Bronchiectasis refers to the pathological dilation of the bronchi caused by inflammatory destruction of the bronchial walls and surrounding pulmonary tissues. In young and middle-aged individuals, it often develops secondary to infections such as pertussis or bronchopneumonia during infancy, whereas in children, it is more commonly associated with congenital malformations. Infection and bronchial obstruction are interrelated factors that play a critical role in the formation and progression of bronchiectasis. Recurrent infections in the bronchial walls and surrounding lung tissues lead to bronchial wall damage and fibrosis, resulting in bronchial dilation. Inflammatory processes can also lead to bronchial obstruction due to lymphadenopathy, thick secretions, mucus plugs, or foreign bodies, further exacerbating infections and worsening bronchial dilation. Bronchiectasis often affects the third- and fourth-order bronchi and is commonly classified as cylindrical, saccular, or mixed forms, predominantly involving the lower lobes of both lungs, the lingular segment of the left upper lobe, and the right middle lobe.
Clinical Manifestations
The clinical features primarily include expectoration, hemoptysis, and recurrent respiratory and pulmonary infections. Patients often produce large amounts of purulent yellow-green sputum, which may have a foul odor. Positional changes, particularly upon rising in the morning, may trigger violent coughing and sputum expectoration, potentially due to drainage of accumulated purulent secretions from dilated bronchi into the proximal airway, causing irritation. Some patients present with blood-streaked sputum or massive hemoptysis. Chronic cases may lead to anemia, malnutrition, or clubbing of fingers and toes.
Diagnosis
Imaging studies are the main diagnostic tools and include:
Chest X-rays
In mild cases, X-ray findings may appear normal, but as the condition progresses, increased and disorganized pulmonary markings or reticular and honeycomb-like patterns may be observed.
CT Scans
Findings include localized inflammatory infiltration, reduced lung volume, and cylindrical or saccular bronchial dilation. High-resolution CT (HRCT) scanning has high sensitivity and specificity for diagnosing bronchiectasis and is currently the most important diagnostic modality.
Surgical Treatment
Treatment options for bronchiectasis include medical treatment, surgical intervention, and bronchial artery embolization therapy. Medical management focuses on addressing underlying causes, treating coexisting conditions, controlling infections, promoting sputum clearance, and alleviating airway spasms. Bronchial artery embolization can be used to manage massive hemoptysis caused by bronchiectasis, particularly in patients who are unsuitable for surgery or have extensive disease. For patients with bleeding confirmed to originate from the bronchial artery, embolization offers better therapeutic outcomes.
Surgical treatment remains the primary approach for managing bronchiectasis, with the goal of removing the diseased areas to eliminate sources of pulmonary infection and bleeding.
Indications for surgery include:
- Patients with good general health and adequate cardiac, hepatic, renal, and other organ functions to tolerate surgery.
- Persistent symptoms, such as copious purulent sputum or recurrent or massive hemoptysis, despite appropriate medical treatment.
- Relatively localized disease.
Contraindications for surgery include:
- Poor general health, with impaired cardiac, pulmonary, hepatic, or renal function; comorbid conditions such as emphysema, asthma, or pulmonary heart disease that preclude surgery.
- Diffuse bilateral disease.
Preoperative preparations include:
- Comprehensive assessment of cardiac, pulmonary, hepatic, and renal function to evaluate surgical feasibility.
- Recent HRCT imaging to determine the extent of disease and plan the surgical approach.
- Fiberoptic bronchoscopy to exclude intrabronchial foreign bodies or tumors and to identify bleeding sites in patients with hemoptysis, facilitating surgical planning.
- Infection control and sputum volume reduction through therapies such as ultrasonic nebulization, postural drainage, sputum clearance, and respiratory training, aiming to reduce daily sputum production to less than 50 mL.
- Sputum culture and sensitivity testing to guide antimicrobial therapy.
- Supportive treatment with a high-protein, vitamin-rich diet to correct malnutrition and anemia.
Surgical Techniques
To prevent aspiration of purulent secretions from the bronchiectatic cavities into the healthy lung during surgery, which could lead to choking or contralateral lung infection, double-lumen endotracheal intubation is used, along with enhanced intraoperative suctioning. The surgical approach varies based on the patient's general condition and the extent of disease.
Unilateral Disease
For disease localized to a single lobe or segment, procedures such as lobectomy or segmentectomy may be performed. For extensive involvement of multiple lobes or the entire lung, a pneumonectomy can be considered if the contralateral lung function is satisfactory.
Bilateral Disease
If one side is severely affected, and sputum production or bleeding is predominantly from the more severely diseased side, a lobectomy or segmentectomy can be performed on that side. Depending on the circumstances, bilateral surgery can be performed either concurrently or staged.
Extensive Bilateral Disease
Diffuse extensive bilateral disease is typically unsuitable for surgery. However, if massive hemoptysis becomes recurrent and unresponsive to aggressive medical treatment, resection of the bleeding lung may be considered as a life-saving measure. In cases of diffuse disease or multi-segment resection, lung transplantation may also be considered.