INTRODUCTION

Bronchiectasis is an abnormal, chronic enlargement of the bronchi, the passageways from the trachea to the alveoli that are the air-exchanging parts of the lungs. Bronchiectasis generally occurs as a result of infection, although noninfectious factors may contribute to the development of this condition. Accompanying the enlargement of the bronchi is their decreased ability to clear secretions. Failure to clear secretions allows microbes and particles to collect in them, which leads to more secretions and inflammation that further damage the airways, causing more dilation in a vicious cycle. Bronchiectasis can be categorized as a chronic obstructive pulmonary lung disease manifested by airways that are inflamed and easily collapsible, resulting in air flow obstruction with shortness of breath, impaired clearance of secretions often with disabling cough, and occasionally hemoptysis. Severe cases can result in progressive impairment with respiratory failure Bronchiectasis most often presents as (1) a focal process involving a lobe, segment, or subsegment of the lung or (2) a diffuse process involving both lungs. The former is by far the most common presentation of bronchiectasis, while the latter is most often associated with systemic illnesses, such as cystic fibrosis (CF), sinopulmonary disease, or both. Diagnosis is usually based on a compatible clinical history of chronic respiratory symptoms, such as daily cough and viscid sputum production, and characteristic radiographic findings on CT scans, such as bronchial wall thickening and luminal dilatation.

Epidemiology
The prevalence of bronchiectasis is unknown largely because the symptoms are variable and the diagnosis is often not made. In the pre-antibiotic era, it was estimated to be as common as or more common than tuberculosis and to be present in 92 percent of cases of chronic bronchitis. It occurs in every age group and, in the pre-antibiotic era, it most often began in childhood . Among all ages, it has been estimated that about 25 people per 100,000 have bronchiectasis,but this number increases to 272 per 100,000 for those over 74 years old. Cases of bronchiectasis are more common in women than men, especially when it is of unknown cause. A wide range of causes of bronchiectasis has been reported in adults, but for more than half of the cases, there is no known cause or association. It is estimated that between 30 and 35 percent of cases follow a lung infection that damages the bronchi for the first time .

DEFINITION
o Bronchiectasis is a condition that is characterized by the permanent dilatation of the bronchi associated with destruction of elastic and muscular components of their walls, usually due to chronic infection. o Bronchiectasis is chronic dilatation of bronchi with impaired drainage of bronchial secretions leading to persistent infection of the affected segments or lobes. o Bronchiectasis is persistent and irreversible dilation and distortion of medium sized bronchi (5th to 9th generation) by more than 2 o Bronchiectasis is a condition in which damage to the airways causes them to widen and become flabby and scarred. The airways are tubes that carry air in and out of your lungs. The anatomic distortion of a conducting bronchi, often with permanent dilation due to elastic and muscular damage to the epithelium, results in bronchiectasis.

ANATOMY
The lungs are the essential organs of respiration they are two in number, placed one on either side within the thorax, and separated from each other by the heart and other contents of the mediastinum. The substance of the lung is of a light, porous, spongy texture it floats in water, and crepitates when handled, owing to the presence of air in the alveoli it is also highly elastic hence the retracted state of these organs when they are removed from the closed cavity of the thorax. The surface is smooth, shining, and marked out into numerous polyhedral areas, indicating the lobules of the organ: each of these areas is crossed by numerous lighter lines. The right lung usually weighs about 625 gm., the left 567 gm., but much variation is met with according to the amount of blood or serous fluid they may contain. The lungs are heavier in the male than in the female, their proportion to the body being, in the former, as 1 to 37, in the latter as 1 to 43. Each lung is conical in shape, and presents for apex, a base, three borders, and two surfaces. The apex (apex pulmonis) is rounded, and extends into the root of the neck, reaching from 2.5 to 4 cm. above the level of the sternal end of the first rib. A sulcus produced by the subclavian artery as it curves in front of the pleura runs upward and lateralward immediately below the apex.

The base (basis pulmonis) is broad, concave, and rests upon the convex surface of the diaphragm, which separates the right lung from the right lobe of the liver, and the left lung from the left lobe of the liver, the stomach, and the spleen. Since the diaphragm extends higher on the right than on the left side, the concavity on the base of the right lung is deeper than that on the left. Laterally and behind, the base is bounded by a thin, sharp margin which projects for some distance into the phrenicocostal sinus of the pleura, between the lower ribs and the costal attachment of the diaphragm. The base of the lung descends during inspiration and ascends during expiration.

Surfaces.The costal surface (facies costalis external or thoracic surface) is smooth,

convex, of considerable extent, and corresponds to the form of the cavity of the chest, being deeper behind than in front. It is in contact with the costal pleura, and presents, in specimens which have been hardened in situ, slight grooves corresponding with the overlying ribs. 5

The mediastinal surface (facies mediastinalis; inner surface) is in contact with the mediastinal pleura. It presents a deep concavity, the cardiac impression, which accommodates the pericardium; this is larger and deeper on the left than on the right lung, on account of the heart projecting farther to the left than to the right side of the median plane. Above and behind this concavity is a triangular depression named the hilum, where the structures which form the root of the lung enter and

leave the viscus.

Borders.The inferior border (margo inferior) is thin and sharp where it separates the
base from the costal surface and extends into the phrenicocostal sinus medially where it divides the base from the mediastinal surface it is blunt and rounded. The posterior border (margo posterior) is broad and rounded, and is received into the deep concavity on either side of the vertebral column. It is much longer than the anterior border, and projects, below, into the phrenicocostal sinus. The anterior border (margo anterior) is thin and sharp, and overlaps the front of the pericardium. The anterior border of the right lung is almost vertical, and projects into the costomediastinal sinus; that of the left presents, below, an angular notch, the cardiac notch, in which the pericardium is exposed. Opposite this notch the anterior margin of the left lung is situated some little distance lateral to the line of reflection of the corresponding part of the pleura.

Fissures and Lobes of the Lungs.The left lung is divided into two lobes, an
upper and a lower, by an interlobular fissure, which extends from the costal to the mediastinal surface of the lung both above and below the hilus. As seen on the surface, this fissure begins on the mediastinal surface of the lung at the upper and posterior part of the hilus, and runs backward and upward to the posterior border, which it crosses at a point about 6 cm. below the apex. It then extends downward and forward over the costal surface, and reaches the lower border a little behind its anterior extremity, and its further course can be followed upward and backward across the mediastinal surface as far as the lower part of the hilus. The superior lobe lies above and in front of this fissure, and includes the apex, the anterior border, and a considerable part of the costal surface and the greater part of the mediastinal surface of the lung. The inferior lobe, the larger of the two, is situated below and behind the fissure, and comprises almost the whole of the base, a large portion of the costal surface, and the greater part of the posterior border other fissure separates the superior from the middle lobe. It begins in the previous fissure near the posterior border of the lung, and, running horizontally forward, cuts the anterior border on a level with the sternal end of the fourth costal cartilage on the mediastinal surface it may be traced backward to the hilus. The middle lobe, the smallest lobe of the right lung, is wedge-shaped, and includes the lower part of the anterior border and the The right lung, although shorter by 2.5 cm. than the left, in consequence of the diaphragm rising higher on the right side to accommodate the liver, is broader, owing to the inclination of the heart to the left side; its total capacity is greater and it weighs more than the left lung.anterior part of the base of the lung.

