PANCE Blueprint Pulmonary (10%)

Bronchiectasis

Patient will present as → a 25-year-old cystic fibrosis patient complaining of chronic, frequent coughing productive of yellow and green sputum. She recently recovered from a Pseudomonas spp. pneumonia requiring hospitalization. On physical examination you notice foul breath, purulent sputum and hemoptysis along with a CXR demonstrating dilated and thickened airways with “plate-like” atelectasis (scarring).

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Bronchiectasis is described as the permanent dilation or destruction of the bronchial walls

It is best considered the common endpoint of various disorders that cause chronic airway inflammation

The dilation and destruction of larger bronchi is caused by chronic infection and inflammation. Common causes are cystic fibrosis, immune defects, and recurrent infections, though some cases seem to be idiopathic

  • Most common cause is Cystic fibrosis
  • < 18 years-old Staphylococcal infections
  • > 18 years old Pseudomonas infection

CXR – linear ("tram track") lung markings, atelectasis, dilated and thickened airways “Plate-like” atelectasis (scarring)

  • Gold standard diagnosis is – CT of the chest
  • Plate like atelectasis

    CXR demonstrating typical "plate-like" atelectasis associated with bronchiectasis

Ambulatory oxygen, aggressive antibiotics, CPT (chest physiotherapy = bang on the back) and eventually lung transplant

IM_MED_Bronchietasis_v1.4_ Bronchiectasis is an obstructive lung disease caused by bronchial obstruction or chronic necrotizing infection. The subsequent muscle and elastic tissue damage permanently dilates the airways, which may trap air in the lungs and lead to collapse of the bronchioles. Common symptoms include increased purulent sputum production and hemoptysis. Bronchiectasis is associated with poor ciliary motility, a result of congenital causes like Kartagener's Syndrome, or acquired causes like smoking. Other predisposing conditions are cystic fibrosis, which impairs clearance of mucus from the airways, and allergic bronchopulmonary aspergillosis (APBA), an immune response to Aspergillus fungus.

View Bronchiectasis Picmonic

Question 1
A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis?
A
Acute bronchitis
Hint:
Barring underlying pulmonary pathology,the chest x-ray in acute bronchitis should be normal.
B
Bronchiectasis
C
Pneumonia
Hint:
While the history may suggest pneumonia, the radiographic findings do not support this diagnosis.
D
Tuberculosis
Hint:
Tuberculosis would present with cavitating granuloma formation more commonly at the apices.
Question 1 Explanation: 
Bronchiectasis typically presents as recurrent episodes of acute bronchitis. Platelike atelectasis and dilated and thickened airways, sometimes described as tram lines, are common radiographic findings.
Question 2
A 69 year-old male with a history of chronic lymphocytic leukemia presents to the clinic complaining of cough, dyspnea and production of copious amounts of foul smelling sputum. Physical examination reveals crackles at the lung bases. Chest x-ray shows dilated and thickened bronchi that appear as ring-like markings. Which of the following is the most likely diagnosis?
A
Bronchiectasis
B
Tuberculosis
Hint:
TB would present with CXR findings in the apical or posterior segments of the upper lobes.
C
Adenocarcinoma
Hint:
Radiographic findings of adenocarcinoma include enlarged nodule or mass; persistent opacity, atelectasis or pleural effusion. The sputum would not likely be foul smelling.
D
Pulmonary fibrosis
Hint:
Pulmonary fibrosis does not present with dilated bronchi or ring-like markings on CXR
Question 2 Explanation: 
This patient has signs and symptoms consistent with bronchiectasis including CXR findings of dilated and thickened bronchi that may appear as tram-tracks or as ring-like markings.
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