| disease | Bronchiectasis |
| alias | Branch Enlargement, Bronchectasis |
Bronchiectasis is currently the most common chronic suppurative respiratory disease managed in thoracic surgery. Pathologically, it involves the destruction of bronchial walls, leading to persistent and irreversible dilation and deformation, accompanied by chronic inflammation of the surrounding lung tissue. This condition is more prevalent in children and young adults and can be caused by various disease factors, with a small proportion involving congenital genetic factors or associated with other congenital abnormalities. Before the widespread use of antibiotics, it was a major cause of death and respiratory disability among respiratory diseases. In recent decades, significant advancements in drug therapy have markedly reduced the causative factors and led to a substantial decline in incidence.
bubble_chart Epidemiology
Since bronchiectasis is diagnosed through bronchography and autopsy, mass screening is not feasible, and there is no reliable data on its incidence in the general population. In 1953, Bedford reported an incidence rate of 1.3%. In 1956, during a campaign to control subcutaneous node disease, chest X-rays of 3.5 million people revealed a bronchiectasis incidence of 1.5%. Other reports indicate an incidence of 0.3%–0.5% in the general population, 2%–3% in routine autopsies, and up to 23.3% in cases of chronic lung infections. Although these figures may not be entirely accurate, they suggest that bronchiectasis was once quite common. General experience shows a significant decline in incidence after the widespread use of antibiotics, as respiratory infections in children became more effectively treated, and predisposing factors such as whooping cough and measles nearly disappeared. Additionally, the prevalence of subcutaneous node disease has gradually decreased. As a result, bronchiectasis has become rare in economically developed Western countries but remains a widespread issue in the Third World.
bubble_chart EtiologyBronchiectasis is an acquired disease in childhood and may also result from some congenital developmental abnormalities or genetic defects (related factors are listed in the table). The main causes of acquired sexually transmitted disease are infection and bronchial obstruction. With most infections now controllable by medication, the proportion of cases due to congenital or genetic factors has relatively increased, though overall it remains rare.
Factors associated with bronchiectasis
(I) Congenital
Further divided into primary and secondary types.
1. Major structural defects: Tracheobronchomegaly, bronchomalacia, pulmonary sequestration, others.
2. Ultrastructural defects: Ciliary dyskinesia syndrome, Kartagener syndrome, Young syndrome.
3. Metabolic defects: Cystic fibrosis, α1antitrypsin deficiency.
(II) Acquired
1. Primary infections (often in childhood): Measles, whooping cough, bronchiolitis, pneumonia, subcutaneous node.
2. Secondary infections due to bronchial obstruction: Foreign bodies, tumors.
(III) Immune pestilence-associated disorders
1. Autoimmune diseases: Ulcerative colitis, Bi disease, lupus erythematosus, idiopathic fibrosing alveolitis, thyroiditis, pernicious anemia.
2. Allergic sexually transmitted disease: Bronchopulmonary mycosis.
(IV) Progression of bronchiectasis itself, recurrent or persistent infections.
Infection is the primary cause, with many cases of bronchiectasis originating from respiratory damage in early childhood. Patients often recall a history of lung diseases, such as pneumonia, whooping cough, measles, or subcutaneous nodules during their childhood.
Bronchial obstruction is a significant factor, but the ultimate cause may still be infection due to poor drainage and retained secretions after obstruction. The lung is sterile beyond the 6th to 7th level of bronchi in the absence of infection. Simple bronchial obstruction leading to atelectasis does not necessarily cause infection. For example, atelectasis following traumatic bronchial rupture may still resolve with healthy re-expansion years later after bronchial anastomosis. Peripheral small bronchial obstruction in children is a common change, and chest X-rays of whooping cough often show small areas of atelectasis. The bronchi in children are narrow and soft, making them prone to compression by enlarged lymph nodes. The most frequently affected is the right middle lobe bronchus, which is relatively narrow and forms an acute angle with the lower lobe. It is surrounded by lymph nodes above, below, and in front. When pulmonary inflammation occurs, enlarged lymph nodes compress the middle lobe bronchus, leading to complete or partial atelectasis or obstructive pneumonia, ultimately resulting in bronchiectasis due to bronchial wall destruction. After the inflammation subsides and the lymph nodes shrink, the middle lobe orifice may reopen, but the bronchiectasis and pneumonic changes are irreversible, forming the common "middle lobe syndrome."