The Root of the Lung (radix pulmonis)A little above the middle of the
mediastinal surface of each lung, and nearer its posterior than its anterior border, is its root, by which the lung is connected to the heart and the trachea. The root is formed by the bronchus, the pulmonary artery, the pulmonary veins, the bronchial arteries and veins, the pulmonary plexuses of nerves, lymphatic vessels, bronchial lymph glands, and areolar tissue, all of which are enclosed by a reflection of the pleura. The root of the right lung lies behind the superior vena cava and part of the right atrium, and below the azygos vein. 8

That of the left lung passes beneath the aortic arch and in front of the descending aorta; the phrenic nerve, the pericardiacophrenic artery and vein, and the anterior pulmonary plexus, lie in front of each, and the vagus and posterior pulmonary plexus behind each; below each is the pulmonary ligament. The chief structures composing the root of each lung are arranged in a similar manner from before backward on both sides, viz., the upper of the two pulmonary veins in front the pulmonary artery in the middle and the bronchus, together with the bronchial vessels, behind. From above downward, on the two sides, their arrangement differs, thus: On the right side their position iseparterial bronchus, pulmonary artery, hyparterial bronchus, pulmonary veins, but on the left side their position ispulmonary artery, bronchus, pulmonary veins. The lower of the two pulmonary veins, is situated below the bronchus, at the apex or lowest part of the hilus .

Divisions of the Bronchi.

Just as the lungs differ from each other in the number of their lobes, so the bronchi differ in their mode of subdivision. The right bronchus gives off, about 2.5 cm. from the bifurcation of the trachea, a branch for the superior lobe. This branch arises above the level of the pulmonary artery, and is therefore named the eparterial bronchus. All the other divisions of the main stem come off below the pulmonary artery, and consequently are termed hyparterial bronchi. The first of these is distributed to the middle lobe, and the main tube then passes downward and backward into the inferior lobe, giving off in its course a series of large ventral and small dorsal branches. The ventral and dorsal branches arise alternately, and are usually eight in numberfour of each kind. The branch to the middle lobe is regarded as the first of the ventral series. The left bronchus passes below the level of the pulmonary artery before it divides, and hence all its branches are hyparterial it may therefore be looked upon as equivalent to that portion of the right bronchus which lies on the distal side of its eparterial branch. The 9

first branch of the left bronchus arises about 5 cm. from the bifurcation of the trachea, and is distributed to the superior lobe. The main stem then enters the inferior lobe, where it divides into ventral and dorsal branches similar to those in the right lung. The branch to the superior lobe of the left lung is regarded as the first of the ventral series.

Structure.The lungs are composed of an external serous coat, a subserous areolar

tissue and the pulmonary substance or parenchyma. The serous coat is the pulmonary pleura it is thin, transparent, and invests the entire organ as far as the root. The subserous areolar tissue contains a large proportion of elastic fibers; it invests the entire surface of the lung, and extends inward between the lobules. The parenchyma is composed of secondary lobules which, although closely connected together by an interlobular areolar tissue, are quite distinct from one another, and may be teased without much difficulty in the fetus. The secondary lobules vary in size those on the surface are large, of pyramidal form, the base turned toward the surface those in the interior smaller, and of various forms. Each secondary lobule is composed of several primary lobules, the anatomical units of the lung. The primary lobule consists of an alveolar duct, the air spaces connected with it and their bloodvessels, lymphatics and nerves. The intrapulmonary bronchi divide and subdivide throughout the entire organ, the smallest subdivisions constituting the lobular bronchioles. The larger divisions consist of: (1) an outer coat of fibrous tissue in which are found at intervals irregular plates of hyaline cartilage, most developed at the points of division; (2) internal to the fibrous coat, a layer of circularly disposed smooth muscle fibers, the bronchial muscle; and (3) most internally, the mucous membrane, lined by columnar ciliated epithelium resting on a basement membrane. 10

Each bronchiole divides into two or more respiratory bronchioles, with scattered alveoli, and each of these again divides into several alveolar ducts, with a greater number of alveoli connected with them. Each alveolar duct is connected with a variable number of irregularly spherical spaces, which also possess alveoli, the atria. With each atrium a variable number (25) of alveolar sacs are connected which bear on all parts of their circumference alveoli or air sacs. The alveoli are lined by a delicate layer of simple squamous epithelium, the cells of which are united at their edges by cement substance. Between the squames are here and there smaller, polygonal, nucleated cells. The pulmonary veins commence in the pulmonary capillaries, the radicles coalescing into larger branches which run through the substance of the lung, independently of the pulmonary arteries and bronchi. After freely communicating with other branches they form large vessels, which ultimately come into relation with the arteries and bronchial tubes, and accompany them to the hilus of the organ. Finally they open into the left atrium of the heart, conveying oxygenated blood to be distributed to all parts of the body by the aorta. The bronchial arteries supply blood for the nutrition of the lung they are derived from the thoracic aorta or from the upper aortic intercostal arteries, and, accompanying the bronchial tubes, are distributed to the bronchial glands and upon the walls of the larger bronchial tubes and pulmonary vessels. Those supplying the bronchial tubes form a capillary plexus in the muscular coat, from which branches are given off to form a second plexus in the mucous coat this plexus communicates with small venous trunks that empty into the pulmonary veins. Others are distributed in the interlobular areolar tissue, and end partly in the deep, partly in the superficial, bronchial veins. Lastly, some ramify upon the surface of the lung, beneath the pleura, where they form a capillary network The bronchial vein is formed at the root of the lung, receiving superficial and deep veins corresponding to branches of the bronchial artery. It does not, however, receive all the blood supplied by the artery, as some of it passes into the pulmonary veins. It ends on the 11

right side in the azygos vein, and on the left side in the highest intercostal or in the accessory hemiazygos vein.

Nerves. The lungs are supplied from the anterior and posterior pulmonary plexuses,
formed chiefly by branches from the sympathetic and vagus. The filaments from these plexuses accompany the bronchial tubes, supplying efferent fibers to the bronchial muscle and afferent fibers to the bronchial mucous membrane and probably to the alveoli of the lung. Small ganglia are found upon these nerves.

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Broncho pulmanory segments :

Each lung is subdivided by connective tissue into ten independently functioning compartments called Broncho pulmonary segments

RIGHT LUNG LOBES A. Upper SEGMENTS 1. apical 2. posterior 3. anterior LOBES

LEFT LUNG SEGMENTS

A. upper 1. apical i. upper division 2. posterior 3. anterior ii. lower division 4. superior lingular 5. inferior lingular

B. Middle

1. lateral 2. medial 1. superior 2. anterior basal 3. medial basal 4. lateral basal 5. posterior basal B. lower 1. superior 2. anterior basal 3. medial basal 4. lateral basal 5. posterior basal

C. lower

Segmental bronchii divide repeatedly to form small terminal bronchioles these in turn divide to form small respiratory bronchioles.

Respiratory bronchioles ends in microscopic passages termed as alveolar ducts around the circumferences of the alveolar ducts are numerous alveoli & alveolar sacs.

