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Medical therapy/ surgery in bronchiectasis When?

Medical therapy/ surgery in bronchiectasis When?. Dr. Uğur Özçelik (uozcelik@hacettepe.edu.tr) HÜTF Çocuk Göğüs Hastalıkları Bölümü. Bronchiectasis is a condition characterized by the permanent dilation of bronchi with destruction of the elastic and muscular components of their walls.

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Medical therapy/ surgery in bronchiectasis When?

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  1. Medical therapy/ surgery in bronchiectasisWhen? Dr. Uğur Özçelik (uozcelik@hacettepe.edu.tr) HÜTF Çocuk Göğüs Hastalıkları Bölümü

  2. Bronchiectasis is a condition characterized by the permanent dilation of bronchi with destruction of the elastic and muscular components of their walls

  3. Bronchiectasis can be classified radiographically and pathologically into cylindrical, varricose and cystic varieties.

  4. Bronchiectasis may have a focal or diffuse distribution.

  5. The goal of treatment of bronchiectasis • İmprove the symptoms of*cough *sputum production *dyspnea • Prevent the progression of airway damage

  6. Treatment modalities • Non surgical/supportive Pharmacotherapy*Bronchodilators*Mucolytics*Antiinflamatuars *Antibiotics Chest physiotherapy • Surgery

  7. Bronchodilators • Bronchodilators, including short acting and long acting β-agonists, anticholinergics can be used for bronchiectasis for bronchial hyperrreactivity or improve mucociliary clearance. • However, there have been no randomized studies that have validated their usefulness in the management of cough, sputum production, dyspnea in patients with bronchiectasis. • In patients with bronchiectasis with airflow obstruction and/or bronchial hyperreactivity, therapy with bronchodilators may be of benefit. (Cochrane Database Syst Rev, 2004)

  8. Mucolytics • The purpose of mucolytic drugs is to assist tracheobronchial clearance by altering the properties of sputum.*N-acetly cystein*rh-DNAse*Hypertonic saline • There is little scientific evidence to recommend the routine use of mucolytic agents in bronchiectasis. (Cochrane Database Syst Rev, 2004)

  9. Recombinant human DNase • DNA release by neutrophils in airways increases sputum viscosity, and rhDNase administered by aeresol digests DNA, thereby decreasing sputum viscosity, mucus plugging, infection and inflammation. • In two randomized controlled studies in patients with non-CF bronchiectasis this agent was not associated with significant benefit and can not be recommended for patients with idiopathic bronchiectasis.(Am J Respir Crit Care Med 1996;14:413; Chest 1998;113:1329)

  10. Recombinant human DNase • In patients with CF treated with rhDNase enjoyed spirometric improvement for up to two years compared with placebo, with a nonsignificant reduction of risk of infectious exacerbations.(Cochrane Database Syst Rev, 2004)

  11. Anti-inflammatory agents • Two randomized short-time (4 and 6 weeks) placebo controlled trials of inhaled corticosteroids in patients with idiopathic bronhiectasis showed no effect on clinical findings (sputum production, cough, wheeze, or dyspnea) and nonsgnificant improvement FEV1, FVC and CO diffusion.(Respir Med 1992;86:121; Am J Respir Crit Care Med 1998;158:723)

  12. Anti-inflammatory agents in CF • In patients with CF, prolonged treatment with systemic corticosteroids should not be recommended because of side effects. There is no data any benefit of inhaled steroids in CF. • The administration of ibuprofen showed modest benefits in patients with mild disease, but its use can not be recommended at this time because of the potential of side effects with prolonged use.(Cochrane Database Syst Rev, 2004)

  13. Antibiotics • The systemic and inhaled administrations of antibiotics were investigated as ways to prevent exacerbations of bronchiectasis by breaking the putative vicious cycle of bacterial colonization leading to inflammation and further airway injury. • Longterm therapy with antibiotics is effective for reducing sputum volume and purulence, but has limited impact on the frequency of exacerbations and the natural history of condition, and may facilitate the emergence of resistant organisms. (Cochrane database-6 studies).

  14. Antibiotics at acute exacerbation • Acute exacerbations are clinically recognized by an increased sputum production that becomes purulent and thicker. • Acute excerbations are usually caused by the colonizing bacterial flora, and therapy should be directed towards these (H.influenzae, Pseudomonas aeruginosa). • 10-14 days course of oral antibiotic will be sufficient in the majority of patients. • Parenteral administration shoul be reserved for those patients with severe impairment of lung function or acute respiratory failure, and those with chronic bronchial sepsis.

  15. Inhaled antibiotics • In patients with CF, therapy with aerosolized anti-pseudomonal antibiotics are recommended. • A randomized placebo controlled trial of inhaled tobramycin delivered by jet nebulizer in patient with CF showed that it was well tolerated, and was associated with improved pulmonary function, decreased density of P.aeruginosa in sputum, and decreased risk of hospitalization. (NEJM 1999;340:23)

  16. Inhaled tobramycin • In patients with idiopathic bronchiectasis, although the treatment group had decreased density of P.aeruginosa and have an improvement in clinical findings they were also have adverse eventssuch as increased cough, dyspnea, wheezing and chest pain which causes of treatment intolerance. (Am J Respir Crit Care Med 2000;162:481; Chest 2005;127:1420)

