Bronchiectasis Treatment

Bronchiectasis is a chronic lung disease characterized by the permanent enlargement and structural distortion of the airways called bronchi. This condition causes mucus not to be cleared adequately from the lungs and prepares the ground for recurrent infections. Diagnosis is usually made with thoracic CT.

The causes and risk factors of bronchiectasis are based on chronic infections such as previous pneumonia, tuberculosis, immune system diseases, and cystic fibrosis. Genetic predisposition and frequent respiratory tract infections in childhood also increase the risk.

The methods used in the treatment of bronchiectasis vary depending on the extent of the disease and the severity of the complaints. Physiotherapy techniques aimed at mucus clearance, antibiotic treatments, bronchodilators, and sometimes surgical intervention are among the treatment options.

Long-term follow-up and strategies to improve quality of life can be achieved with regular breathing exercises, protection from infections, vaccination schedule, and smoking cessation. Monitoring of patients under the supervision of a pulmonology specialist ensures early prevention of complications.

What Is Bronchiectasis?

Bronchiectasis is a chronic lung disease characterized by the permanent widening of the bronchi and damage to their wall structure. This condition prepares the ground for sputum accumulation and recurrent infections. Although the most common cause is previous lung infections, immune system disorders and genetic diseases may also play a role. Early diagnosis and appropriate treatment are important in terms of controlling infections and preserving lung functions.

What Are the Causes of Bronchiectasis?

When we go down to the root of the disease, we encounter a wide variety of causes. Sometimes a congenital genetic inheritance, and sometimes infections encountered later in life, initiate this process. However, the vast majority of cases, about 75%, are acquired bronchiectasis.

Especially if we speak specifically for our country, tuberculosis infections, which are a legacy of past years, occupy an important place. Even if tuberculosis is overcome and healed, the damaged scars it leaves in the lungs may turn into bronchiectasis years later. Apart from this, severe pneumonias in childhood and diseases such as measles or whooping cough may also leave permanent scars on the bronchial walls.

Although the causes differ in developed countries, infection sequelae still take the lead in our geography. However, there is a very interesting statistic: when we look at patient series in Turkey, we cannot find a specific cause in almost half of the patients (50%). We call this “idiopathic bronchiectasis.” That is, even if there is no underlying rheumatic disease, immune problem, or known previous infection, the bronchial structure may still be impaired.

Some conditions that may pave the way for the disease are as follows:

• Tuberculosis sequelae
• Childhood pneumonias
• Measles infection
• Whooping cough
• Foreign body aspiration
• Immune system deficiencies
• Rheumatoid arthritis
• Inflammatory bowel diseases
• Sjögren syndrome
• Cystic fibrosis

What Are the Types and Stages of Bronchiectasis?

Not every bronchiectasis patient is the same, and not every patient receives the same treatment. As thoracic surgeons, we classify the disease according to the shape and severity of the damage. This classification is the most critical guide in determining whether surgery is appropriate.

The types according to the severity of the disease are as follows:

• Cylindrical bronchiectasis
• Varicose bronchiectasis
• Cystic bronchiectasis (Saccular)

In the first stage, the “Cylindrical” type, there are tubular, relatively regular, and mild enlargements in the bronchi. We usually do not consider surgery at this stage; medical treatment is at the forefront.

In the second stage, the “Varicose” type, the bronchi become knotted and irregular just like varicose veins in the legs. The terminal parts of the airways begin to decrease, and the damage deepens.

The third and most severe form is “Cystic or Saccular” bronchiectasis. This is the group that concerns us most surgically and requires radical decisions. Here, the bronchi have completely lost their function as airways and have turned into grape-like clusters or sacs filled with pus. The cartilage and muscle tissue in the bronchial wall have eroded. This type is generally like a reservoir that constantly produces infection and does not respond to medical treatment. It is biologically impossible for lung tissue that has reached this stage to repair itself.

What Symptoms Do Patients Experience?

This disease may begin insidiously and over time turn the patient’s life into a nightmare. The most characteristic feature is the production of large amounts of sputum that increases in the mornings. Because the inflammatory fluids that accumulate in the widened bronchi throughout the night begin to move with the effect of gravity upon waking up in the morning and trigger the cough reflex.

The complaints our patients frequently experience are as follows:

• Persistent cough
• Large amounts of purulent sputum
• Shortness of breath
• Chest pain
• Frequent recurrent fever
• Fatigue
• Loss of appetite
• Weight loss
• Bad breath
• Bloody sputum

These symptoms deeply affect not only physical health but also the patient’s social life. Because of the constant cough and concern about producing foul-smelling sputum, our patients may avoid mingling in society and may develop a depressive mood. Therefore, treatment aims to improve not only the lungs but also the patient’s social life.