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14

PHYSIOLOGY Pulmonary Mechanics

Successful exchange of gases in the lungs is predicated on efficient ventilation of the lungs. Tidal respiration is based on cyclical expansion and contraction of the lungs. During inhalation, active contraction of the diaphragm and external intercostal muscles of the ribcage draw air into the lungs. Each of these muscle groups acts together to expand the lungs. During inhalation, intrathoracic pressures decrease and intraabdominal pressures increase. Intercostal contraction results in visible expansion of the chest wall, whereas diaphragmatic contraction pushes the abdominal contents downward and outward. Expansion of the chest and abdominal walls should be well coordinated. If the abdomen and chest move in opposite directions, one or the other of these systems is either weak or paralyzed. Furthermore, the left and right diaphragms should move together. Weakness of one or both diaphragms can reduce the ventilatory capacity of the lungs. This can be tested with a "sniff test": the subject is asked to sniff while the movement of the diaphragms is evaluated by fluoroscopy or ultrasound. During inspiration, downward movement of the diaphragm on the intact side increases intraabdominal pressures and decreases intrathoracic pressures, resulting in an upward movement of the paralyzed side. The auxiliary muscles include the scalenus (which are active during normal inspiration) and the sternocleidomastoid muscles (which are only used with high levels of respiratory effort). The overall strength of the respiratory apparatus can be easily evaluated by measuring the maximum inspiratory and expiratory pressures (PImax and PEmax) that the patients can exert against a fixed obstruction of the mouthpiece. Although inhalation requires active muscle contraction, exhalation is normally a passive process and is dependent on the elasticity of the pulmonary tissues. When the inward 15

force exerted by the elastic tissues of the lungs matches the outward force of the thorax, the lung volume becomes stable at the "resting midposition" of the lungs . This is equivalent to the functional residual capacity (FRC) of the lungs. The rate and volume of exhalation can be increased by contracting the abdominal and internal intercostal muscles. Loss of elastic tissues within the lungs due to emphysema reduces the ability of patients with this disorder to exhale. Patients with severe intrathoracic obstruction characteristically utilize abdominal muscles to force the diaphragms upward during exhalation. However, this maneuver also reduces the diameter of the bronchi, limiting the rate at which they can exhale. More time is consequently needed during the expiratory phase and this must be kept in mind when adjusting the inspiratory/expiratory time ratios during mechanical ventilation. Breathing pattern;The term for the normal pattern of quite breathing is eupnea. Eu = normal. Pnea = breath. Eupnea can consists of shallow, deep or combined shallow and deep breathing. Costal breathing. Diaphraqgmatic. i. Costal breathing;A pattern of shallow (chest)breathing called costal breathing. It consists of upward and downward movement of the chest due to contraction of the intercostals muscles. ii. Diaphragmtic breathing;good. Easy or

A pattern of deep (abdominal)breathing called diaphramtic breathing. It consists of the upward movement of the abdomen due to contraction and descent of the diaphragm.

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TERMS Vital capacity

SYMBOLS VC

DESCRIPTION Maximal volume of Air exhaled after forced inspiration.

VALUE 4.5 litres

Tidal volume

TV

Volume of air inhaled or exhaled during quiet breathing.

500 ml

Inspiratory volume Expiratory volume

reserve reserve

IRV ERV RV IVC FEV FRC TLC

After a quiet inspiration Maximal air that can be breathed out after quiet expiration. Volume of air remaining in lungs after full expiration. Maximal volume of air inhaled after full expiration Volume of air inhaled in a given period of complete forced expiration. Amount of air remained Iin the lungs at the residual expiration Amount of air present in the lungs after a maximal deep inspiration

2.3 3 lits 1 ltr 1.2 lits 3.5 lits

Residual volume Inspiratory vital

capacity Forced expiratory volume Functional residual capacity Total lung capacity

2200 ml 6000ml

Respirsatory minute volume

RMV

Amount of air breathed in and out of lungs at every minute

6000 ml

BIO-MECHANICS:
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1) Chest wall movements. 2) Muscles of respiration.

Chest wall movements;i. ii. Pump handle movement : During inspiration the ribs elevate in the upper ribs most of the movement occurs at the anterior aspect of the rib, given the nearly coronal axis at the vertebrae.the costocartilage become more horizontal.the movement of the ribs pushes the sternum ventrally and superiorly.the excursion of the manubrium is less that of the body of the sternum.because of the first rib is shortest, with the caudal ribs increasing in lengh until rib.the discrepancy in lengh causes movement of the ms joint.the motion of the upper ribs and sternum has its greatest effect by increasing the anteroposterior diameter of thorax.this combined rib and sternal motion that occurs in a predominatetly saggital plane has been termed the pump handle motion. Pump handle movement. Bucket handle movement

Bucket handle movement : -

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Elevation of the lower rib about the axis of motion lying nearly in the sagital plane. The lower ribs have more angled shape ( obliquity increases from rib 1-10 ) and an indirect attachment anteriorly to the sternum. These factors allow the lower ribs more motion at the lateral aspect of the ribcage. The elevation of the lower ribs has its greatest effect by increasing the transverse diameter of the lower thorax. This motion that occurs in a nearly frontal plane has been termed the Bucket handle motion

Muscles of respiration : The ventilatory muscles are most accurately classified as either primary or accesory muscles,

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Primary muscles : These include the diaphragm, intercostal muscles and the scalene muscles. These muscles all act on the ribcage to promote inspiration.

Diaphragm : The diaphragm is the primary muscle of the ventilation accounting approximately 70-80% of inspiration force during quiet breathing, the diaphragm is a circular set of muscle fibres that arises from the sternum, costocartilage, ribs and vertebral bodies the fibres travels superiorly to insert insert into a central tendon. Functionally the muscular portion of the diaphragm is divided into the costal portion . Which arises from the sternum, costo cartilage and ribs. The crural portion which arises from the vertebral bodies. Intercostal muscles : The external and internal intercostal muscles are categorized as Ventilatory muscles. The parasternal muscles are considered as primary muscles of ventilation. The internal intercostal and external intercostal and the subcostales muscles connect adjacent ribs to one another. The external intercostal muscles are activated during inspiration and the internal intercostal muscles are active during exhalation. Scalene muscles : The scalene muscles are also primary muscles of quiet ventilation. The scalene muscles attached on the transverse process of c3 c7 and descend to the upper borders of 1st and 2nd rib, their action lifts the sternum and the 1st to ribs in the pump handle motion of the upper rib cage. The scalene muscles also function as stabilizers of ribcage. Accessory muscles : These muscles assesd with inspiration or expiration in situations of stress such as increased activity or disease. When the trunk is stabilized the accessory muscles of ventilation move the vertebral column, arm, head or pelvis on the trunk.

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The accessory muscles of inspiration increases the thoracic diameter by moving the rib cage upward and downward. The accessory muscles of expiration move the diaphragm upward and the thorax downward and inward. The most common accessory muscles are sternocleidomastoid, trapezius, pectoralis major, pectoralis minor, subclavius. The abdominal muscles are trasversus, abdominalis, internal oblique abdominalis, external oblique abdominalis, rectus abdominalis,are expiratory muscles.

