1EM00011.2012-06 © 2012 Copyright Electromed, Inc. Bronchiectasis William Grimm, RRT 33 rd Annual Mountain Air Symposum 10/9/2014

1EM00011.2012-06 © 2012 Copyright Electromed, Inc.

Bronchiectasis

William Grimm, RRT

33rd Annual Mountain Air Symposum

10/9/2014


The Challenge


Presentation Agenda

• Bronchiectasis Types Causes Symptoms Effects on the Body Diagnosis Treatment Bronchiectasis Research Registry

• Airway Clearance• High Frequency Chest Wall Oscillation (HFCWO)• Patient Satisfaction with the SmartVest® Airway Clearance

System


What is Bronchiectasis?

• Abnormal stretching and enlarging of the respiratory passages caused by mucus blockage

• The blockage and accompanying infection cause inflammation, leading to the weakening and widening of the passages*

• Bronchiectasis = dilation of proximal and medium-sized bronchi >2mm with transmural inflammation, edema scarring, and ulceration– Laennec, 1819– Osler, late 1800s– Reid, 1950s

*Source: American Lung Association


A. Normal lung and airway

Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93

B. Bronchiectasis lower lobes, most common, saccular dilatations and grape-like

clusters with pools of mucus

Bronchiectasis


COPD Education

Run COPD Education System.lnk


Types of Bronchiectasis

• Focal Bronchiectasis– Occurs in a single lobe of the lung and can be

the result of an obstruction by a large foreign object, a tumor, or an unusual development in the airway

• Diffuse Bronchiectasis– Occurs in more than a single lobe– An underlying immune deficiency, infection, or

toxic exposure that involves multiple lobes– Cystic Fibrosis and Primary Ciliary Dyskinesia


What Historically Caused Bronchiectasis?

• The most common causes have been severe lung infections during childhood such as whooping cough or severe viral infections


What Causes Bronchiectasis Today?

• Tuberculosis is the single leading cause worldwide• Genetic disorders such as CF and PCD are the leading

causes in Western countries• Aspiration (focal bronchiectasis)• GERD• Complications of primary infections such as bronchitis,

pneumonia, whooping cough, or tuberculosis• Not all cases are caused by infection or genetic defect

– Exact cause is never determined in many cases• Higher incidence in older women and native American

population in Alaska


Prevalence of Bronchiectasis

• USA - 52 in 100,000

• South Korea Study – 1,409 patients ages 23 to 86– HR CT Scan

» 129 of study group had bronchiectasis on HR CT Scan (9.1%)

» 53% of the 9.1% above exhibited respiratory Symptoms

Source: Kwak, et al., Highprevalence of bronchiectasis in adults: analysis of CT findings in a health screening program, Department of Internal Medicine, Hanyang University of Medicine, Seongdong-gu, Seoul, Korea


Economic Burden of Bronchiectasis in the USA

• Annual cost of care in 2001 = $13,244Greater than the cost of heart disease ($12,000)

and COPD ($11,000 to $13,000)• For the estimated 110,000 patients with

Bronchiectasis the total medical care cost annually = $1.4 billion


Chronic Respiratory Symptoms

• Cough and sputum production (90 to 100%)• Areas of scarring• Mucus gland enlargement• Coughing up blood occasionally• Wheezing, possibly from asthma• Shortness of breath (75%)• Pleurisy or chest pain with breathing (50%)



Bronchiectasis Symptoms

• Persistent productive cough

• Production of large quantities of purulent (infected)

sputum

• Chronic respiratory infection, including infection with rare

and/or opportunistic organisms

• Shortness of breath

• Cyanosis


Effects on the Body

• Vicious Cycles– Once bronchiectasis is established in the lobe or

lobes of the lung, it compromises airway clearance which leads to respiratory infections

– These infections take up in the nooks, crannies, and pockets of the airway which the bronchiectasis has created

• Inflammation– Loss of structural integrity of muscle, elastic tissue,

and sometimes bronchial cartilage making the airway susceptible to infection which leads to inflammation


1. Top - Foamy mucus2. Middle - Watery layer3. Bottom - Cell debris

3-Layer Sputum

Source: Barker AF and Albert: Clinical Respiratory Medicine, 2nd ed., © 2004 Mosby


Infections Associated with Bronchiectasis

• Staphylococcus aureus• Haemophilus influenza• Mycoplasma pneumoniae• Mycobaterium tuberculosis• Nontuberculous Mycobacterium (avium-complex)• Pseudomonas aeruginosa


How is Bronchiectasis Diagnosed?