bubble_chart Pathological Changes
The general changes of bronchiectasis: It involves medium-sized bronchi, approximately from the 4th to the 9th generations. The bronchiectatic areas are covered by squamous or columnar epithelium, often lacking cilia, and the surface may sometimes show no epithelium. Depending on the severity of the lesions, the bronchial walls exhibit varying degrees of atrophy, with destruction of the muscular and elastic layers, replaced by fibrous tissue. In some cases, only small amounts of muscle or cartilage remain. The walls are infiltrated with neutrophils, and in some cases, dense lymphocyte infiltration is present. Based on the extent of the lesions, small lateral bronchi and bronchioles may become disconnected, obstructed, or disappear (a result of inflammation). These changes of obliterative bronchitis are more damaging to lung function than the dilation itself. Morphologically, bronchiectasis is classified into three types: cylindrical, cystic, and mixed. Sometimes, two types coexist, such as cystic dilation in the lower lobe and cylindrical dilation in the lingular segment. The pathological changes in cylindrical bronchiectasis are milder, while those in cystic bronchiectasis are more severe. Cystic cavities can be seen macroscopically, connecting to the bronchi, with thin walls composed of fibrous or granulation tissue. Some are covered with metaplastic epithelium and contain retained mucoid material. The cysts in cystic bronchiectasis are filled with pus, indicating active infection. If no infection is present, only a small amount of mucous secretion remains, termed "dry bronchiectasis." Cases with chronic infection and persistent large amounts of mucous secretions are called "wet bronchiectasis."
Locations of bronchiectasis: More common in the left side and lower lobes, less common in the upper lobes, and moderately common in the middle lobe and lingular segment. The most frequent combination is the left lower lobe plus lingular segment involvement.
bubble_chart Clinical Manifestations
Bronchiectasis is more common in men than in women.
The symptoms of bronchiectasis vary greatly depending on the severity of the condition, whether it is stable or worsening, and the response to treatment, among other factors. Mild cases may be asymptomatic and only discovered during routine health check-ups. Severe cases involve persistent cough, copious mucopurulent or foul-smelling sputum, and patients may experience prolonged dyspnea and lack of strength. Due to the widespread use of antibiotics, patients with persistent severe symptoms are now rare, and many can maintain a certain level of health and work capacity. However, recurrent lung infections (often in the same location) are common, accompanied by chest discomfort, cough, and small amounts of purulent sputum, leading to a diminished quality of life and reduced work tolerance.
Chronic cough, sputum production, and hemoptysis are the main symptoms. Cough is most commonly persistent, caused by inflammatory irritation, primarily to expel sputum. Paroxysmal coughing occurs during morning sputum expulsion or postural drainage, and lying on the affected side in a lateral position can alleviate the cough. Cough worsens when the condition deteriorates and sputum production increases. Sputum production is related to the severity and extent of the lesions and whether the bronchial drainage is unobstructed. If the condition worsens, with fever or bronchial obstruction, sputum volume may decrease instead. Stable conditions may produce no sputum, resulting in "dry bronchiectasis." Mild cases may produce small amounts of yellow sputum daily, while severe cases can expel several hundred milliliters of sputum per day, which, upon standing, separates into an upper layer of foam, a middle layer of mucus, and a lower layer of yellow-green purulent clumps. Sputum may have a foul odor if anaerobic bacteria are present. Currently, due to the availability of various potent antibiotics, cases with copious purulent sputum are rare.
Due to chronic lung infections and recurrent exacerbations, systemic toxic symptoms such as low-grade fever, loss of appetite, weight loss, and anemia are common. In children, this can lead to growth retardation and malnutrition. If the lesions involve the pleura, pleuritis or empyema may occur, with chest pain being a frequent complaint. Repeated exacerbations can eventually destroy part or all of the lung, leading to cor pulmonale or even right heart failure. In the pre-antibiotic era, hematogenous spread of infection could cause brain abscesses, but this is now extremely rare. Associated symptoms include upper respiratory infections, sinusitis, and tonsillitis.