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TYPES OF BRONCHIECTAISIS:
Types of bronchiectasis include: 1-Cylindric/Fusiform/Tubular: Cylindrical bronchiectasis produces "tram-lines"

because the distal bronchus has the same lumen size as parent and extends to the lung periphery. This is the most common form of bronchiectasis. It may occur secondary to infection, ciliary dyskinesia, or cystic fibrosis. Patients may have only mild symptoms such as a cough, with small amounts of sputum production. On HRCT there are thick walled (smooth, not irregular) bronchi which extend into the peripheral 3 cm of the lung.

Cylindrical bronchiectasis with signet-ring appearance.The luminal airway diameter is greater than the diameter of the adjacent vessel. 2- Saccular/Cystic: This is the most severe form of bronchiectasis. It is characterized by progressive dilatation of the bronchi toward the periphery which terminate in cytic cavities resembling balloons. The findings may resemble a cluster of cysts. Air-fluid levels within the massively dilated bronchi are seen frequently due to retained secretions, and are usually not seen in uncomplicated lung cysts. Remember, that in contrast to bronchiectasis, emphysematous bullae have no discernible walls.

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3. Traction/ Varicose: Unlike most other causes of bronchiectasis, the airway changes are not caused by a primary insult to the airways themselves, but rather as a result of adjacent parenchymal fibrosis. In this form of bronchiectasis the bronchial walls are characteristically more irregular and may assume a beaded appearance when in the plane of section (resembling a "varicose" vein). Differentiation from cylindrical bronchiectasis is difficult when viewed in cross section.

Varicose bronchiectasis with alternating areas of bronchial dilatation and constriction.

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AETIOLOGY
Bronchiectasis is caused by recurrent inflammation or infection of the airways. It may be present at birth, but most often begins in childhood as a complication from infection or inhaling a foreign object. Prior to the widespread use of immunizations, bronchiectasis was often the result of a serious infection with either measles or whooping cough. Now, viruses that cause influenza (flu) or influenza-like syndromes, may lead to development of bronchiectasis. Some other Causes of Bronchiectasis may be: Respiratory syncytial virus can cause bronchiectasis in some Childs. Some inherited conditions. For example, a condition called primary ciliary dyskinesia affects the cilia so they do not 'beat' Correctly to clear the mucus. Cystic fibrosis is another condition that affects the lungs and causes 'bronchiectatic' airways. Inhaled objects, such as peanuts, can become stuck and block an airway. This may lead to local damage to that airway. Acid from the stomach that is regurgitated and inhaled can also damage airways. Inhaling poisonous gases may also cause damage. Some rare immune problems can also cause lung infections and damage to airways thereby causing bronchiectasis. Severe lung infections such as tuberculosis (TB), whooping cough, pneumonia or measles can damage the airways at the time of infection. Ongoing bronchiectasis may then develop. Less commonly, bronchiectasis may be caused by cystic fibrosis, an inhaled foreign body such as a peanut, following tuberculosis, or lung infection in Aids. Other causes include inhalation of damaging gases, dust or smoke. The condition is worsened by smoking. It is also seen in later life after severe lung infections such as pneumonia in childhood, and it is sometimes Some other Symptoms of Bronchiectasis may be: 24

o Cough worsened by lying on one side o Shortness of breath worsened by exercise o Weight loss. o Coughing up of blood is also common. o Fatigue. o Wheezing. o There may be frequent bouts of pneumonia or hemoptysis. o Recurrent fever, chills, o Skin discoloration, bluish. o Paleness. o Abnormal chest sounds.

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Pathology
Bronchial obstruction may be localized (due perhaps to an inhaled foreign body such as a pea nut or broken tooth or obstruction due to a tumor or enlarged gland) or generalized (eg .pneumonia that is slow to resolve owing to whooping cough or measles). The bronchial obstruction will cause absorption of air from the lung tissue distal to the obstruction and this area will therefore shrink and collapse. This causes traction forces to be exerted upon the more proximal air ways, which will distort and dilate them. If the obstruction can be cleared and the lung re-expanded quickly then the dilatation is reversible. Secretions may collect distal to the obstruction if it is not relieved quickly and these easily become infected. This causes inflammation of the bronchial wall with destruction of the elastic and muscular tissue. These infections occur repeatedly, with walls becoming weaker and weaker. They will eventually dilate owing to the negative intrapleural pressure. As the disease advances, the bronchi become grossly dilated and pockets containing pus are formed. The elastic and muscle tissue is destroyed and the mucus lining is replaced by granulation tissue with loss of cilia. Therefore the mucociliary transport mechanism is disrupted and the of mucus out of the lungs is thus hindered. Several types of obstructions are recognized pathologically: tubular, fusiform, or saccular. The arterial vessels within the bronchial walls anastomose with the pulmonary capillaries and this results in the common feature of haemoptysis.

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Clinical manifestations Cough and sputum:

Patients complains of persistent cough with purulent sputum since childhood. Initially, it is present only following colds or influenza, but if the disease is allowed to progress in severity the effected segments continually accumulate purulent secretions, resulting in cough and sputum production. The sputum is usually in green, often foulsmelling and present fairly large volume. The cough is particularly troublesome on a change of position and on raising first thing in the morning.

Dyspnoea:
Shortness of breath is noticeable only if disease is particularly severe and widespread. If the bronchiectasis is localized, other well-ventilated and perfused alveoli should maintain blood gases at a reasonable level, although bronchospasm may be a Feature, particularly during an exacerbation.

Haemoptysis:
This occurs quite commonly, usually in association with an acute infection. It can be life-threatening if severe and may require surgical resection of the affected lung tissue.

Recurrent pneumonia:
Characteristically this will affect the same site and is a common feature.

Chronic sinusitis:
. This occur in approximately 70per cent of patients

General ill-health:
Patients may suffer pyrexia, night sweats, anorexia, malaise, weight loss, lassitude and oint pains.

Clubbing:
In about 50per cent of patients fingers and toes become clubbed. The first sign of clubbing is loss of the angle between the nail and the nail bed. This is followed by curvature of the nail, and an increase in the soft tissue of the ends of the fingers, forming so- called drumstick fingers. 27

Thoracic Mobility
This gradually decreases, as do shoulder girdle movements.

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DIFFERENTIAL DIAGNOSIS:
The typical history that suggests bronchiectasis is chronic cough with mucopurulent secretions. Bronchiectasis can be confirmed with chest radiographs and HRCT. The differential diagnosis of bronchiectasis is one of the most challenging in pulmonary medicine. Bronchiectasis occurs in several suppurative lung diseases. One useful distinction is that of focal versus diffuse disease. Bronchiectasis involving a single lobe or segment of the lung typically results from focal bronchial obstruction or severe lobar pneumonia. Patients present with a history of recurrent or persistent lobar pneumonia. Bronchial obstruction proximal to the region of bronchiectasis may be secondary to a foreign body, carcinoma, broncholith, or lymph nodes (as occurs in middle lobe syndrome). Multilobar disease is usually secondary to diffuse infections such as influenza, S aureus, P aeruginosa, or Klebsiella species, to toxic inhalation, or to defects in host defense. The latter occurs in chronic granulomatous infections, immunodeficiency disorders, autoimmune diseases, and congenital diseases

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INVESTIGATIONS
Diagnostic Tests and Procedures:

Chest Computed Tomography Scan: The most commonly used test to diagnose bronchiectasis is a chest computed tomography scan, or chest CT scan. This painless test creates precise images of your airways and other structures in your chest. It can show how much your airways are damaged and where the damage is. A chest CT scan gives more detailed pictures than a regular chest x ray.

