Bronchiectasis: diagnosis

Physical examination of the lungs reveals:

• dullness of percussion sound in the affected area (the severity of this sign depends on the size and number of bronchiectasis, the vastness of infiltrative-fibrous changes in the adjacent parenchyma of the lungs, and single small bronchiectasies blunt percussion sound). With the development of emphysema, a boxed hue of percussion sounds appears;
• Auscultative changes - in the period of exacerbation of the lesion, hard breathing, various wet moist wheezing, usually large and medium bubbles, decreasing or even disappearing after vigorous coughing and sputum discharge are heard. Along with the damp, dry rattles are heard. In the phase of remission, the number of wheezing is significantly reduced, sometimes they even completely disappear. With the development of bronchoobstructive syndrome (secondary obstructive bronchitis), the exhalation becomes elongated, a lot of dry low-tonal and high-toned wheezing are listened. These symptoms are accompanied by increasing dyspnea, a decrease in exercise tolerance.

With prolonged existence of bronchiectasis, myocardial dystrophy develops. Clinically, it manifests itself as tachycardia, interruptions in the work of the heart, deafness of the heart tones, extrasystole.

The most characteristic complications of bronchoectatic disease are: chronic obstructive bronchitis, emphysema of the lungs with the subsequent development of respiratory failure, chronic pulmonary heart, pulmonary hemorrhage, amyloidosis of the kidneys. A rare but dangerous complication is metastatic brain abscesses.

Laboratory data

1. General analysis of blood - with exacerbation of the disease observed leukocytosis, a shift in the leukocyte formula, an increase in ESR. It should be emphasized that these changes may be due to the development of perifocal pneumonia. In the long course of bronchoectatic disease, hypochromic or normochromic anemia is noted.
2. Biochemical analysis of blood - in the period of exacerbation of the disease there is an increase in the content of sialic acids, fibrin, seromucoid, haptoglobin, alpha2 and gamma globulins (nonspecific signs of the inflammatory process). With the development of amyloidosis of the kidneys and chronic renal failure, the level of urea and creatinine increases.
3. Immunological studies - the level of immunoglobulins G and M may decrease, possibly increasing the level of circulating immune complexes (AN Kokosov, 1999).
4. The general analysis of urine - without characteristic changes, with the development of amyloidosis of the kidneys are characterized by proteinuria and cylindruria.
5. General clinical analysis of sputum - a large number of neutrophilic leukocytes, erythrocytes, elastin fibers can be detected (rarely). A bacterioscopy of sputum reveals a large number of microbial bodies.

Instrumental research

Radiography of the lungs reveals the following changes (preference is given to lung radiographs in two mutually perpendicular projections):

• deformation and strengthening of the pulmonary pattern due to peribronchial fibrotic and inflammatory changes; cellular pulmonary pattern in the region of the lower segments of the lung;
• thin-walled cystlike enlightenments (cavities) sometimes with a liquid level (usually with significantly expressed saccystic cystic bronchiectasis in the middle lobe);
• decrease in the volume (shrinkage) of the affected segments;
• increased transparency of healthy segments of the lung;
• "Amputation" of the lung root;
• indirect signs of bronchiectasis in their localization in the lower lobe of the left and middle lobes of the right lung - a change in the position of the head of the left root due to a decrease in the volume of the lower lobe, a rarefaction of the pulmonary pattern of the swollen upper lobe as a manifestation of compensatory emphysema, a displacement of the heart to the left due to wrinkling or atelectasis of the lower lobe.
• concomitant fibrosis of the pleura in the lesion or exudative pleurisy.

These radiologic signs of bronchiectasis are particularly well revealed with the help of multi-axis X-ray super-exposure and tomography.

Bronchography is the main, finally confirming diagnosis method. He not only ascertains the presence of bronchiectasises, but also allows to specify their localization, shape and size. Bronchography is performed after preliminary sanation of the bronchial tree with the help of mucolytic and expectorants (and sometimes even bronchoscopic lavage of the bronchi) and arresting the inflammatory process.

