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Bronchiectasis.
- 2. Bronciectasis (Greek word) Bronkos ---- Wind pipe Ektesis ---- Stretching
- 3. Irreversible airway dilation that involves the lung in focal/ diffuse manner. 4 types of airway dialation - (Reid’s classification) Cylindrical Tubular (most common) Varicose Cystic
- 6. ETIOLOGY Focal Obstruction – tumors, foreign body. Diffuse Infection – bacterial, non-bacterial & mycobacterium. Immunodeficiency – hypogammaglobulinemia, HIV, bronchiolitis obliterans after lung transplantation. Genetic causes – cystic fibrosis, kartagener’s, α1 AT deficiency. Autoimmune/rheumatologic – RA, sjogren’s syndrome. Recurrent aspiration Miscellaneous – yellow nail syndrome, traction bronchiectasis from post radiation, IPF. Idiopathic
- 7. PATTERNS OF INVOLVEMENT Cystic fibrosis and post radiation fibrosis – upper lobe c/c recurrent aspiration, end stage fibrotic lung d/s, recurrent immunodeficiency conditions – lower lobe Non TB mycobacteria, ciliary motility dysfunction disorders – middle lobe ABPA, tracheomegaly (Moynier – Kuhn syndrome), williams campbell syndrome – central airways.
- 8. EPIDEMIOLOGY Most commonly affects right upper lobe Incidence increases with age. More common in women. MAC – more in non smoking women >50yrs of age. Cystic fibrosis – presents in late adolescence or early adulthood.
- 9. BRONCHIAL INSULT INFLAMMATION IMPAIRED MUCOCILLIARY CLEARENCE BRONCHIAL OBSTRUCTION BRONCHIAL DAMAGE FURTHER INFLAMMATION BRONCHIECTASIS PATHOGENESIS & PATHOLOGY
- 10. PATHOGENESIS & PATHOLOGY Vicious cycle hypothesis Microbes -> c/c inflammation -> damage to airway and impaired mucociliary clearance –> more infection. Ongoing inflammation – reactive oxygen species, proinflammatory cytokines – damage to lung tissues – obstruction to airflow. Non infective conditions – immune mediated damage to airways and lungs
- 11. CLINICAL FEATURES M.C symptom – persistent productive cough with ongoing production of thick tenaceous sputum. Signs – clubbing, crackles and wheeze on auscultation. PFT – shows mild to moderate airway obstruction Acute exacerbations – characterized by change in nature of sputum production and increase in volume and purulence.
- 12. DIAGNOSIS Clinical history + radiographic features. Lab testing – CBC – TC,DC , Sputum culture X Ray chest HRCT thorax – imaging modality of choice – findings include – Airway dilation – tram track, signet ring Lack of bronchial tapering Bronchial wall thickening in dilated airways Inspissated secretion – tree in bud FOB to r/o foreign body or underlying mass
- 14. CT IMAGES OF BRONCHIECTASIS
- 15. PULMONARY FUNCTION TESTS • Reveal an obstructive pattern with reduced FEV1 and reduced FVC. • Other bedside tests include : • Sabrasez breath holding test • Schneider’s match blowing test • Cough test – ability, strength and effectiveness
- 16. OTHER DIAGNOSTIC TESTS • bronchial biopsy (ciliary ultrastructure) • bronchoscopy – obstructing lesion? • aspergillus precipitins / antibodies • serum IgE • alpha 1 – antitrypsin (concentracion / phenotype) • RA factor
- 17. SPUTUM ANALYSIS Amount of sputum 24 hr Sputum Production Mild < 10 ml/day Moderate <150 ml/day Severe >150 ml/day Visual Impression – colour, consistency Microbiology Sputum AFB -3 sputum samples on 3 consecutive days
- 18. MANAGEMENT Anti microbial therapy to decrease the microbial load. Maintenance of hygeine and clearance of secretions by postural drainage and mucolytics. Anti inflammatory therapy and bronchodialation with corticosteroids and bronchodilators. Refractory cases – resection of the affected lung.