This CT scan shows areas of both cystic bronchiectasis and varicose bronchiectasis.

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Chest X Ray: You also may have a chest x ray. This painless test creates pictures of the structures in your chest, such as your heart and lungs. A chest x ray may show areas of abnormal lung and thickened, irregular airway walls.

Cystic and cylindrical bronchiectasis of the right lower lobe on a posterior-anterior chest radiograph.

Other Tests: You also may have other tests, such as: Blood tests: These tests can show whether you have an underlying condition that can lead to bronchiectasis. They also can show whether you have an infection or low levels of certain infection-fighting blood cells. A sputum culture: Lab tests of a sample of your sputum can show whether you have bacteria (such as the bacteria that cause tuberculosis) and fungi. Lung function tests: These tests measure the size of lungs, how much air you can breathe in and out, how fast you can breathe air out, and how well your lungs deliver oxygen to your blood. Lung function tests help show how much lung damage you have. 31

A sweat test or other tests for cystic fibrosis.

Bronchoscopy: If bronchiectasis doesn't respond to treatment, Bronchoscopy is a procedure used to look at the insides of the airways. During this procedure, a long, narrow, flexible tube with a light on the end is inserted through your nose or mouth into your airways. This tube is called a bronchoscope. It provides a video image of your airways. You'll be given medicines to numb the upper airway and to help you relax during the procedure. Bronchoscopy can show whether something is blocking your airways. If there is bleeding, this procedure can show where the bleeding is coming from. Ciliary function test: A screening test can be performed in patients suspected of having a cilary dysfunction syndrome by assessing the time taken for a small pellet of saccharin placed in the anterior chamber of nose to reach pharynx, when the patient can taste it. This time should not exceed 20minutes and is greatly prolonged in patients with ciliary dysfunction. It is also possible to assess ciliary function by measuring ciliary beat frequency using biopsies taken from nose. If ciliary function is thought to be impaired, the ciliary ultrastructure should also be determined by electron microscopy.

MANAGEMENT
1. CONSERVATIVE 32

2. SURGICAL 3. PHYSIOTHERAPY

CONSERVATIVE MANAGEMENT
Antibiotics and chest physiotherapy are the mainstay modalities. Other modalities (beyond those for specific associated conditions) may include bronchodilators, corticosteroid therapy, dietary supplementation Antibiotic therapy is as follows: o Antibiotics have been the mainstay of treatment for more than 40 years. o Oral, parenteral, and aerosolized antibiotics are used, depending on the clinical situation. -Oral- ciprofloxacin (250-750mg twice daily). o Intravenous treatment is indicated for severe infections. -Ceftazidime by intravenous injection or infusion (100150mg/kgdaily in divided dose). o Inhaled nebuliser or continuous oral therapy may be used for chronic sepsis and more resistant pathogens.(e.gstaphylococcus aureus ) - In acute exacerbation, broad-spectrum antibacterial agents are generally preferred. Acceptable choices for the outpatient who is mild to moderately ill include amoxicillin, tetracycline, trimethoprim-sulfamethoxazole, a newer macrolide e.g., azithromycin85 or c larithromycin86 a second-generation cephalosporin, one of the fluoroquinolones.

In general, the duration is 7-10 days. For patients with moderate-to-severe symptoms, parenteral antibiotics, such as an aminoglycoside 33

gentamicin, tobramycin and an antipseudomonal synthetic penicillin, a third-generation cephalosporin, or a fluoroquinolone, may be indicated.

Additionally, some patients with chronic bronchial infections may need regular antibiotic treatment to control the infectious process. -The oral antibiotics of choice are the same as those mentioned previously. -Potential regimens include daily antibiotics for 7-14 days of each month, alternating antibiotics for 7-10 days with antibiotic-free periods of 7-10 days, or a long-term daily dose of antibiotics Bronchodilator therapy is as follows: Bronchodilators, including -beta-agonists and anti-cholinergic- may help some patients with bronchiectasis, presumably reversing bronchospasm associated with airway hyperreactivity and improving mucociliary clearance. -Treatment with inhaled bronchodilators may be appropriate.

Anti-inflammatory medication therapy is as follows: The rationale is to modify the inflammatory response caused by the microorganisms associated with bronchiectasis and subsequently reduce the amount of tissue damage. o Inhaled corticosteroids, o Oral corticosteroids, o Leukotriene inhibitors and nonsteroidal anti-inflammatory agents have all been examined. Although evidence tends to support some benefit from the use of these agents, findings are not universally definitive. 34

On inhaled corticosteroids are beneficial to patients with bronchiectasis compared with a placebo, particularly patients with associated P.aeruginosa infections, while another study showed improvement in quality-of-life scores. Azithromycin has known anti-inflammatory properties and long-term use has been studied in patients with both CF and non-CF bronchiectasis. In non-CF patients, azithromycin has been shown to decrease exacerbations and improve spirometry and microbiologic profiles. In CF patients a meta-analysis suggests that it improves lung function, especially in those patients colonized with Pseudomonas.

SURGICAL MANAGEMENT:
35

Surgery is an important adjunct to therapy in some patients with advanced or complicated disease. Surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality in patients of any age. In general, surgery should be reserved for patients who have focal disease that is poorly controlled by antibiotics. The involved bronchiectatic sites should be completely resected for optimal symptom control. Single- or double-lung transplantation has been used as treatment of severe bronchiectasis, predominantly when related to CF. In general, consider patients with CF and bronchiectasis for lung transplantation when forced expiratory volume in 1 second (FEV1) falls below 30% of the predicted value. Other indications for surgical intervention may include the following: * Reduction of acute infective episodes * Reduction of excessive sputum production * Massive hemoptysis (Alternatively, bronchial artery embolization may be attempted for the control of hemoptysis.) * Foreign body or tumor removal * Consideration in the treatment of Aspergillus species infections. Although there is conflicting evidence regarding the efficacy of surgery when compared to conservative treatment.

Complications of surgical intervention include empyema, hemorrhage, prolonged air 36

leak, and persistent atelectasis. Patient selection plays an important role in preoperative mortality rates, which may be as low as 1% in the surgical treatment of segmental or even multisegmental bronchiectasis. Female patients and younger patients may need to be considered even sooner.

