Changing Paradigms in the Diagnosis and Management of Bronchiectasis
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Am J Respir Med 2002; 1 (5): 339-347 1175-6365/02/0005-0339/$25.00/0 © Adis International Limited. All rights reserved.
Changing Paradigms in the Diagnosis and Management of Bronchiectasis Michael Greenstone Medical Chest Unit, Castle Hill Hospital, Cottingham, East Yorkshire, UK
Abstract
The face of bronchiectasis may have changed in recent years but individual cases continue to pose difficult challenges. As childhood infection becomes less of a problem, alternative causes of bronchiectasis are increasingly recognized which themselves offer new problems of diagnosis and management. Evolving concepts of pathogenesis suggest alternative strategies for treatment but as yet the evidence base on which to make firm decisions is lacking. Antibacterial regimens are not universally applicable and individualized protocols with parenteral, nebulized or continuous antibacterial therapy are increasingly used in the treatment of patients with bronchiectasis. Despite the theoretical appeal of using mucolytic or anti-inflammatory drugs their roles are still uncertain and have yet to be examined in adequate clinical trials. The factors determining disease progression are still poorly understood but in some patients worsening airflow obstruction heralds the onset of ventilatory failure. The management of the latter requires bronchodilators and controlled oxygen therapy, and strategies including non-invasive ventilation are increasingly an option. Changing indications for surgery are evident with fewer palliative resections but a developing role for transplantation.
It is a truth universally acknowledged that a disease is receiving insufficient recognition unless a professional body of health professionals deems it in want of a guideline. That no such guidance on best practice has yet been published might indicate that, in terms of morbidity or costs, bronchiectasis is not a major problem to either patients or health professionals. Experience, however, suggests otherwise. We have all seen patients with bronchiectasis who have progressed inexorably to incapacity and premature death and where advice on optimal management might have been both useful and reassuring. Although the incidence of severe bronchiectasis is less than tobacco-induced chronic obstructive pulmonary disease (COPD), bronchiectasis is not so uncommon that we can afford to dismiss the problem. Narrative reviews inevitably lack the rigor of systematic literature searches and no claim is made on optimal management practices. The aim of this review is to summarize current knowledge and highlight some recent developments which may underpin future clinical practice in the management of patients with bronchiectasis. Older textbooks described patients with bronchiectasis as cachectic individuals with gross finger clubbing who expectorated
large volumes of offensive sputum; however, such individuals are now rarely seen except in specialized clinics suggesting that the nature of the disease must have changed. There is a dearth of reliable epidemiological data but the avai
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