Bronsiectazia

Prezentare caz
 Istoric
Barbat, 55 de ani, nefumator, fara expunere la noxe respiratorii, prima prezentare
la INP Marius Nasta. Nu a reusit sa fac copii cu toate ca si-a droit si a incercat
(infertilitate?)

Dispnee la efort mic (mers 200m  in urma cu 1 an putea merge 1-2km)

Tuse cronica, productiva de o luna zile. In ultima saptamana mucopurulenta

(~50ml/zi)

Afebril
Istoric - APP
Vaccinari conform program national (BCG, DTP)

BRGE, hernie hiatala

Sinuzita cronica, polipectomie nazala recurenta

Micobacterioza (MAC) – 2016 (52 ani) – tratament 18 luni

Insuficienta pancreatica, esec crestere in copilarie

Clinic
Afebril, stare generala moderat alterata, subponderal (IMC 17kg/m2)

Hipocratism digital

Pulmonar: Submatitate la percutie 1/3 medie stanga, cu MV diminuat la acest

nivel, raluri bronsice bilateral, raluri crepitante 1/3 medie stg, SO2 94-95% aa

TA 130/70mmhg, fara edeme gambiere

Abdomen nedureros, TI 1-2 scaune moi/zi

Bronsiectazii???

Investigatii
 Bronsiectazii – investigatii necesare
(prima evalaure)
Evaluare istoric pacient si comorbiditati: BPOC, astm, BRGE, boli inflamatorii intestinale, etc

Rx pulmonara + CT torace cu s.c.

HLG completa, IgE totale, prezenta A. Fumigatus

Imunograma – IgG, IgM, IgA
Testare pentru fibroza chistica (suspiciune?)
Testare pentru diskinezie ciliara (suspiciune?)
Testare pentru deficit de alpha1-anti-tripsina (suspiciune?)
Bronhoscopie (cand la prima evaluare?)

Cultura sputa – flora si BK

The BTS Guideline for Bronchiectasis in Adults, 2019
The BTS Guideline for Bronchiectasis in Adults, 2019
Hemoleucograma – leucocite in limite normale
VSH 110mm la 1h, CRP 5 (+)
Imunograma in limite normale. IgE valori normale

Sputa – absenta mycobacterium, absenta fungi, P. Aueruginosa

(sensibilitate pastrata)
 Probe functionale respiratorii
Spirometrie: Gazometrie arteriala (repaus)
FVC 72% pH 7.38
VEMS 65% pO2 88mmHg,
pCO2 36mmHg
IT 62% HCO3- 23mmol/L

Test de mers 6 minute

A parcurs 360m (80% in distanta prezisa)
Pretest: dispnee 1/10 Borg, obosela 2/10 Borg, SO2 95%, TA 120/60mmHg, AV 80/min
Pos-test: dispnee 6/10 Borg, oboseala 4/10 Borg, SO2 90%, TA 150/90mmhg, AV 100/min
Analize specifice
Fibroza chistica
Disfunctie pancreatica + Testul sudorii –
esesc crestere + pacient 25mEq/L (?)
subponderal?

Dischinezie ciliara Biopsie mucoasa

Sinuzita cronuca, polipoza nazala (raclaj nazal) –
nazal, +/- infertilitate? structura normala cili
Diagnostice
Bronsiectazii bilatarale. Fibroza chistica forma atipica
BPOC stadiul II GOLD clasa de risc B
Insuficienta respiratorie latenta
Sechele TB pulmonara
BRGE
Rinosinuzita cronica
Bronsiectazii – evaluare severitate

The BTS Guideline for Bronchiectasis in Adults, 2019

Bronsiectazii – abordare terapeutica

The BTS Guideline for Bronchiectasis in Adults, 2019

 Masuri generale
Profilaxia infectiilor de cai aerine
– vaccinare antigripala (anual)
- Vacccinare antipneumococica

Hidratare corespunzatoare

Aport caloric sufficient, tratament BRGE (microaspiratii  infectii respiratorii)

Masuri adresate in functie de cauza – enzime pancreatice, substitutie vitamine

liposolubile, etc.

The BTS Guideline for Bronchiectasis in Adults, 2019

 Tratament antibiotic
Conform antibiogramei (actuale sau anterioare)

De exclus
Colonizare P. Aeruginosa – AB pe termen lung mycobacterium
- nebulizare: colistin, tobramicina
- macrolide (ex. Azitromicina 250mg/zi, 3 zile/sapt, 3 luni)

The BTS Guideline for Bronchiectasis in Adults, 2019

Imbunatatirea drenajului cailor aeriene
Mucolitice: umidifiere, nebulizare solutii saline, acetil-cisteina (ACC), bromhexin,
erdosteina (Erdomed).

Bronhodilatatoare – B-agonisti cu durata lunga de actiune/antimuscarinici

NB: nu folositi CSI de rutina (doar daca are alta indicatie – astm bronsic)

Drenaj postural

Metode bronhoscopice – cand?

Metode mecanice (cough assist)

The BTS Guideline for Bronchiectasis in Adults, 2019

 Drenaj postural

3
 Metode mecanice
VNI ( + insuficienta respiratorie)
Cough asssist
Brosiectazii – monitorizare pacienti

The BTS Guideline for Bronchiectasis in Adults, 2019

Caz actual – Tratament?
1. Mucolitice
2. Bronhodilatator – Formoterol (BADLA) + SABA la nevoie (BPOC)
3. Antibiotic ? Antipseudomonas – conform antibiograma
4. Enzime pancreatice + vitamine (A, D, E, K – II, VII, IX, X)
5. IPP (BGRE) + tratament anti-HP (+/-)  consult gastro
6. Profilaxie – vaccinari
7. Regim hypercaloric + hidaratare
8. Sfat genetic
Tratament chirugical

Rezectii – boala localizata + exacerbari frecvente/hemoptizii

Transplant pulmonar
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8863
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8863
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8863
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8863
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8863