PHSYIOTHERAPY ASSESSMENT :
37

I. SUBJECTIVE ASSESSMENT : Name Age Gender Occupation Chief complaints

HISTORY OF PATIENT:
Past history Present history Medical history Personal history Family history Socio economic history Environmental history II. OBJECTIVE ASSESSMENT: Observation: Breathlessness Dyspnea Cough Sputum Wheeze Other symptoms: 1.Fever 2. High fever with sweating 3. Head ache- early morning 4. Peripheral edema General observation: vital signs: 1. Temperature:98.4 38

2. Heart rate: 60-100/min 3. Pulse rate: 12-16/min 4. Blood pressure: 128/80mm of hg Pulse deficit: Pulse paradox: Body weight: body mass index-kg/m2 Observation of chest: Land marks of heart and lung shape Shape Chest deformities: Chest movements: Breathing patterns:

ON PALPATION; Pain Tenderness Warmth Swelling Dull sounds Hyper resonant

ON PERCUSSION:

ON AUSCULTATION: Sounds Breath sounds I. Normal II. Abnormal III. Add ( or ) Adventious

Normal : 39

a. Bronchial. b. Bronchovesicular. c. Vesicular. Abnormal breath sounds : a. Bronchial sounds. b. Decreased sounds. c. Absence of sound Added or adventitious sound : a. Cracked rales / crepitus sounds b. Ronchi c. Wheeze 1. Extra pulmonary sounds 2. voice sounds 3. heart sounds a. S1 sounds b. S2 sounds INVESTIGATIONS: a. X-rays b. Sputum examination c. E.C.G d. A.B.G. Analysis e. Stress test f. Pulmonary function test g. ciliary function test Differential daignosis : Provisional diagnosis : Management: Short term Goal 40

Plan Long term --- Goal Plan Progress note : Discharge summary:

PHYSIOTHERAPY AIMS:
The principal aims of physiotherapy in bronchiectasis are: To remove secretions and clear lung fields. To teach an appropriate sputum clearance regimen. To educate the patient in the pathology and management of the condition. To promote good general health and maintain or improve exercise tolerance. To teach the patient how to fit in home treatment within his or her llifestyle.

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PHYSIOTHERAPY MANAGEMENT:
In early stage : Postural drainage Coughing Humidification Relax position Breathing exercises Segmental Diaphragmatic In later stage : Inspiratory muscle traing Exercise tolerance Home program

Postural Drainage and Chest Physiotherapy:

Postural drainage therapy (PDT) is a component of bronchial hygiene therapy. It consists of postural drainage, positioning, and turning and is sometimes accompanied by chest percussion and/or vibration. Cough or airway clearance techniques are essential components of therapy when postural drainage is intended to mobilize secretions. Postural drainage therapy is often used in conjunction with aerosol administration and other respiratory care procedures. Chest physiotherapy, Postural drainage and percussion, Percussion and vibration.

Postural drainage therapy is designed to improve the mobilization of bronchial secretions and the matching of ventilation and perfusion, and to normalize functional residual capacity based on the effects of gravity and external manipulation of the thorax. 42

Turning Turning is the rotation of the body around the longitudinal axis to promote unilateral or bilateral lung expansion and improve arterial oxygenation. Regular turning can be to either side or the prone position, with the bed at any degree of inclination (as indicated and tolerated). Patients may turn themselves or they may turned by the caregiver or by a special bed or device. Postural Drainage Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways (where they can be removed by cough or mechanical aspiration). Each position consists of placing the target lung segment(s) superior to the carina. Positions should generally be held for 3 to 15 minutes (longer in special situations). Standard positions are modified as the patient's condition and tolerance warrant. Percussion Percussion is also referred to as cupping, clapping, and tapotement. The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung. This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained. No convincing evidence demonstrates the superiority of one method over the other. Vibration Vibration involves the application of a fine tremorous action (manually performed by pressing in the direction that the ribs and soft tissue of the chest move during expiration) over the draining area. No conclusive evidence supports the efficacy of vibration, the superiority of either manual or mechanical methods, or an optimum frequency. Postural drainage positions : Upper lobe;Apical 43

Anterior Posterior Apical ;1) Anterior segment; Position; Posterior segment; Position; Anterior segment; Position; Posterior segment; Right side Position; Left side Position; one quartern turn from prone patient lies flat and quarter turn from prone Techniques apply; right scapula supine lying Techniques apply; directly over the nipple forward lean sitting Techniques apply; directly above the scapula half lying Techniques apply ; directly under clavicle

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45

Middle lobe; Medial and lateral broncho pulmonary segmen position; patient lies one-quarter turn from supine on left side supporting placing a pillow from shoulder. Techniques apply; under the right breast Lingular segments; Position; patients lies one-quarter turn from supine on Right side supported with pillow and in 30 degrees head down position Techniques apply; under the left breast Lower lobe; Apical broncho pulmonary segments; Position; patient lies prone placing pillow under the Abdomen. Techniques apply; directly below the scapula Anterior segments : Position; patient lies on supine pillow under the knees in a 30-40 degrees head down Techniques apply; over the lower portion of the ribs. 46

Posterior segments; Position; patient lies prone position 45 degrees down Position Techniques apply; Lateral segments(right); Position; on the left side in a30-45 degrees head down position techniques apply; Lateral segment ( left ) : Position down position Technique apply INDICATIONS: Turning Inability or reluctance of patient to change body position. (eg, mechanical paralysis) Poor oxygenation associated with position(eg, unilateral lung disease) Potential for or presence of atelectasis Presence of artificial airway Postural Drainage 47 ventilation, neuromuscular disease, drug-induced over the lateral aspect of the rib cage. on the right side in a 30-40 degrees head over the lateral aspect of the rib cage. lower portion of the ribs.

Evidence or suggestion of difficulty with secretion clearance Difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult) Evidence or suggestion of re-tained secretions in the presence of an artificial airway. Presence of atelectasis caused by or suspected of being caused by mucus plugging. Diagnosis of diseases such as cystic fibrosis, bronchiectasis, or cavitating lung disease Presence of foreign body in airway. External Manipulation of the Thorax Sputum volume or consistency suggesting a need for additional manipulation (eg, percussion and/or vibration) to assist movement of secretions by gravity, in a patient receiving postural drainage

CONTRAINDICATIONS: The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Listed contraindications are relative unless marked as absolute. Positioning All positions are contraindicated for: Intracranial pressure (ICP) > 20 mm Hg(59,60) Head and neck injury until stabilized Active hemorrhage with hemodynamic instability Recent spinal surgery (eg, laminectomy) or acute spinal injury Acute spinal injury or active hemoptysis Empyema Bronchopleural fistula Pulmonary edema associated with congestive heart failure 48

Large pleural effusions pulmonary embolism Aged, confused, or anxious patients who do not tolerate position changes Rib fracture, with or without flail chest Surgical wound or healing tissue patients in whom increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye surgery) Uncontrolled hypertension Distended abdomen

ASSESSMENT OF NEED: The following should be assessed together to establish a need for postural drainage therapy o Excessive sputum production, o Effectiveness of cough, o Decreased breath sounds or crackles or rhonchi suggesting secretions in the airway o Change in vital signs o Abnormal chest x-ray consistent with atelectasis, mucus plugging, or infiltrates o Deterioration in arterial blood gas values or oxygen saturation Pulmonary problems treated successfully with PDT (eg, bronchiectasis, cystic fibrosis, lung abscess)

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Active cycle of breathing techniques (ACBT) It is the cycle of breathing control thoracic expansion exercise and force expiration technique. ACBT used to mobilize and clear excess bronchial secretions. it has been effective in clearance of bronchial secretions improve lung function

Breathing control

Thoracic expansion exercises

Breathing control

Thoracic expansion exercises

Forced expiration technique

Breathing control : It is normal tidal breathing using the lower chest with relaxation of upper extremities. 50

Forced expiratory technique : Combination of forced expiration a period of breathing control. Huff from high lung volume will clear secretions that have reach more proximal airway. Huffing: Open expectoration against open glottis Types : High volume huffing dislodge secretions from proximal airways. Mid lung volume huffing dislodge secretions from mid airways of zone ll Low lung volume huffing dislodge secretions from tertiary airways. Techniques: Ask the patient to take 3-4 deep breaths. Then diaphragmatic breathing Then again diaphragmatic breathing exercises are carries out. If the secretions reach the proximal airways there the patient to made to Coughing technique actually the cuff coughing is contraindicated when the secretions is stable the technique coughing are using. Closed expectoration against closed glottis. For a cough to be effective, there shall be High pressure during expiration. High expiratory flow rate. Expiration has to be at higher volumes. exercise are carried out and then 3-4 huff from mid lung volume to low volume.

cough or huff with high lung volume in order to clear the secretions in proximal airways.