- 19. COMPLICATIONS Life threatening hemoptysis – erosion into a blood vessel. Recurrent pneumonia Empyema Pneumothorax Lung abscess Brain abscess Cor pulmonale Anti microbial resistance due to repeated infections and repeated use of antibiotics
- 20. PRE OP EVALUATION Adequate history – to r/o other coexisting diseases, frequency of exacerbations, onset and duration, sputum – amount, colour, dyspnea, stridor. Examination of vitals, chest examination and CVS examinaion to r/o RVH and signs of PAH, airway assessment. Optimisation of pulmonary status – antibiotics, bronchodilators, postural drainage to clear off secretions. Pulmonary function tests and baseline ABG
- 21. Cough - indirectly increases airway irritability. Blood-stained sputum or episodes of gross hemoptysis should raise the possibility of a tumor invading the respiratory tract (e.g., the main stem bronchus), which might interfere with endobronchial intubation. Smoking increases the airway reactivity and increases the incidence of post operative complications. Presence of central cyanosis –suggestive of poor cardiopulmonary reserve
- 22. Acute phase – airway hyper reactivity will take 6wks or more to subside – increased secretions can increase incidence of broncho/laryngospasms. Tracheal mucociliary flow and pulmonary bactericidal activity can be reduced by GA. Positive pressure ventilation can cause increase spreading of infections from upper to lower respiratory tract.
- 23. PRE OP PFT PFT with special reference to VC, FEV1, PEFR. Criteria which indicates increased mortality & morbidity after lung resection: FVC <50% of predicted value FEV1 <50% of FVC Maximum breathing capacity <50% of predicted value PaCO2 > 45mmHg Gas transfer <50% of predicted value Mean Pulmonary artery pressure >30mm Hg during unilateral occlusion of pulmonary artery.
- 24. RESPIRATORY MECHANICS Rather than absolute values, % values are more important in predicting the post operative outcomes. Single most important – predicted postoperative FEV1: = preoperative FEV1% x (1-%lung tissue removed/100) Patients with >40% of ppoFEV1 – less chance of post thoracotomy complications
- 27. SPLIT LUNG FUNCTION TESTS Regional lung function studies - predict the function of the lung tissue that would remain after lung resection. Regional Perfusion Test - Intravenous injection of insoluble radioactive xenon (133Xe). The peak radioactivity of each lung is proportional to the degree of perfusion of each lung. Regional Ventilation Test - Using an inhaled, insoluble radioactive gas, the peak radioactivity over each lung is proportional to the degree of ventilation. Combining radiospirometry with whole-lung testing (FEV1, FVC, maximal breathing capacity) has resulted in a fair degree of correlation between predicted volumes and pulmonary function tests measured after pneumonectomy.
- 28. CLUBBING -
- 29. BREATH SOUNDS Wet sounds (crackles) are usually caused by excessive fluid in the airways and indicate sputum retention or edema. Dry sounds (wheezes) are produced by high-velocity gas flow through bronchi and are a sign of airway obstruction.
- 30. POSITION OF TRACHEA The trachea should be in the midline. Displacement of the trachea may be secondary to a number of causes, including mediastinal mass, and should raise the possibility of difficult intubation of the trachea or airway obstruction at induction of anesthesia.
- 31. ABG Important to know the baseline blood pH status and blood gas status. Patients with underlying COPD – especially blue bloaters – have high levels of blood CO2 – have a hypoxic drive to breath – supplementing high oxygen – abolish the respiratory drive. Pink puffers – usually have a near normal ABG
- 32. EVALUATION OF CVS Pulmonary circulation - normally a low-pressure, high- compliance system In COPD- decreased compliance - increase in pulmonary vascular resistance - pulmonary hypertension Acidosis, sepsis, hypoxia, and application of positive end-expiratory pressure (PEEP), all further increase the pulmonary vascular resistance and increase the chance of right ventricular failure.
- 33. EVALUATION OF CVS In patients with ischemic or valvular heart disease, the function of the left side of the heart should also be carefully evaluated. Electrocardiogram - features of right atrial and ventricular hypertrophy and strain - low-voltage QRS complex due to lung hyperinflation and poor R-wave progression across the precordial leads. Enlarged P wave (“P pulmonale”) in standard lead II is diagnostic of right atrial hypertrophy. The electrocardiographic changes of right ventricular hypertrophy are an R/S ratio of greater than 1.0 in lead V1
- 34. CHEST RADIOGRAPHY Hyperinflation and increased vascular markings - COPD. Prominent lung markings -bronchitis, but decreased in emphysema, particularly at the bases. A mediastinal mass may indicate difficulty with ventilation, a difficult and bloody dissection, difficulty in placing a double-lumen tube (DLT; because of deviation of the main stem bronchus), or a collapsed lobe owing to bronchial obstruction. Presence of pneumothorax should be ruled out
- 35. CT & PET-Patients normally undergo CT scanning. The CT scan can delineate the size of the tumor. It can also reveal if there is airway or cardiovascular compression. PET scan can detect tumor based on the metabolic activity. DLCO –denotes the ability of the lung to perform gas exchange – impaired in interstitial lung disease,. A predicted postoperative diffusing capacity for carbon monoxide <40% is associated with increased risk.