Signs: Early or mild bronchiectasis may show no positive signs. Generally, patients have persistent moist rales in the affected area, which temporarily disappear after coughing up sputum. If bilateral widespread dry rales are present, it suggests bronchiectasis complicated by bronchitis. Clubbing of fingers was reported in 44% of cases in 1994 but decreased to 7% 20 years later. Other complications present with corresponding signs.
The extent of pulmonary function impairment depends on the amount of damaged tissue. Grade I bronchiectasis often shows no abnormalities on examination, which is of little diagnostic significance but must be considered in surgical treatment.
(1) Symptoms
Highly suspect bronchiectasis if the following conditions are present:
1. Chronic bronchial infection symptoms, persistent purulent sputum, with or without a history of hemoptysis.
2. Simple recurrent hemoptysis.
3. Frequent fever, general malaise, chest pain, with or without sputum.
4. Localized or widespread lung moist rales, especially persistent localized moist rales, sometimes accompanied by wheezing.
5. Presence of clubbing fingers.
6. Accompanied by suppurative sinusitis.
(2) Chest X-ray examination
1. Chest plain film: This is the most basic X-ray examination. A small portion of bronchiectasis patients (less than 10%) show completely normal plain films, but upon careful reading, most plain films show some changes. However, these changes are often nonspecific and cannot provide a reliable diagnosis. A definitive diagnosis ultimately requires bronchography.
The pathological changes in bronchiectasis range from mild to severe and are very complex, involving the bronchi, lung parenchyma, and pleura. The chest film reflects the gross pathological anatomy, so the findings are also diverse.
(1) Due to chronic infection of the bronchial wall, wall thickening, and surrounding connective tissue hyperplasia, the lung markings in the affected area increase, thicken, and become disorganized, remaining prominent even to the outer lung zones. If the thickened walls contain air, parallel double thick lines may appear on the film, known as the "tram track sign." If there is pus retention, thick streaks or even club-shaped shadows may appear. Enlarged bronchi in cross-section appear as circular shadows, and when multiple small circles cluster together, a honeycomb pattern emerges. Large cystic dilatations may show multiple round or oval lucent areas, ranging from a few millimeters to 2–3 cm in size, with thickened lower walls resembling curly hair, also called the "signet ring sign." Fluid levels may sometimes be seen within the cysts.
(2) Bronchiectasis is often accompanied by lung parenchymal inflammation. During acute episodes, patchy shadows may appear locally. After acute infection subsides, small patches, nodules, and fibrosis often remain, leading to lung volume reduction and corresponding changes: lung markings converging, increased density, displacement of fissures, reduced and displaced hilar shadows, compensatory emphysema in unaffected areas, and ultimately atelectasis. Bilateral lower lobe atelectasis, if the volume is very small, may adhere to the mediastinum and be difficult to detect on plain films. Right upper lobe atelectasis may resemble mediastinal widening. Right middle lobe atelectasis may appear as a hazy shadow along the right heart border, sometimes indistinguishable from thickened oblique fissures on lateral films.
The left lower lobe is a common site for bronchiectasis. When the lower lobe volume shrinks, it may completely overlap with the cardiac shadow on plain films, leading to misdiagnosis. However, with lateral films and attention to changes in the left hilum and lung markings, it is not difficult to detect.
(3) Pleural changes: Bronchiectasis patients often experience recurrent lung infections, sometimes involving the pleura, causing inflammation and adhesions. Therefore, pleural changes are frequently seen on films. In cases of extensive and severe bronchiectasis, atelectasis, and fibrosis, thickened pleura may lead to dense shadows in one lung, diaphragmatic elevation, and mediastinal shift. Lucent areas of bronchiectasis may be visible within the dense shadows, forming the so-called "destroyed lung."
(4) Advanced-stage bronchiectasis may affect the heart, leading to pulmonary hypertension, with dilated pulmonary arteries at the hilum and fine peripheral lung markings. The cardiac shadow may also enlarge.