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Techniques of cough : An inspiratory gulp of about 90% of total lung capacity. Closure of glottis and trapping of air inside at a power positive pressure of about 30 mmhg Ask the patient to mimis swallowing in order to increase in the intra thoracic pressure. For abdominal contraction and internal intercostal muscle contraction. Ask the patient to pronounce the alphabet K to increase the intra abdominal pressure. Forcibly expire against the open glottis costal expansion is crried out to improve ventilation and optimize gaseous exchange.

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Relaxation position for breathless patient : These relaxation position will assist relaxation of upper chest while encouraging diaphragmatic breathing control during an attack of breath less.

High side lying : Position : Pillow placement : 5 or 6 pillows are used to rise the patienst shoulder while lying on his shoulder One pillow placed between the waist and axills to keep the spine straight. One pillow must be above the shoulder so thst only the head and neck are supplied. One pillow- the underneath the forearm. One pillow underneath the pillow in the waist. One pillow if the knees are bent on top leg place in front of the one beneath. These patients who are suffering from acute breathlessness during the night :

Forward lean sitting : Position; patient sits on the table leaning forward from the hips with head and upper chest supported on several pillows. Pillow placement : The back must be kept straight, so diaphragmatic movement is not inhibited.children can sit or kneel with the head and upper chest resting against pillows. Relaxed sitting : This is an obstructive position can be taken up easily. the back should be kept straight , the forearms resting on the thighs and the wrists relaxed. 53

Forward lean standing : The patient should lean forward with the forearm resting on an object of suitable height such as the windows, banisters. Relaxed standing : The patient can lean back against a wall with the fet placed slightly apart and approximately 30 cms away from it. The shoulder and arm should be relaxed. Improve the breathing pattern : Breathing exercises : These are fundamentals interventions for the prevention of or acute comprehensive or chronic management

pulmonary disorder. Diaphragmatic breathing. Segmental breathing. Pursed breathing. Low frequency breathing. Sustained maximal breathing.

Diaphragmatic breathing : Uses : 1. To induced relaxed pattern of breathing. 2. To have a controlled pattern of breathing. 3. To improve the efficiency of ventilation. 4. To mobilize lung secretions during postural drainage.

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55

Diaphragmatic breathing exercise gives : 1. Concentrates on forward movement of whole abdominal wall. 2. Concentrates on upper abdominal wall and lower lateral ribs. 1st method : Concentrates on upper abdominal wall and lateral ribs. Position : semi- fowlers position. Procedure : Patient places hands on anterior central margin or upper abdominal wall and ask the patient to breath out gently as he does. The lower ribs are sinking down and in towards the mid line. During the technique the patient should relax shoulder and upper chest quiet the abdominal rise. Then the patient to slowly tell all the air our using control expiration. 2nd method : Position : Procedure : Therapist places both hands on anterior abdominal valve then the patient to breath out gently. He felt abdomen is sinking down and ask him to breath in through his nose. The air is concentrated and directed to abdomen and it bulges achieve the therapist places hands. Segmental breathing : In this expansion exercises are includes. In COPD costal expansions exercise are gives : 1. To improve ventilation to the lung after relieving bronchospasm. 2. To mobilize the secretions. 3. To improve the thoracic cage movements. 56 Half lying

57

Lateral costal expansion : It is done unilaterally, bilaterally emphasing deep breathing with a focus of movements of this position of the lower rib cage on diaphragmatic excursion. Position : Technique : Procedure : Relaxed half lying ( or ) sitting position. The therapist placed the pattern of hand over the mid axillary line of 7th and 8th rib. Ask the patient to breath out gently and the therapist applies a firm pressure against chest wall and ask the patient to breath air through nose the pressure maintained during inspiration. Before inspiration give up stretch and pressure is relaxed at the end of inspiration. Apical expansion exercise : Position : Technique : Procedure : Relaxed half lying ( or ) sitting position. Pressure in applied below the clavicle using the tips of fingers. The patient is instruction to breathe to breathe in expand the upper chest against pressure. Maximal inspiration holds for 3 to 5 second and expiration slowly. Thoracic mobility exercises : Chest mobilization exercises are any exercises that they are designed to maintained ( or ) improve mobility of chest wall trunk, and shoulder girdle when it effect ventilation or postural alignment. Exercises that combine stretching of these muscle with deep breathing ventilation on that side of the chest and control the expiration. thoughts to facilitate

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Specific technique : To mobilize one side of the chest : Postion : Sitting position Patient bend away from the right side lengthen hypomobile stricter expands that side of the chest during inspiration. Patient push the fisted hand into lateral aspect of chest and patient bend towards the right side and breath out. Progress by having the patient rise the arm on the right side. To mobilize the upper chest stretch the pectoralis muscle : Position : Procedure : Sitting position in a chair The patient hands closed behind the head ; patients horizontally abducts the arms during a deep inspiration. Then instruct the patient to bring the elbow together and bend forwards during expiration. To mobilize the upper chest and shoulders : Position : Procedure : sitting position in a chair Patient reach with both arms over head during inspiration. Patient bend forward and the hip and reach for the floor during expiration. In addition to exercises therapist may also instruct the patient in posture correction. To enhance expiration ; It is a process of moisturing of the air for gases we breath. Function : Normally one of the functions of upper respiration tract, the air way add heat and water to the inspired gas and extract heat and water from expired gas. Procedure :

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If the secretions are very thick and tenacious the patient may be given humidification through nebulizer inhalation with penio oil added to near be oiling water may also be given prior to treatment to remove excess brochial secretions. Inspiratory muscles training : Inspiratory muscles training is used in pulmonary rehabilitation to increase and endurance of the inspiratory muscles, general and specific training program are used ininspiratory muscle training. General : Aerobic exercises Walking Swimming Cycling Jogging Treadmill Gymnastics Specific: Inspective spirometry :Types : Volume oriented incentive spirometry Flow oriented incentive spirometry It is use to encourage the patient to take long slow deep breath and thus prevent athlectasis. It may be most commonly use respiratory therapy in post operative patient. Gardon - Barach Belt : Gardon barach belt and diaphragmatic breathing with active abdominal contraction during expiration in design to cause a cephalic displacement of diaphragm. Before inspiration give quick stretch is apply and pressure is maintained during inspiration at the end of inspiration pressure is relieved. Posterior basal expansion exercise : Position : patient sit and lean forward on pillow slightly bending the rib. 60

Technique : Pressure is given unilaterally over the posterior aspect of the lower rip and pressure is relieved at end of inspiration.

