Bronchiectasis

Dr. med. Fabian Sinowatz is a freelancer in the medical editorial team.

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Bronchiectasis is a sac-shaped widening of the bronchi in the lungs that cannot regress. Bronchiectasis can have both congenital and acquired causes. A strong cough with a lot of slimy sputum is typical of bronchiectasis. If left untreated, bronchiectasis can seriously damage the lungs. Find out more about the causes, symptoms and treatment of bronchiectasis.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. Q33A16J47

Bronchiectasis: description

Bronchiectasis (Greek: éktasis “expansion”) is a pathological enlargement of the bronchi in the lungs. The condition when numerous bronchi are dilated in this way is therefore called bronchiectasis. Various causes lead to damage to the bronchial walls, which ultimately results in permanent expansion of the bronchi. Thanks to targeted antibiotic therapy and vaccinations, bronchiectasis is less common in Germany today than it used to be. With the high-resolution computed tomography (HR-CT) images, bronchiectasis is discovered more frequently and earlier, which leads to an apparent increase in the number of cases.

How do bronchiectasis develop?

The bronchi are the airways in the lungs. With each breath, inhaled air flows through them to the pulmonary alveoli, where gas exchange takes place. However, pathogens and dirt particles also get into the bronchial system with the air we breathe, which in healthy people are continuously transported back outside by a sophisticated self-cleaning mechanism (the so-called mucociliary clearance). The airways are lined with certain cells that produce a slimy secretion and the finest cilia are located on the surface. The secretion helps kill pathogens. The cilia constantly carry out a fanning movement towards the mouth (ciliate stroke), through which the mucus and the pathogens and foreign bodies attached to it are transported to the throat. Once there, they are swallowed or coughed up.

This self-cleaning mechanism is important to keep the lungs free of foreign objects and to prevent infections of the respiratory tract. The mechanism can be disturbed by various causes, as a result of which the bronchial mucus cannot drain well. This provides an ideal breeding ground for pathogens and therefore leads to recurring infections. The frequent inflammations damage the walls of the bronchi, so that they expand over time and bronchiectasis occurs. This pathological expansion (bronchiectasis) is an irreversible process. As a result of the expansion, the bronchial mucus can drain even more poorly, which in turn leads to even more frequent infections. One speaks here of a vicious circle (vicious circle).

Bronchiectasis: symptoms

The main symptom of bronchiectasis is a strong cough with large amounts of slimy sputum ("mouthful expectorations"). The sputum has a typically sweet, putrid smell and often contains blood (hemoptysis) or pus. If you put it in a glass, you get a three-layer (“three-layer sputum”): a foamy top layer, a middle layer of mucus and a tough, purulent sediment at the bottom.

In addition to coughing, bronchiectasis can cause fever, shortness of breath and repeated pneumonia due to the chronic inflammation and suppuration of the bronchi. In bronchiectasis, bacteria very rarely reach the brain from the ulcerated bronchi via the bloodstream (brain abscess). Chronic oxygen deficiency can lead to the formation of so-called watch glass nails and drumstick fingers. The end links of the fingers are blown like a piston and the fingernails are strongly arched and rounded.

Bronchiectasis: causes and risk factors

There are a number of congenital or acquired causes of bronchiectasis. The most common reason for bronchiectasis are recurring infections of the lower respiratory tract, especially in childhood. Most of the causes listed below lead to a disruption of the self-cleaning function (mucociliary clearance) of the bronchi: The fine cilia are then no longer able to remove mucus and foreign bodies from the bronchial system. This makes it easier for pathogens to multiply in the stuck mucus and trigger inflammation. In rare cases, a clear cause for the development of bronchiectasis cannot be found (idiopathic bronchiectasis).

Congenital causes of bronchiectasis:

Cystic fibrosis (cystic fibrosis) is a hereditary disease in which, among other things, tough mucus forms in the finely branched bronchi and trachea. This blocks the airways, causing repeated infections, which can lead to bronchiectasis.

If there is a lack of antibodies (immunodeficiency), too few antibodies are formed to defend against pathogens. The weakened immune system leads to frequent infections of the respiratory tract, which damage the bronchial walls, so that bronchiectasis can develop.

Primary ciliary dyskinesia (PCD) is a rare, genetic disorder of the fine cilia. As a result, the self-cleaning mechanism (mucociliary clearance) of the bronchi is disturbed, which leads to repeated infections of the bronchi. The disease occurs as part of the so-called Kartagener syndrome.

In alveolar malformations, the alveoli are incorrectly formed from birth. This causes secretion to build up in the alveoli, which is a good breeding ground for infections.

Acquired Causes of Bronchiectasis:

The most common cause of bronchiectasis are repeated infections of the bronchial system that occur in childhood. Pneumonia, measles, and whooping cough can also damage the bronchi and lead to bronchiectasis.

Foreign bodies or tumors can narrow the bronchi (bronchus stenosis). As a result, the bronchial secretion cannot drain off well and recurrent inflammation and bronchiectasis occur.

After pneumonia or tuberculosis (Tbc), scars can develop in the bronchial system, which also impede the normal outflow of bronchial secretions.