The common sites for bronchiectasis are the bilateral lower lobes, middle lobe, left lower lobe plus lingular segment, and right middle and lower lobes. Therefore, changes on chest films are often localized to these areas. With frontal and lateral films, the extent can be clearly defined. Even in cases of widespread bilateral bronchiectasis, some bronchi may remain normal.
Bronchiectasis caused by pulmonary tuberculosis typically occurs in the upper right lobe or left apical-posterior segment, common sites for tuberculosis. Tuberculosis must be severe to cause bronchiectasis, and fibrocaseous lesions may be visible on films. Before confirming the diagnosis, it is best to review all past chest films. If inflammation repeatedly occurs in a specific area, bronchiectasis may be present there.
2. Tomography Generally, bronchiectasis is not diagnosed solely based on tomography. Various pulmonary changes and dilated yet patent bronchi can be observed on routine posteroanterior or oblique radiographs, but the extent cannot be clearly defined. Current thin-section CT provides clearer visualization of bronchiectasis, yet it still cannot replace bronchography.
3. Bronchography can confirm the presence of bronchiectasis, the type of lesions, and their distribution. Since the procedure involves certain discomfort and risks, it is unnecessary for patients who are not surgical candidates and are only receiving medical treatment, as the management of bronchiectasis is similar to that of general pulmonary suppuration and does not require precise delineation of bronchial changes. Bronchography is essential only for those being considered for surgery or who may require surgery in the future, to establish a definitive diagnosis and determine the extent of lesions, thereby guiding surgical decision-making and approach.
As previously mentioned, bronchography is unnecessary for patients not being considered for surgery. However, in clinical practice, it can sometimes be difficult to determine the need for surgery without bronchography. The following scenarios, even with strong suspicion of bronchiectasis based on other tests, may not require or may temporarily defer bronchography: ① Bilateral extensive lesions on chest radiographs, clearly inoperable. ② Advanced age (e.g., over 50–60 years), generally not considered for surgery. ③ Poor cardiopulmonary function, rendering surgery unsuitable. ④ Mild symptoms, infrequent episodes, easily controlled inflammation, and no immediate surgical consideration—may defer the examination (though long-term, such patients should ideally undergo evaluation, as lesions may progress, and massive hemoptysis often occurs without obvious triggers; post-bronchography localization of bronchiectasis provides a basis for future surgery if needed). ⑤ Patient or family refusal of the procedure.
For surgical planning, bronchography should be performed bilaterally even if one side appears entirely normal on chest radiographs, given the high incidence of bilateral bronchiectasis. Whether bilateral imaging is completed in one session or split into two depends on the patient’s tolerance and the radiologist’s experience. Performing the procedure separately is technically simpler, better tolerated by the patient, and typically yields higher-quality images with no overlap, facilitating interpretation. Simultaneous bilateral imaging avoids the need for a repeat examination, and proper positioning during imaging ensures clear visualization of both sides. However, if anesthesia is inadequate or the patient cannot tolerate it, the planned bilateral procedure may be halted after completing one side.
For recent pulmonary infections, it is preferable to wait at least three months after resolution of pneumonia, as dilated bronchi may return to normal post-inflammation (historically termed "reversible bronchiectasis"). Patients with significant cough and sputum should receive medical treatment to reduce sputum before the procedure. During active bronchial inflammation, tolerance to contrast agents is poor; severe coughing may expel the contrast, compromising results, and frequent coughing during the procedure obscures observation. Excessive sputum can obstruct individual bronchi, leading to inadequate filling and indeterminate findings. Avoid bronchography during active hemoptysis to prevent massive bleeding. Patients with minor hemoptysis (e.g., a few blood-streaked sputum daily) that persists despite treatment may undergo the procedure, but those with major hemoptysis must wait at least two weeks after bleeding cessation.
Specific methods and precautions for bronchography:
Bronchography is typically performed by the radiology department, but the thoracic surgeon should ideally be present during the examination. Prior communication with radiology should highlight clinically significant areas of concern (e.g., the more affected side based on radiographs). The surgeon’s presence allows real-time observation of bronchial dynamics during the procedure. Understanding why certain bronchi fail to fill—whether due to insufficient contrast volume, improper positioning, loss of negative pressure in distal diseased bronchi preventing contrast uptake, inflamed and hypersensitive bronchi expelling contrast, or complete obstruction—aids in interpreting the images. The procedure carries risks such as anesthetic allergy, and the surgeon’s involvement facilitates patient monitoring and emergency response.