Pursed-lip breathing : Increased the tidal volume Improve exercise tolerance Develop this pattern of breathing Procedure : be avoided. Place your hand over the patient abdominal muscle to detect breath in slowly and deeply then have the patient loosely pure the lips and in able. patient assumes a comfortable position and relax as much as possible. Explain to the patient that expiration must be relaxed on that contract of abdomen must

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PREVENTION:

Early identification and treatment of conditions that tend to cause bronchiectasis may prevent its development or reduce its severity.

More than half the cases of bronchiectasis in children can be accurately diagnosed and promptly treated.

Childhood immunizations against measles and whooping cough, improved living conditions, and good nutrition have markedly reduced the number of people who develop bronchiectasis.

Influenza vaccines, pneumococcal vaccine, and use of appropriate antibiotics early in the course of lung infections help to prevent bronchiectasis or reduce its severity.

Receiving immunoglobulin for an immunoglobulin deficiency syndrome may prevent recurring infections.

Avoiding toxic fumes, gases, smoke, and injurious dusts also helps prevent bronchiectasis or reduce its severity.

Inhalation of foreign objects into the airways by children may be prevented by watching what they put in their mouth.

Avoiding over-sedation from drugs or alcohol and seeking medical care for neurologic symptoms (such as impaired consciousness) or gastrointestinal symptoms (such as difficulty in swallowing and regurgitation or coughing after eating) may help to prevent aspiration. Also, drops of mineral oil or petroleum jelly should never be

placed in the nose because they can be inhaled into the lungs

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DISCUSSION
Bronchiectasis has a heterogeneous clinical profile, secondary to the multiple aetiologies from which it may originate. Although the precise global prevalence is unknown, bronchiectasis remains a cause of excessive morbidity. In the current climate of limited health resources, it is important to provide interventions which not only contribute to improved HRQoL, but positively impact on disease progression and prognosis. This intervention study evaluating the short and long term efficacy of pulmonary rehabilitation, including exercise training and self-management in ACT compared to standard care, in patients with non-cystic fibriosis bronchiectasis. Currently, progression of respiratory symptoms is evident in this heterogenous population despite optimal medical intervention. The symptoms of chronic cough, sputum production and fatigue, associated with reduced exercise capacity in patients with mild to moderate bronchiectasis. This implies that strategies such as a pulmonary rehabilitation program which incorporates self management and adherence to ACT may have an equally positive impact on both diminished exercise capacity and clinically relevant dimensions of HRQoL, both of which will be important outcomes for all patients with bronchiectasis. Given the relationship between exacerbation rate and decline in pulmonary function, it would be highly significant if pulmonary rehabilitation were to impact on the incidence of acute exacerbations in bronchiectasis. As both declining respiratory function and reduced physical activity are associated with increased mortality in this population, achieving a reduction in the incidence of pulmonary exacerbations would result in pulmonary rehabilitation being one of the few available treatments with the potential to modify the disease course and prognosis in bronchiectasis and may be an inexpensive complement to existing medical care.

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CASE STUDIES: CASE STUDY-I

Name: Venkateswarlu Age: 45 Gender: male Occupation: Farmer Address: ramachandrapuram, A.konduru mandalam, Krishna district. Chief complaint: chronic cough, difficulty in breathing. History of patient: Past history: severe cough during childhood Present history: present history since one month Medical history: taking drugs for cough Family history: not relevant Personal history: smoking, alcoholic Socio-economic history: poor Environmental history: spraying pesticides OBJECTIVE EXAMINATION: On observation: Dyspnoea: present (grade-II) Cough: productive cough, purulent cough and is worst in early morning Wheeze: present General examination: Vitals: Temperature: 98.4F Heart rate: 70-100/min 64

Pulse rate: 85 beats Blood pressure: 140/80mm of Hg Observation of chest: Chest deformity: barrel chest Breathing pattern; abnormal On percussion: hyper resonant sounds On auscultation: Breath sounds: diminished Adventitious sounds: wheeze is present Investigations: X-ray: enlarged bronchovesicular margins Special tests: Stress test: positive Pulmonary function test : lung capacities and lung volumes are increased. Medical management: Antibiotics and anti-inflammatory drugs Physiotherapy management: Breathing exercises Coughing and huffing techniques Postural drainage

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CASE STUDY-II

Name: Uma devi Age: 28 Gender: Female Occupation: cooli Address: vuyuru, Krishna district, vijayawada. Chief complaint: difficulty in breathing. History of patient: Past history: sufferd from T.B Present history: present history since two month Medical history: taking drugs for T,B Family history: not relevant Personal history: -----Socio-economic history: poor Environmental history: living in industrial areas OBJECTIVE EXAMINATION: On observation: Dyspnoea: present (grade-III) Cough: productive cough, purulent cough and worst in early morning. Wheeze: present General examination: Vitals: Temperature: 98.4F Heart rate: 70-100/min Pulse rate: 80 beats/min Blood pressure: 120/80mm of Hg

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Observation of chest: Chest deformity: barrel chest Breathing pattern; abnormal On percussion: dull sounds On auscultation: Breath sounds: diminished Adventitious sounds: wheeze is present Investigations: X-ray: enlarged bronchovesicular margins, ring shadow sign Special tests : Stress test : positive Pulmonary function test : lung capacities and lung volumes are increased. Medical management: Antibiotics and anti-inflammatory drugs Physiotherapy management: Breathing exercises Coughing and huffing techniques Postural drainage

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CASE STUDY-III

Name: Narayana Age: 39 Gender: male Occupation: driver Address: krishnalanka, Krishna district, vijayawada. Chief complaint: difficulty in breathing, unable to work for long time. History of patient: Past history: sufferd from recurrent infections Present history: present history since two month Medical history: taking drugs for cough Family history: not relevant Personal history: chain smoker Socio-economic history: middle class Enivironmental history: living in slum area OBJECTIVE EXAMINATION: On observation: Dyspnoea: present (grade-III) Cough: productive cough, purulent cough and is worst in early morning Wheeze: present General examination: Vitals: Temperature: 98.4F Heart rate: 70-100/min Pulse rate: 80 beats/min Blood pressure: 110/90mm of Hg

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Observation of chest: Chest deformity: barrel chest Breathing pattern; abnormal On percussion: hyper resonant sounds On auscultation: Breath sounds: diminished Adventitious sounds: wheeze is present Investigations: X-ray: deflated lung Special tests : Stress test : positive Pulmonary function test : lung capacities and lung volumes are increased. Medical management: Antibiotics and anti-inflammatory drugs Physiotherapy management: Breathing exercises Coughing and huffing techniques Postural drainage

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CONCLUSION
According to the treatment i have conclude that prevention is always better than cure. Hence the patient is advice to stop smoking, if he is chronic smoker. Patient is also advice to take care of personal and environment hygine, health and good diet. Physiotherapist has main role in treating the bronchiectasis patients, to prevent the condition becoming worse. The patient is given chest physiotherapy in the early stages itself to improve the condition. Chest physiotherapy techniques include breath exercises, coughing, huffing, manual techniques, postural drainage, mobility exercises, relaxation positions ect. Hence physiotherapy plays a major role in bringing out a good prognosis.

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BIBILOGRAPHY:
1. HUMAN ANATOMY: Grays anatomy B.D, Chaurasia 2. PHYSIOLOGY; Chowdary

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