- 36. SIGNIFICANCE OF BRONCHODILATOR THERAPY Pulmonary function tests - before and after bronchodilator therapy - to assess the reversibility of airway obstruction. A 15% improvement in pulmonary function tests may be considered a positive response to bronchodilator therapy and indicates that this therapy should be initiated before surgery.
- 37. CARDIOPULMONARY RISK INDEX (CPRI) FOR LUNG RESECTION Cardiac and pulmonary risk indices CPRI score of 4 or higher is associated with 22 fold increase in post thoracotomy complications than in patients with score less than 4
- 38. CARDIAC RISK INDICES VARIABLE SCORE Congestive heart failure 11 MI (within 6 months of surgery) 10 > 5 PVCs per minute 7 Other arrythmias 7 Age > 70yrs 5 Aortic stenosis 3 Poor general medical condition 3 Thoracic operation 3 Score = 1 (0-5 CRI points) 2 (6-12 points) 3 (12-25 points) 4 (>25 points)
- 39. PULMONARY RISK INDICES VARIABLE SCORE Obesity 1 Cigarette smoking (within 8 weeks of surgery) 1 Productive cough (within 5 days of surgery) 1 Diffuse wheeze or ronchi (within 5 days of surgery) 1 FEV1/FVC <70% 1 PaCO2 >45 mm Hg 1
- 40. CPRI SCORE Score is calculated by adding CRI and PRI scores CPRI score of 4 or higher is associated with 22 fold increase in post thoracotomy complications than in patients with score less than 4
- 41. PRE OPERATIVE PREPARATIONS Infection, dehydration, electrolyte imbalance, wheezing, obesity, cigarette smoking, cor pulmonale, and malnutrition, show particular correlations with postoperative complications.
- 42. SMOKING cessation of smoking for a period of longer than 4 to 6 weeks before surgery - reduced postoperative complications. Most of the beneficial effects of cessation of smoking, such as improvement in ciliary function, improvement in closing volume, increase in FEF25– 75%, and reduction in sputum production, usually occur 2 to 3 months after smoking has ceased.
- 43. INFECTION Appropriate antibiotic therapy based on culture and sensitivity
- 44. Hydration and Removal of Bronchial Secretions Correction of hypovolemia and electrolyte imbalance should be accomplished before surgery - adequate hydration decreases the viscosity of bronchial secretions and facilitates their removal from the bronchial tree. Humidification of inspired gas is extremely useful. Mucolytic drugs, such as acetylcysteine, or oral expectorants (potassium iodide) can be beneficial to patients with viscous secretions. Commonly used methods for removing secretions from the bronchial tree include postural drainage, vigorous coughing, chest percussion, deep breathing, and the use of an incentive spirometer.
- 45. Wheezing and Bronchodilation In the presence of acute wheezing elective surgery should be postponed until effective treatment has been instituted. Chronic wheezing is often seen in patients with COPD and is attributable to the presence of gas flow obstruction secondary to smooth muscle contraction, accumulation of secretions, and mucosal edema.
- 46. Sympathomimetic Drugs – increase the formation of 3′5′-cyclic adenosine monophosphate (cAMP). cAMP - produces bronchodilation, and cGMP produces bronchoconstriction, determines the state of contraction of the bronchial smooth muscle. The β1 (cardiac effects) of these drugs are often undesirable in patients with COPD. Selective β2 sympathomimetic drugs, such as albuterol, terbutaline, and metaproterenol, given as inhaled aerosols, are the preferred drugs for the treatment of bronchospasm, particularly in patients with cardiac disease.
- 47. Phosphodiesterase Inhibitors – inhibit the breakdown of cAMP by cytoplasmic phosphodiesterase - increase the level of cAMP, resulting in bronchodilation. Aminophylline improves diaphragmatic contractility and increases the patient's resistance to fatigue. Therapeutic blood levels of aminophylline are 5 to 20 µg/mL and can be achieved by infusing a loading dose of 5 to 7 mg/kg over 20 minutes, followed by a continuous intravenous infusion of 0.5 to 0.7 mg/kg/hr. Aminophylline may cause ventricular dysrhythmias, and this side effect should be borne in mind when treating patients who have myocardial ischemia.
- 48. Steroids – traditionally considered to decrease mucosal edema and may prevent the release of bronchoconstricting substances. Cromolyn Sodium – o stabilizes mast cells and inhibits degranulation and histamine release. It is useful in the prevention of bronchospastic attacks. Parasympatholytic Drugs – o include atropine and ipratropium. In the past, atropine has been avoided in patients with COPD and bronchitis because of concern regarding increases in the viscosity of mucus produced by this agent. However, atropine blocks the formation of cyclic guanosine monophosphate and therefore has a bronchodilator effect. Pulmonary Rehabilitation – o included education in a variety of areas such as breathing, exercise, and nutrition. It has reduced the incidence of complications following surgeries and have shown to accelerate the healing process and improvement of lung functions.
