aeruginosa
Nocardia asteroides
Mycobacterium spp. (vida libre)
Antimicoticos
Aspergillus Fumigatus
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
25. Toma de cultivo de expectoración
• Amoxicilina 500mg bid o claritromicina 500mg bid x
14 días
Prima línea sin cultivo
• Ciprofloxacino 500 750 mg bid x 14 días
Colonización por Pseudomonas
Pasteur M. C. «British Thoracic Society guideline for non-CF bronchiectasis” BTS.
26. HIGIENE BRONQUIAL
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
Mal apego
Hipoxemia potencial
Incomodidad torácica
27. Dispositivo de vibración
mecánica de presión
espiratoria positiva
Dispositivo de vibración mecánica con
válvula Flutter
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
28. ACLARAMIENTO DE MOCO
Estado inflamatorio
crónico
Hipersecreción de
moco
Prevenir la retención de expectoraciones
Mantener un estado de hidratación adecuado
Humidificación del oxigeno inhalado
Nebulizacion
Solución salina 0.9%
Solución Salina 3%,
Acetilcisteina
Fishman A. et Al. «Fishman’s pulmonary deseases and disorders». 4th edition . McGraw Hill; 2008
29. BIBLIOGRAFÍA
Fishman A. et Al. «Fishman’s pulmonary deseases and
disorders». 4th edition . McGraw Hill; 2008
Adam A. Et Al. «grrainger and allison’s diagnnóstic radiology».
6th Edition. Churchil-Livingsone-Elsevier. 2015
Pasteur M. C. «British Thoracic Society guideline for non-CF
bronchiectasis” BTS. Thorax.2010
Notas del editor
The abnormal bronchial dilatation in bronchiectasis principally affects the medium-sized bronchi, but often extends to the more distal bronchi and bronchioles. The affected bronchi show transmural inflammation, mucosal edema, cratering, ulceration, and neovascularization
t has been suggested thatfollowing bronchial obstruction, airways proximal to the collapse are exposed to strong dilating forces caused by thedifference in the atmospheric pressure in the bronchi andthe negative pressure in the pleural space. Over time, theseforces acting on weakened, inflamed airways may result inpermanent and pathological airway dilatation.
Aspiration or inhalation of foreign matter, such as noxious fumes or particulates into the airways, may result in bronchiectasis. This may involve aspiration of oropharyngeal secretions containing microaerophilic and anaerobic bacteria, which may result in a necrotizing pneumonia.
Refluxed material from the esophagus or stomach containing food particles, gastric, biliary, and pancreatic secretions, and gutmicrobes may enter and damage airways, especially if the aspiration events are large and repeated. Depressed sensorium (stroke, alcohol and drug use, seizure, postanesthetic), brain stem dysfunction (amyotrophic lateral sclerosis, multiple sclerosis, syringomyelia), defective laryngeal function (postsurgery, postirradiation), esophageal disorders (dysmotility, gastroesophageal reflux disease [GERD], achalasia, tracheoesophageal fistula), and gastric disorders (gastric outlet obstruction) influence the likelihood and frequency of aspiration. Bronchiectasis may present years after foreign body aspiration (aspiration is often unrecognized), though bronchiectasis has been seen to occur in animals as soon as 2 to 8 weeks after experimental foreign body introductioninto the bronchial tree. GERD is the most common condition in this category contributing to the risk of bronchiectasis, and several studies are available documenting increased frequency of reflux in patients with bronchiectasis, asthma, and pulmonary fibrosis, all chronic pulmonary inflammatoryconditions. The cause-effect conundrum of GERD in these conditions is still being debated. However, given the high rate of association of GERD with bronchiectasis and the fact that it is often treatable, GERD evaluation should be part of the bronchiectasis work-up
ABPA manifests as recurring episodes of asthma, pulmonary infiltrates, and central bronchiectasis that may progress to fibrosis
Rosenberg-Patterson 1977 criteria for diagnosis of ABPA.Primary criteria (1–6 suggestive, +7 definite) : 1. Episodic bronchial obstruction 2. Peripheral eosinophilia 3. Positive immediate skin test to Aspergillus 4. Positive preciptin test to Aspergillus 5. Increased total serum IgE 6. History of transient or fixed lung infiltrates 7. Proximal bronchiectasis
Secondary (supportive) criteria: . Brown plugs/flecks in sputum2. Positive late (6–12 h/Arthus) skin test to Aspergillus
Cough is invariably present and often may be the only symptom for years. Purulent, tenacious sputum production, frequently worsein the morning (having accumulated during recumbency in sleep) is present in most patients. Sputum production may be intermittent, being affected by recurrent infections, bronchial plugging, and antibiotic therapy.
“Dry bronchiectasis” presenting as cough, minimal sputum expectoration, and/or hemoptysis is occasionally described. Hemoptysis may beseen in 40 to 70 percent of patients and may vary from blood streaks to large clots.
Increasing cough, dyspnea, and volume of sputum production, fever, hemoptysis, and chest pain are hallmarks of acute exacerbations. Often patients give a history of recurrent chest infections, although single episodes of severe pneumonia, tuberculosis, or pertussis with secondary pneumonia may also result in bronchiectasis.
Chest auscultation usually reveals findings of early and mid-inspiratory crackles as well as diffuse rhonchi and prolonged expiration. Bronchial breath sounds may be heard in severe cases or patients with a complicating pneumonia. Digital clubbing and hypertrophic pulmonary osteoarthropathy,although common in the pre-antibiotic era, are rarely seen now. In severe advanced cases, there may be evidence of respiratory insufficiency and cor pulmonale.
The chest x-ray may be abnormal and show the presence of increased pulmonary markings, ringlike structures, atelectasis, dilated and thickened airways (tram lines), and mucus plugging (finger-in-glove) appearance; however, the chest radiograph may be normal even in the presence of bronchiectasis
The HRCT has been proved to be a reliable and noninvasive method for assessment of bronchiectasis. HRCT can accurately (sensitivity of 97 percent) diagnose bronchiectasis,localize and describe areas of parenchymal abnormality, andidentify bronchiolar abnormalities and mucus plugging tothe level of fifth- and sixth-order bronchi. It also can identifyfocal areas of air trapping as an indicator of small airway disease. It is indicated in the evaluation of bronchiectasis whensurgical resection is contemplated, bronchiectasis is stronglysuspected clinically and routine chest radiographs are normal, and other parenchymal abnormalities have to be betterdefined.Airway dilatation can be detected by finding tram linesor end-on-ring appearance. A luminal diameter more than1.5 times the adjacent vessel is indicative of bronchiectasis(Fig. 125-1). Bronchial wall thickening may also be seen. Evidence of small airway plugging with debris (tree-in-bud) mayalso be seen (Fig. 125-3).Reports are available suggesting that the distributionand pattern of bronchiectasis may be sufficient to implicatea specific cause. Cartier et al. found that bilateral predominantly upper lobe bronchiectasis is seen most commonly inCF and allergic bronchopulmonary aspergillosis, a unilateralupper lobe predominance in tuberculosis and a lower lobepredominance in childhood viral infections