• Computed Tomography (CT Scan) of the chest, required

by Medicare

• Chest X-ray

• Bronchoscopy

• Lung function tests

• Blood tests

• Sputum culture


Physical Exam

• Adventitious breath sounds • Crackles (70%)• Rhonchi (44%)• Wheezing (34%)• Clubbing (3%)• Findings of primary causative disease (eg. rash, joint

deformities, situs inversus, lymphadenopathy, dwarfism, yellow nails, IV needle tracks, etc.)



Treating Bronchiectasis

• Airway Clearance Therapy (ACT)

– Reduces obstruction and infection of the bronchi

– Examples: exercise, CPT, inhaled medications, and mechanical devices

• Antibiotics

– To control infections

– Tobi, which is inhaled, for P. Aeruginosa

– Azithromycin, which is taken orally

• Lung Transplants

– For those who are approaching respiratory failure

– For focal bronchiectasis, possible treatments include a lobectomy, or partial lung resection


Bronchiectasis Registry

• Consolidated database of non-CF bronchiectasis patients from multiple clinic institutions– Stores information about bronchiectasis patients and

the disease itself– Enrolled 10,000 patients in October 2011

Source: COPDFoundation.org


Bronchiectasis Study via Registry

• 54 Stable COPD Patients• Mean age = 69• Mean FEV1 = 0.96• 50% had Bronchiectasis in HRCT Scan• Increased in reported COPD exacerbations, sputum

markers, and bacterial colonization


Natural airway clearance includes three essential components

Normal Airway Clearance

Mucus traps impurities

Cilia beat carry mucus to large airways

A strong cough clears mobilized secretions

In most individuals, these three components work in harmony to keep our airways clear


Inadequate Airway Clearance

Inadequateclearance

Inadequateclearance

InfectionsInfectionsScarringScarringDecreasepulmonary

function

Decreasepulmonary

function

Increasedhealthcosts

Increasedhealthcosts

Loss ofproductivity

Loss ofproductivity


Mucociliary SystemDisorders

• Cystic Fibrosis (CF)• Primary Ciliary

Dyskinesia• Immotile Ciliary

Syndromes

Obstructive Pulmonary Conditions

• COPD Chronic

Bronchitis Emphysema

• Bronchiectasis

Neuromuscular Disease

• ALS• Muscular Dystrophy• Spinal Muscular

Atrophy• Post Polio

Neuromotor Disease/Conditions

• Cerebral Palsy• Multiple Sclerosis• Spinal Cord

Injuries

Restrictive Airway Disorders

• Scoliosis• Kyphoscoliosis

Acute Care in Hospital setting

• Post surgical• Ventilator• Etc.

Inadequate Airway Clearance

Problems may occur with diseases or conditions characterized by


Complications of Retained Secretions

Atelectasis

Increased Work of Breathing

Hypoxemia

Infection

Lung Damage


High Frequency Chest Wall Oscillation (HFCWO) - Considerations for Use

• High Frequency Chest Wall Oscillation is designed specifically for airway clearance therapy to enhance mucus transport and improve bronchial drainage.

• Indications for HFCWO are not diagnosis specific; however, it can be considered when retained secretions cause pulmonary compromise. Thus, individual assessment of each patient is appropriate.


Patient Satisfaction with HFCWO via the SmartVest® Airway Clearance SystemThe SmartVest® incorporates many features designed for the comfort and convenience of the user. These features are intended to increase the ease of use to encourage better cooperation and compliance for all ages – small children to adults.

What do patients say they like about the SmartVest®?

• The SmartVest® is gentler on the body, with comparable efficacy

• Only soft, breathable, washable fabrics touch the skin (SmartVest Wrap® must be spot cleaned)

• All Velcro™-type closures make adjustments and “on and off” simple

• A single offset hose improves maneuverability during treatment


THANK YOU

QUESTIONS?

Documents

1EM00011.2012-06 © 2012 Copyright Electromed, Inc. Bronchiectasis William Grimm, RRT 33 rd Annual Mountain Air Symposum 10/9/2014