- 49. POSTURAL DRAINAGE Method of drainage of secretions from bronchial airways. Aided by gravity and the secretions easily coughed out. Chest percussion and vibration. Best done before meals or one and half to two hours after meals to decrease the chance of vomiting.
- 52. POSTURAL DRAINAGE All the positions are contraindicated in: Increased ICP Active hemoptysis Unstable head and neck injury Bronchopleural fistula Empyema Hemodynamically unstable patient Rib fracture without flail chest Pulmonary embolism Large pleural effusions
- 53. INTRA OPERATIVE MANAGEMENT Lung isolation techniques – single lumen tube, double lumen tube, bronchial blockers. Ventilation – problems include the VQ mismatch – increase in the shunt – arterial hypoxemia – minimised by Optimal ventilatory pattern Early clamping of pulmonary vessels Insufflation of oxygen to upper lung and cessation of two lung ventilation as late as possible
- 54. INTRA OPERATIVE MANAGEMENT Optimal ventilatory pattern – small tidal volume (7ml/kg) delivered at an increased respiratory rate (20 per min), short inspiratory duration (I:E approx 1:2), reduced PEEP – all these prevents excess rise in intra alveolar pressure – hence reduces the blood diversion from alveoli - maintain PaCO2 (36-40 mmHg) Early clamping of pulmonary vessels – eliminate most of the venous admixture during OLV, but not always possible
- 55. INTRA OPERATIVE MANAGEMENT Insufflation of oxygen to the upper lung – improves oxygenation if carried out at a positive pressure of 10cm H2O – particularly applicable in oesophageal surgeries. Cessation of ventilation to the upper lung – both lungs to be ventilated as long as possible – decreasing the period and extent of hypoxia.
- 56. MAINTENANCE OF ANAESTHESIA Light GA with muscular relaxation and controlled ventilation is the ideal combination. Opioids – increase the quality of analgesia. Low concentration of inhaled anaesthetics can increase the depth of anaesthesia, prevent the excess rise in blood pressure and decreases the patient awareness – iso, sevo or desflurane is preferred. Volatile agents themselves can act as bronchodilators – like halothane, enflurane, desflurane, isoflurane and sevoflurane
- 57. Drugs with histamine release property are preferably avoided – can cause bronchospasm (TPS, ms relaxants like atracurium, mivacurium and curare). Ketamine – bronchodilatory properties, maintain hypoxic pulmonary vasoconstriction response – minimises VQ mismatch
- 58. MONITORING Blood pressure – NIBP/arterial. Arterial line – advantage of drawing arterial samples for ABG analysis IJV cannulation – preferably on the same side of surgery – for CVP monitoring, fluid and blood transfusions during the procedure – also a wide bore peripheral cannula. Heat loss – minimised by using a warming blanket, warm fluids and warming of inspired gases.
- 59. CHEST CLOSURE AND DRAINAGE Aim at the end of thoracotomy – to achieve full expansion of all remaining lung tissue with the mediastinum approximately central. Wide bore tubing – usually two – anterior and posterior – to allow the escape of air (tube at apex) and clots/fluids (tube at base). Underwater seal – to prevent air from entering during inspiration back to the tube. Drains are closed when there is no appreciable blood loss and air leak.
- 60. IMMEDIATE POST OPERATIVE PERIOD Muscle relaxation reversed – lungs suctioned – remaining lung tissue reinflated with chest drains open before ET tube is removed once satisfactory pattern of respiration has been established. Mechanical ventilation is usually avoided post surgery – due to the complications of infection, air leaks. If controlled ventilation needed – inflation pressures kept to the minimum.
- 61. IMMEDIATE POST OPERATIVE PERIOD Post extubation – humidified oxygen delivered by face mask & patient made to sit up as soon as possible – to avoid abdominal contents interfering with diaphragmatic movements. Post operative analgesia – by NSAIDs, narcotics IM/IV – continuous/intermittent, intercostal blocks intraoperatively, paravertebral and thoracic epidural, interpleural instillation of drugs (A/E – increased systemic absorption and loss through drains). Cryoanalgesia – by freezing of intercostal nerves
- 62. POST OP COMPLICATIONS Atelectasis Airway trauma Penumothorax Caridac herniation Haemorrage Post pneumonectomy pulmonary edema. Dysrhytmias Right heart failure