Why Doesn’t It Improve with Medication and Why Is Surgical Treatment Required?

This is the issue our patients most frequently ask us about and complain about in the clinic: “Doctor, I used bags of antibiotics, I’ve been taking medicine for years, but why am I not getting better?”

The answer to this question is hidden in the “anatomical” nature of the disease. Medications can kill the existing microbe at that moment and dry up the infection. However, they cannot restore the widened, hollowed-out, structurally damaged bronchial wall to its former healthy state. As long as that cavity (damaged bronchus) remains there, once the medication is stopped, it will fill with secretions again and produce microbes again.

In medicine, we call this the “Septic Sink” theory. The damaged area acts as a constant reservoir of infection for the body. The body’s defense cells have difficulty reaching there. Even if you suppress the microbe with antibiotics, the infection recurs in a short time because the environment is very favorable for bacteria to multiply. This area even becomes a source that continuously pumps inflammation to other healthy organs in the body.

This is the logic of surgery: physically removing this “infection production center” from the body, which medications cannot reach, cannot correct, and which constantly spreads poison to the body. Once this is done, the vicious cycle is broken.

Who Is Suitable for Bronchiectasis Surgery?

The decision for surgery is not a simple one where we can just look at the scans and say, “Let’s remove this part.” It requires a very meticulous, multidisciplinary evaluation process. Not every bronchiectasis patient is operated on. For us, the correct patient selection is half of surgical success.

The criteria for suitability for surgery are as follows:

• The disease being localized
• Resistance to medical treatment
• Saccular type damage
• Adequate respiratory capacity
• Acceptable cardiac reserve
• Good general condition

The ideal candidate is the patient in whom the disease is confined to only a certain part of the lung (for example, in a single lobe or segment). If the disease is limited to one point, the patient is completely cured when we remove that region. In addition, the patient’s complaints must persist despite adequate medical treatment, physiotherapy, and vaccinations. In other words, surgery is the most effective method we resort to after using all our weapons.

In Which Situations Is Surgical Treatment Not Recommended?

In some situations, surgery may bring more harm than benefit to the patient. Determining these situations, which we call “contraindications,” is of vital importance. While our aim is to heal the patient, we must not make them dependent on a breathing machine.

The situations in which surgery is not recommended are as follows:

• Diffuse bilateral disease
• Advanced-stage COPD
• Severe heart failure
• Primary ciliary dyskinesia
• Severe immune deficiencies
• Insufficient lung reserve

Especially in genetic diseases such as “Primary Ciliary Dyskinesia,” the problem is not only in the shape of the bronchus but in the motility of the cilia in the respiratory tract. Since this genetic disorder affects the entire respiratory tract, a local surgical intervention does not solve the problem; because the tissue that appears “healthy” but remains behind is also למעשה diseased, and its cilia do not work. Likewise, in patients whose disease has spread to both sides of the lungs, surgery is generally not preferred because it is not possible to remove all the diseased areas (because no lung would remain).

How Are Diagnosis and Surgical Planning Made?

In the diagnostic process, standard chest X-rays only give us a rough idea and do not show the details. The gold standard diagnostic method for bronchiectasis is “High-Resolution Computed Tomography” (HRCT). With this method, we examine your lungs in millimetric slices. We can clearly see which segment is involved and how much the bronchial wall has thickened.

However, in patients for whom we decide on surgery, this is still not enough. More advanced mapping is required for the safety of the surgery. Because a lung with bronchiectasis is a complex area where there are adhesions due to chronic inflammation, vascular structures may be displaced, or abnormal vessels may have formed. Therefore, we use “3-Dimensional (3D) CT Angiography.”

The benefits of these advanced imaging methods are as follows:

• Showing vascular variations
• Predicting adhesion areas
• Determining the resection boundary
• Reducing the risk of bleeding
• Shortening the operation time

In addition, we обязательно perform “Bronchoscopy” before surgery. We enter the airways with a lighted camera, check whether there is a tumor or foreign body inside, and take samples for microbiological examination.

What Is the Preoperative Preparation Process Like?

The secret of a successful bronchiectasis surgery lies more in the preoperative preparation period than on the operating table. The approach of “let’s hospitalize the patient immediately and operate tomorrow” is extremely wrong in this disease. First, we enter a preparation process that we call “Optimization.”

