Transcript Linde-Gas - American Lung Association
Bronchiectasis
William Grimm, RRT 33 rd Annual Mountain Air Symposum 10/9/2014 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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The Challenge
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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
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Bronchiectasis
A. Normal lung and airway B. Bronchiectasis lower lobes, most common, saccular dilatations and grape-like clusters with pools of mucus
Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93
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COPD Education
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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What Historically Caused Bronchiectasis?
• The most common causes have been severe lung infections during childhood such as whooping cough or severe viral infections EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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
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Economic Burden of Bronchiectasis in the USA
• • Annual cost of care in 2001 = $13,244 Greater 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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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%)
Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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3-Layer Sputum
1. Top - Foamy mucus 2. Middle - Watery layer 3. Bottom - Cell debris
Source: Barker AF and Albert: Clinical Respiratory Medicine, 2nd ed., © 2004 Mosby
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Infections Associated with Bronchiectasis
• • • • • • Staphylococcus aureus Haemophilus influenza Mycoplasma pneumoniae Mycobaterium tuberculosis Nontuberculous Mycobacterium (avium-complex) Pseudomonas aeruginosa EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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.)
Source: Barker AF. Bronchiectasis. NEJM 2002; 346(18):1383-93
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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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
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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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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Normal Airway Clearance
Natural airway clearance includes three essential components
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
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Inadequate Airway Clearance
Inadequate clearance Loss of productivity Increased health costs Decrease pulmonary function Scarring Infections EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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Inadequate Airway Clearance
Problems may occur with diseases or conditions characterized by
Mucociliary System Disorders Obstructive Pulmonary Conditions Neuromuscular Disease • Cystic Fibrosis (CF) • Primary Ciliary Dyskinesia • Immotile Ciliary Syndromes • COPD Chronic Bronchitis Emphysema • Bronchiectasis • 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.
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Complications of Retained Secretions
Atelectasis Increased Work of Breathing Hypoxemia Infection Lung Damage
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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. EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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Patient Satisfaction with HFCWO via the SmartVest
®
Airway Clearance System
The SmartVest ages ® 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 – 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 EM00011.2012 06 © 2012 Copyright Electromed, Inc.
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THANK YOU QUESTIONS?
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