  17. Macrolides in bronchiectasis • Macrolide antibiotics are clinicaly very effective in patients with diffuse panbronchiolitis. • Their effects cannot be ascribed to their antibacterial action alone. Their immunoregulatory and anti-inflammatory functions are significant too. (Respiration 1991;58:145; Chest 1994;106:1116)

  18. Macrolides in bronchiectasis • Postulated mechanisms of anti-inflamatory actions include the down regulation of inflammatory cytokines (TNF-alfa, IL-8, IL4, IL-1ß) and chemotaxis of neutropils, lymphocytes, histiocytes; inhibition of superoxide generation and production/secretion of IL-8 and acceleration of apoptosis of neutrophils. • Macrolides activate ciliary movement, and diminsh mucus secretion. • (J Infect Dis 1989;5:966; Antimicrobial Agents and Chemotherapy 1998;42:1605; ERJ 1999;13:1371; Pediatr Pulmonol 2001;31:464)

  19. Effects of claritromycin on inflamatory parameters and clinical conditionsin children with bronchiectasisYalçın E, Kiper N, Özçelik U, et al. J Clin Pharmacy Therapeutics; 2006:31:49-55 • 17 BE patients; randomized CAM or supportive treatment for 3 months.17 BE patients as control group. At initiation and at the end of 3 months. *BAL: IL-8, TNF-alfa, IL-10, cell profiles *PFT and sputum production measured. • Compared with the control group, the treatment group showed a significant decrease in IL-8 levels, total cell count, netrophil ratios in BAL fluid and daily sputum production; increase BAL fluid macrophage ratios at the end of the third month • The differences in PFT were not significant.

  20. Chest physiotherapy In patients with conditions associated with the hypersecretion of mucus and the inability to expectorate effectively, chest physiotherapy should be used.

  21. Chest physiotherapy • In ten randomized controlled studies including 153 patients in diffent ages, 67 patients showed some improvement with physiotherapy (decreased daily sputum production, increased radioaerosolized clearance) but no significant effect on PFT.(Cochrane Library, 1998)

  22. Surgery Two major indication of surgery • Patients with localized bronchiectasis if they suffer from frequent acute exacerbations despite appropriate medical management • Life-threatening infectious complications(lung abcesses) or massive haemopthysis that is not responding to medical treatment, or bronchial embolization

  23. Surgery • Multisegmental or bilateral bronchiectasis is generally regarded as a contraindication for surgery. • Cases of bronchiectasis, with failure of conservative therapy, for which surgical intervention may be considered when the remaining lung is esentially unaffected.

  24. Surgery • Some authors use hemodynamic (functional and morphologic) classification for the indication of surgery (HRCT and V/Q scan) • The area affected is considered indicated for surgery when the perfusion less than 10% of the expected at ventilation/perfusion lung scan. (J Thorac Cardiovasc Surg 2005;130:1385)

  25. Surgery • Agasthian T, et al. Surgical management of bronchiectasis. Ann Thorac Surg 1996;62:990. • Prieto D, et al. Surgery for bronchiectasis. Eur J Cardiothorac Surg 2001;20:19. • Kutlay H, et al. Surgical treatent in bronchiectasis: analysis of 166 patients. Eur J Cardiothorac Surg 2002;21:634. • Balkanli K, e al. Surgical management of bronchiectasis: analysis and Short-term results in 238 patients. Eur J Cardiothorac Surg 2003;24:699. • Haciibrahimoğlu G, et al. Surgical management of childhood bronchiectasis due to infectious disease. J Thorac Cardiovasc Surg 2004;127:1361 • Ayed Adel Khader. Lung resection in children for infectious pulmonary disease. Pediatr Surg Int 2005,21.604. • Otgun I, et al. Surgical treatment of bronchiectasis in children. J Pediatr Surg 2004;39:1532.

  26. Surgery • Mortality %1.7-2.8Morbidity %9.4-24.6 • In surgical treatment of bronchiectasis complications (bleeding, bronchopleural fistula, empyema, pulmonary embolism, pleural effusion, air leak, wound infection, atelectasis) and mortality are low. Better results were obtained in patients who had undergone a complete resection of bronchiectatic lung tissue.

  27. Surgery • There have been no randomized controlled studies comparing surgery with conservative treatment. (The Cochrane Library, 2006)

  28. Lung transplantation • Lung transplantation must be regarded as an alternative in end-stage lung disease, in patients with an expected survival of less than 2 years. • Of the 6126 lung transplant procedures recorded by the St. Louis International Lung Transplant Registry since January 1997, 932 patients had CF (15%) and 129 (2%) had non CF bronchiectasis. J. Heart Lung Transplant 1999; 18:611.

  29. Does knowing the etiology lead to changes in management? • The case records of all patients who were diagnosed as having bronchiectasis by CT (Royal Brompton Hospital, Great Ormond Street Hospital for Children, UK) • All patients had undergone extensive investigations for etiology. • 136 patients (median age 12.1; range 3.1-18.1). • Immunodeficiency, aspiration and PCD accounted for 67% of the cases.In 77 (56%) children, the identification of a cause led to a spesific change in management. (Eur Respir J 2005;26:8)

  30. Conclusion Each patient with bronchiectasis must be evaluated individually for the etiology of bronchiectasis, severity of clinical findings, severity and extent of bronchiectasis and functions of the remaining lung tissue for the selection treatment modalities.

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