The aim of this process is to minimize the active infectious burden and the amount of sputum in the patient’s lungs. We begin to use targeted antibiotics determined according to sputum culture results at least two weeks before surgery. In addition to this, we apply intensive respiratory physiotherapy. With the method we call “Postural Drainage,” we ensure that the patient drains the accumulated inflammation in the lung.

The importance of this preparation is ثابت with historical data. In the old periods when antibiotics and these meticulous preparation protocols did not exist, the mortality risk in bronchiectasis surgeries was at terrifying levels such as 46%. Because cutting “dirty” and infected tissue carried great risks. However, today, thanks to this detailed cleansing and preparation process, the surgical risk has dropped to levels around 1.5%. In other words, not making an incision before reducing the infectious burden is the key to surgical success.

How Is Bronchiectasis Surgery Performed?

With the development of technology, major changes have also taken place in thoracic surgery. Surgeries once performed with large incisions have given way to minimally invasive methods. Today, the standard approach in bronchiectasis surgery is the methods known among the public as “Closed Surgery,” namely VATS (Video-Assisted Thoracoscopic Surgery) or Robotic Surgery.

In this method, instead of opening the chest cavity with a large incision and separating the ribs, we perform the procedure by entering with a camera and special instruments through only 1 or 2 small holes of a few centimeters. By seeing the inside on a high-resolution screen, the surgeon frees the diseased lung lobe or segment and removes it in a special bag.

The advantages of minimally invasive (closed) surgery are as follows:

• Less pain
• Smaller scar
• Less bleeding
• Fast recovery process
• Shorter hospital stay
• Less risk of complications

We now reserve open surgery (Thoracotomy) only as an option in very rare cases where there are very dense adhesions, where the closed method is technically not possible, or in emergency bleeding situations.

What Should Be Done in Case of Coughing Up Blood?

One of the conditions that bronchiectasis patients fear most is “Hemoptysis,” that is, coughing up blood. The enlarged and superficial vessels in the damaged area may rupture under the effect of infection. If the amount is small (streaks in the sputum), it may be monitored, but the heavy bleeding that we call “Massive Hemoptysis” carries a life-threatening risk.

In such a situation, the priority is to stop the bleeding. Usually, the first choice is not surgery but “Interventional Radiology.” With the procedure we call “Bronchial Artery Embolization” (BAE), entry is made through the groin, the thin bleeding vessel in the lung is found, and it is blocked. This procedure is often life-saving and stops the bleeding without the need for surgery.

However, in some cases, especially in patients with tuberculosis sequelae or when embolization fails, emergency surgery may be required. This is a risky decision, but if the bleeding does not stop, the only remedy to save the patient’s life is to remove that bleeding tissue (Emergency Resection).

What Is the Postoperative Recovery Process Like?

The postoperative period is the time when cooperation between the patient and the doctor is at its most intense. We usually host our patients in the hospital for between 4 and 6 days. If you have had surgery with the closed method, pain control is much easier and you start walking the next day.

The most critical issue in this period is to ensure that the lung re-expands. For this, you need to continuously exercise with the “blowing balls” (triflow) we give you. Early mobilization and breathing exercises eliminate the risk of pneumonia.

The biggest concern of our patients is, “Will my breath be enough when part of my lung is removed?” Here, it must be clearly stated that the tissue we remove with surgery is not tissue that is already “working” and providing you oxygen. It is dead tissue filled with inflammation, not participating in air exchange, and having lost its function. It even compresses the healthy areas and hinders them.

When we remove this useless and burdensome tissue, the remaining healthy lung tissue expands more comfortably. Since the chronic infectious burden in the body is removed, the patient’s general energy level increases. Scientific studies show that in most patients who undergo surgery, exercise capacity does not decrease but on the contrary increases.

What Are the Results After Surgery?

The results of bronchiectasis surgery performed with the correct patient selection and good surgical technique are gratifying. Our goal is not only that the scans improve, but that the patient’s quality of life improves.

When we look at the long-term results, 66% to 82% of patients become completely symptom-free. In other words, the cough ends, the sputum stops, and recurrent fever attacks become a thing of the past. In the remaining patients, complaints decrease very significantly and become manageable.

In quality-of-life questionnaires, it has been observed that by the 9th postoperative month, patients’ physical and social functions approach the average of society. They come out of the psychology of being a “constantly sick person” and mingle with social life confidently.

Frequently Asked Questions