Bronchiectatic disease - Diagnosis

Physical examination of the lungs reveals:

• dullness of percussion sound in the affected area (the severity of this symptom depends on the size and number of bronchiectasis, on the extent of infiltrative-fibrous changes in the adjacent lung parenchyma; isolated small bronchiectasis does not produce dullness of percussion sound). With the development of pulmonary emphysema, a box-like shade of percussion sound appears;
• auscultative changes - during the exacerbation period, harsh breathing, moist rales of various sizes, usually large and medium-sized, decreasing or even disappearing after vigorous coughing and expectoration of sputum are heard over the lesion. Along with moist rales, dry rales are also heard. During the remission phase, the number of wheezes decreases significantly, sometimes they even disappear completely. With the development of broncho-obstructive syndrome (secondary obstructive bronchitis), exhalation becomes elongated, many dry low-pitched and high-pitched wheezes are heard. These symptoms are accompanied by increasing dyspnea, decreased tolerance to physical activity.

With prolonged existence of bronchiectasis, myocardial dystrophy develops. Clinically, it is manifested by tachycardia, interruptions in the work of the heart, muffled heart sounds, extrasystole.

The most typical complications of bronchiectasis are: chronic obstructive bronchitis, pulmonary emphysema with subsequent development of respiratory failure, chronic pulmonary heart disease, pulmonary hemorrhage, renal amyloidosis. A rare but dangerous complication is metastatic brain abscesses.

Laboratory data

1. General blood analysis - during exacerbation of the disease, leukocytosis, shift in the leukocyte formula, and increased ESR are observed. It should be emphasized that these changes may be due to the development of perifocal pneumonia. With a long course of bronchiectasis, hypochromic or normochromic anemia is observed.
2. Biochemical blood test - during the period of exacerbation of the disease, an increase in the content of sialic acids, fibrin, seromucoid, haptoglobin, alpha2- and gamma-globulins (non-specific signs of the inflammatory process) is noted. With the development of renal amyloidosis and chronic renal failure, the level of urea and creatinine increases.
3. Immunological studies - the level of immunoglobulins G and M may decrease, the level of circulating immune complexes may increase (A. N. Kokosov, 1999).
4. General urine analysis - no characteristic changes; with the development of renal amyloidosis, proteinuria and cylindruria are characteristic.
5. General clinical analysis of sputum - a large number of neutrophilic leukocytes, erythrocytes are determined, elastic fibers can be detected (rarely). Bacterioscopy of sputum reveals a large number of microbial bodies.

Instrumental research

Chest X-ray reveals the following changes (preference is given to chest X-ray in two mutually perpendicular projections):

• deformation and strengthening of the pulmonary pattern due to peribronchial fibrous and inflammatory changes; honeycombed pulmonary pattern in the lower segments of the lungs;
• thin-walled cyst-like cavities, sometimes with a fluid level (usually with significantly pronounced saccular-cystic bronchiectasis in the middle lobe);
• reduction in volume (wrinkling) of the affected segments;
• increasing the transparency of healthy lung segments;
• "amputation" of the root of the lung;
• indirect signs of bronchiectasis when localized in the lower lobe of the left and middle lobe 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, rarefaction of the pulmonary pattern of the swollen upper lobe as a manifestation of compensatory emphysema, displacement of the heart to the left due to wrinkling or atelectasis of the lower lobe.
• concomitant pleural fibrosis at the site of the lesion or exudative pleurisy.

The above-mentioned radiographic signs of bronchiectasis are particularly well detected using multi-axial superexposed radiographic and tomographic examination.

Bronchography is the main method that finally confirms the diagnosis. It not only confirms the presence of bronchiectasis, but also allows to specify its localization, shape and size. Bronchography is performed after preliminary sanitization of the bronchial tree with the help of mucolytic and expectorant agents (and sometimes even bronchoscopic lavage of the bronchi) and relief of the inflammatory process.

On the bronchogram in the affected section, there is expansion of the bronchi of various shapes, their convergence and the absence of filling with a contrast agent of the branches located distal to the bronchiectasis. Bronchographically, bronchiectasis is distinguished as cylindrical, saccular, fusiform, mixed, as well as single, multiple, limited and widespread. To judge the nature of bronchiectasis, L. D. Lindenbraten and A. I. Shekhter (1970) proposed measuring the diameter of the bronchi communicating with the bronchiectasis at the narrowest point and the diameter of the bronchiectasis at the widest point, and then determining the percentage ratio of these values. With cylindrical bronchiectasis, this ratio is no more than 15%, with fusiform - it is in the range from 15 to 30%, with saccular - more than 30%. With the help of bronchography, it is possible to draw a conclusion to a certain extent about the drainage function of the bronchi - by their ability to evacuate the radiotracer substance iodine. The evacuation time in bronchiectasis is sharply increased, and the degree of increase depends on the form, size, localization of bronchiectasis and the severity of the bronchospastic syndrome.

Kinematobronchography is the determination of the ability of the bronchi to change their lumen depending on the phases of respiration. Bronchiectasis is characterized by a significant impairment of the contractility of the bronchiectatic wall, which is expressed by a very small or almost complete absence of change in the diameter of the bronchiectasis depending on the phases of respiration. Kinematobronchography thus allows us to differentiate between bronchiectasis with mobile and rigid (slightly or almost immobile) walls. In addition, this method can be used to judge the nature of the evacuation of the contrast, which depends on both the functional ability of the wall of the dilated bronchus and the shape of the bronchiectasis. From cylindrical and fusiform bronchiectasis, evacuation is slow and very uneven, saccular bronchiectasis is characterized by an almost complete absence of evacuation.

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

Serial angiopulmonography - reveals anatomical changes in the pulmonary vessels and hemodynamic disturbances in the pulmonary circulation. They are more pronounced in multiple large bronchiectases.

Bronchial arteriography - reveals dilated anastomoses between the bronchial and pulmonary vessels.

Spirometry - reveals a disorder of the external respiration function with significant clinical manifestations of bronchiectatic disease. In case of extensive bilateral bronchiectasis, restrictive disorders (significant decrease in VC) are revealed; in the presence of broncho-obstructive syndrome - an obstructive type of respiratory failure (decrease in FEV1); in the combination of pulmonary emphysema and bronchial obstruction syndrome - a restrictive-obstructive type of disorders of the external respiration function (decrease in FVC and FEV1).

Diagnostics

The following signs are important in diagnosing bronchiectasis:

• indications in the anamnesis of a long-term (usually from early childhood) persistent cough with expectoration of purulent sputum in large quantities;
• a clear connection between the onset of the disease and previous pneumonia or acute respiratory infection;
• frequent outbreaks of the inflammatory process (pneumonia) in the same location;
• a persistent focus of wet rales (or several foci) during the period of remission of the disease;
• the presence of thickening of the terminal phalanges of the fingers in the form of “drumsticks” and nails in the form of “watch glasses”;
• gross deformation of the pulmonary pattern, most often in the area of the lower segments or the middle lobe of the right lung (on chest X-ray);
• detection of bronchial dilation in the affected area during bronchography is the main diagnostic criterion for bronchoecgases.

Formulation of diagnosis

When formulating a diagnosis of bronchiectasis, it is necessary to indicate the location and form of bronchiectasis, the severity and phase of the disease, and complications.

Example of diagnosis

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

Survey program

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

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