On the bronchogram in the affected area there is an enlargement of the bronchi of various forms, their convergence and the absence of filling with the contrast material of the branches located distal to the bronchiectasis. Bronchographically distinguish bronchiectasis cylindrical, saccular, fusiform, mixed, as well as single, multiple, limited and widespread. To judge the nature of bronchiectasis, LD Lindenbraten and AI Shekhter (1970) proposed measuring the diameter of the bronchial tubes communicating with the bronchoeukases at the narrowest point and the diameter of bronchiectasis at the widest point, and then determining the percentage of these values. With cylindrical bronchiectasis, this ratio is no more than 15%, with spindle-shaped - it is in the range of 15 to 30%, with saccular - more than 30%. With the help of bronchography it is possible to make a definite conclusion about the drainage function of the bronchi - according to their ability to evacuate the X-ray fluorescent substance iodolpol. The time of evacuation with bronchiectasises is sharply increased, and the degree of increase depends on the form, magnitude, localization of bronchiectasis and the severity of bronchospastic syndrome.

Kinematobronhografiya - the definition of the ability of the bronchi to change the lumen depending on the phases of breathing. Bronchiectasis is characterized by a significant disruption in the contractility of the bronchiectasized wall, which is expressed by a very small or almost complete absence of changes in the diameter of bronchiectasis, depending on the phases of breathing. Kinematobronhography allows, thus, to distinguish between bronchiectasises with moving and rigid (little or almost immovable) walls. In addition, using this method, one can judge the nature of the evacuation of the contrast, which depends both on the functional capacity of the wall of the enlarged bronchus and on the form of the bronchiectasis. Of the cylindrical and spindle-shaped bronchiectasis, the evacuation is slowed and very uneven, the saccular bronchiectasis is characterized by an almost complete absence of evacuation.

Bronchoscopy - reveals purulent endobronchitis of varying severity in the affected segments of the bronchopulmonary tree.

Serial angiopulmonography - reveals anatomical changes in the vessels of the lungs and hemodynamic disorders in the small circle of the circulation. They are more pronounced in multiple large bronchiectasises.

Bronchial arteriography - reveals enlarged anastomoses between bronchial and pulmonary vessels.

Spirography - shows a violation of the function of external respiration with significant clinical manifestations of bronchial ectatic disease. With extensive bilateral bronchiectasis, restrictive disorders (a significant decrease in GEL) are detected, in the presence of bronchial obstructive syndrome - obstructive type of respiratory failure (decrease in FEV1), with a combination of emphysema and bronchial obstruction syndrome - restrictive-obstructive type of external respiratory function (decrease in FVC and FEV1 ).

Diagnostics

In the diagnosis of bronchiectasis, the following symptoms are important:

• indication in the history of a prolonged (usually from an early age) constant cough with expectoration of purulent sputum in large quantities;
• a clear association of the onset of the disease with a history of pneumonia or acute respiratory infection;
• frequent outbreaks of the inflammatory process (pneumonia) of the same localization;
• persistently persistent focus of wet wheezes (or several foci) in the period of remission of the disease;
• presence of thickening of terminal phalanges of fingers of brushes in the form of "drumsticks" and nails in the form of "hour glass";
• gross deformity of the pulmonary pattern most often in the region of the lower segments or middle lobe of the right lung (with lung radiography);
• the detection of bronchial dilatation of the bronchus in the affected department is the main diagnostic criterion of bronchoejection.

Formulation of the diagnosis

Formulating the diagnosis of bronchiectasis, it is necessary to indicate the localization and form of bronchiectasis, severity and phase of the disease course, complications.

An example of a diagnosis

Bronchoectatic disease - cylindrical bronchiectasis in the middle lobe of the right lung, moderate course, exacerbation phase. Chronic obstructive bronchitis, mild degree of obstructive type respiratory failure.

Survey program

1. Common blood tests, urine tests.
2. Biochemical blood test: content of total protein, protein fractions, haptoglobin, seromucoid, fibrin, sialic acids, iron.
3. Immunological studies: the content of T- and B-lymphocytes, subpopulations of T-lymphocytes, immunoglobulins, circulating immune complexes.
4. General clinical and bacteriological analysis of sputum, determining the sensitivity of flora to antibiotics.
5. ECG
6. Radiography of the lungs.
7. Bronchoscopy and bronchography.
8. Spirography.
9. Consultation of an ENT specialist.

[1], [2], [3], [4], [5], [6], [7], [8], [9]