For a long time, 40% iodized oil has been used as a contrast agent. Because the oil agent is relatively thin, it quickly enters the small bronchi and is difficult to control. Sulfonamide powder needs to be added (5–10g per 20ml), with a bilateral dosage of 20–30ml. Iodopropanone is an aqueous suspension, which is easily coughed out after contrast imaging. Some also use meglumine diatrizoate mixed with sulfonamide powder. For iodine-based agents, an iodine allergy test must be conducted first. However, based on angiography experience, some so-called allergies may be caused by impurities in the agent, and high-quality contrast agents should be acceptable. In cases of iodine allergy, barium gelatin was used in the past, but it is best to avoid it. Once barium gelatin enters the lungs, it is difficult to expel and can produce numerous small granulomas in the lungs, significantly affecting pulmonary function.
Specific method: Fast for 4 hours before the contrast examination, and inject sedatives and antitussives before going to the contrast room. The patient first sits upright, and after anesthesia of the nasal cavity and throat, a thick rubber catheter is inserted through the nostril until slightly above the carina. Anesthetic is then injected to fully numb both bronchi. The patient then lies flat on the contrast table, adopting various positions such as head-low and limbs-high, left and right lateral positions, and oblique positions to allow the contrast agent to be injected into each bronchus. Under fluoroscopy, it is confirmed that each bronchus is filled up to the 5th–6th level, and then images are taken in different positions. For the right side, frontal and right lateral images are taken; for the left side, frontal and oblique images are taken; for both sides, frontal and bilateral oblique images are taken to avoid overlap. It is best to first perform fluoroscopic localization for spot imaging.
The contrast agent can also be injected using a specialized Metrass tube with a flexible tip, directed under fluoroscopy to specific bronchi for injection. Contrast injection via fiberoptic bronchoscopy is even better, as it allows for complete suction of bronchial secretions, observation of each bronchial orifice, and uniform injection of anesthetic. After the procedure, the contrast agent can be suctioned out. Note that the biopsy channel of the fiberoptic bronchoscope is very narrow, only 2.0–2.2 mm, making it difficult to quickly inject thicker contrast agents. Excessive injection may obscure the bronchoscope's objective lens, making visualization difficult. Therefore, the bronchus to be injected must be identified under fluoroscopy, and the bronchoscope should be cleaned immediately after the procedure to avoid damage.
After imaging, the catheter is removed, and the patient is instructed to cough lightly to expel the contrast agent. Upon returning to the ward, postural drainage is performed. Water-based contrast agents are rapidly expelled, while iodized oil may remain in the "alveoli" for an extended period, though it is usually completely expelled within a few days.
Some patients may experience fever for a few days post-procedure, requiring symptomatic treatment.
4. Notes on reading and analyzing bronchograms
(1) Compare with plain films and try to locate all previous chest films (as lesions often start from childhood "pneumonia"). Bronchiectasis is often found in areas of recurrent lung infections. On plain films, thickened and clustered lung markings and round lucent areas generally indicate bronchiectasis. If previous contrast films are available, even from several years ago, try to avoid repeat examinations, as contrast procedures are somewhat painful and bronchiectasis often begins in childhood. The bronchiectatic area may experience recurrent infections and pneumonia, but new bronchiectasis rarely develops in previously normal bronchi.
(2) First assess the quality of the contrast. Generally, filling should extend to the 5th–6th level bronchi or slightly further. The contrast agent should not enter the bronchioles or "alveoli," and there should not be excessive overlap in bilateral simultaneous contrast examinations. Normal bronchi should gradually taper from proximal to distal, with smooth edges.