Bronchiectasis: examinations and diagnosis

If you have bronchiectasis, your family doctor or a pulmonologist (pulmonologist) are the right people to talk to. The medical history and physical examination provide the doctor with important information about whether bronchiectasis is present. The diagnosis of bronchiectasis is made with high-resolution computed tomography (HR-CT).

Medical history (anamnesis):

Before the actual examination, the doctor asks a few questions in order to find out more about the nature and duration of the current symptoms. Any previous illnesses or accompanying symptoms are also relevant for the doctor. The doctor will ask various questions, for example:

• What complaints do you have and when do they appear particularly severe?
• How long have you had these complaints?
• Do you have a cough?
• Do you have slimy sputum when you cough?
• Does the sputum look bloody or purulent?
• Do you smoke? If so, how much and how long?
• Are you breathless? If so, in what situation?
• Are you or family members known to have any lung diseases?
• Do you take medicine?

Physical examination

After the anamnesis, the doctor will examine you. Listening to the lungs with a stethoscope (auscultation) is particularly important. In the case of bronchiectasis, audible rattling noises and a humming noise when breathing occur with the stethoscope. The doctor may look at your fingers to look for signs of chronic oxygen deficiency: this can lead to what is known as drumstick fingers and watch glass nails, among other things.

Further investigations:

Further examinations are necessary to reliably determine bronchiectasis. These are partly carried out by the family doctor or pulmonologist himself. Imaging procedures such as x-rays or computed tomography (CT) are carried out by a specialist in radiology. Blood tests and molecular tests can help identify the cause of the bronchiectasis.

High-resolution computed tomography (HR-CT)

The final diagnosis of bronchiectasis is made by high-resolution computed tomography of the chest (CT chest).

X-ray and bronchography

A chest x-ray (chest x-ray) can be used as a guide if bronchiectasis is suspected. However, it is not enough to confirm the diagnosis alone. In bronchography, the bronchi are briefly filled with X-ray contrast medium in order to make them visible on the X-ray image.

Three-layer sputum

If you fill the sputum into a glass, the sputum separates into three layers: a foamy top layer, a middle layer of mucus and a tough, purulent sediment at the bottom. During the sputum examination, a microbiological smear is taken to identify any pathogens involved.

Blood tests and molecular biological tests

A blood sample and molecular biological examinations (genetic tests) can determine possible causes such as defects in the immune system or inherited diseases such as cystic fibrosis.

Lung function test ("Lufu")

Here, some lung volumes and other parameters of lung function can be measured. This enables the doctor to assess how severely the bronchiectasis is hindering breathing (ventilation disorders).

Electrocardiogram (EKG) and cardiac ultrasound (UKG)

The bronchiectasis can also affect the heart and develop a so-called cor pulmonale. Whether this is the case can be checked with an EKG and an ultrasound scan of the heart.

Blood gas test

If you have difficulty breathing, a blood gas test (BGA) may be done to determine the level of oxygen deficiency in your blood.

Nasal mucosa sample

If the fine cilia are suspected of malfunctioning (ciliary dyskinesia), a sample can be taken from the nasal mucosa.

Bronchoscopy (lung specimen)

Lungoscopy is rarely used to diagnose possible constrictions in the bronchi.

Bronchiectasis: treatment

The most important measures for the treatment of bronchiectasis are the regular mobilization of secretions and the prevention or treatment of infections. In the case of congenital forms of bronchiectasis, it is also important to recognize them at an early stage in order to initiate therapy for the underlying disease if necessary - for example, intravenous administration of antibodies in the event of an antibody deficiency.

A daily "bronchial toilet" must be learned to mobilize secretions. To do this, the mucus in the bronchi is first liquefied by inhalation with expectorant agents (mucolytic agents) or brine solutions. The mucus is then loosened (mobilized) by tapping the back and chest and should finally be coughed up in the so-called Quincke position.

The Quincke position is a special posture in which the upper body lies lower, making it easier to cough up mucus. Special physiotherapeutic breathing techniques can make it easier to cough up. This bronchial toilet can take up to an hour a day and should also be carried out if there are no symptoms. By coughing up the mucus, the lungs are better ventilated and pathogens are deprived of the breeding ground for them to spread.

If an infection has nevertheless occurred in the lungs, this should be treated with as targeted antibiotic therapy as possible. For this purpose, the pathogen should be determined and tested for its sensitivity to various antibiotics (antibiogram). In severe cases of bronchiectasis, it may also be necessary to use an antibiotic regularly to prevent worsening due to chronic infections (exacerbation).

In the case of shortness of breath caused by bronchiectasis, medication can be used to dilate the bronchi (bronchodilators). These are available as inhalation sprays, tablets, drops or as a drinking solution.

Surgical treatment of bronchiectasis is only possible in particularly severe cases. Either a segment of the lung (segment resection) or an entire lobe of the lung (lobectomy) can be removed.

Bronchiectasis: disease course and prognosis

Bronchiectasis is a chronic disease. How well infections can be avoided is decisive for the course and prognosis of bronchiectasis. This requires a daily bronchial toilet and early, targeted antibiotic therapy. The course can be significantly improved so that the life expectancy of people with bronchiectasis is hardly limited.

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