(3) Carefully review bilateral contrast films, ensuring all branches are identified. If a branch is missing, investigate the reason—whether it is due to anatomical variation, technical issues with contrast filling, or pathological changes. In bronchography, the contrast agent is primarily drawn into the bronchial periphery by intrathoracic negative pressure. If the contrast dose is sufficient and an unfilled branch is suspected to have pathology, selective contrast via fiberoptic bronchoscopy should be performed.
(4) Check for stenosis at each orifice. If the distal bronchus is as wide as or wider than the proximal bronchus, bronchiectasis can be diagnosed. Cystic changes make the diagnosis even clearer. Associated changes include clustered bronchi, reduced lung volume, and compensatory emphysema in normal lungs, where the bronchi are more dispersed.
(III) Fiberoptic bronchoscopy
Fiberoptic bronchoscopy is generally not required for diagnosing bronchiectasis, but it is indicated in the following situations:
1. To rule out bronchiectasis caused by foreign body obstruction. Elderly, weak, pediatric, psychiatric, anesthetized, or sedated patients may unknowingly inhale foreign bodies. Long-term foreign body obstruction can lead to bronchiectasis, which may resolve after removal.
2. To assess the presence of endobronchial tumors: Lung cancer progresses rapidly, causing obstructive pneumonia or atelectasis in a short time. Benign tumors or polyps grow slowly and may cause long-term obstruction leading to dilation.
3. For patients with a large amount of purulent sputum and poor response to postural drainage and drug therapy, bronchoscopy can help identify the source of the purulent sputum, clarify the lesion location, determine the appropriate position for postural drainage, and facilitate rapid improvement through sputum suction and drug administration (such as antibiotics, bronchodilators like Ephedrine, etc.), thereby preparing the patient for surgery.
4. For massive hemoptysis, bronchial artery embolization should be performed to occlude the bleeding vessels. If the volume of hemoptysis is too large, pre-embolization examination may be risky. Examination can be conducted immediately after embolization, while blood traces remain in the bronchi, to verify whether the embolized site is appropriate.
5. If bronchography results are unsatisfactory, such as poor or absent filling of certain branches, fiberoptic bronchoscopy can identify whether the issue stems from technical problems during contrast imaging or other causes, such as mucus, tumors, granulation tissue obstruction, or scar formation at the opening. Selective angiography of the affected branch may be performed as needed (by injecting contrast agent through the biopsy channel of the fiberoptic bronchoscope).
6. For recurrent hemoptysis or increased purulent sputum after bronchiectasis surgery, examine the bronchial stump for granulation tissue, suture remnants, ulcers, etc., and identify the source of bleeding to guide further treatment.
7. If a specific infection, such as fungal infection, is suspected, fiberoptic bronchoscopy can be used to collect secretions from the distal bronchi for examination, avoiding contamination by respiratory tract secretions.
(4) Pulmonary Function and Radionuclide Studies
Pulmonary function tests: Include ventilation, gas exchange, and blood gas analyses. For patients undergoing medical treatment, repeated tests allow comparison to evaluate treatment efficacy and prognosis. For those considered for surgical treatment, these tests assess tolerance to surgery, aid in better surgical planning, and serve as benchmarks for evaluating postoperative outcomes.
Radionuclide scanning: Evaluates bilateral pulmonary blood perfusion, aiding in decisions regarding resection methods and predicting postoperative outcomes. When lung disease is present, pulmonary artery thrombosis is common. In cases of unilateral destroyed lung, the pulmonary artery may be obstructed at the main trunk. Resecting lung tissue with no blood perfusion is expected to yield better postoperative recovery.
bubble_chart Treatment Measures
The condition of bronchiectasis is complex, with varying symptoms and significant differences in severity. Determining the treatment plan requires consideration of multiple factors:
1. Presence and severity of symptoms, history of recurrent pulmonary infections, frequency of episodes, and treatment efficacy. If symptoms are mild and infections are easily controlled, medical treatment may suffice; otherwise, surgery should be considered.
2. History of hemoptysis. This must be emphasized, as some cases of so-called "dry bronchiectasis" may show few pulmonary infection symptoms but can suddenly lead to hemoptysis. Bronchiectasis is a benign disease, and with the availability of various antibiotics today, most infections can be controlled, allowing patients to survive for many years. However, massive hemoptysis is life-threatening. Although emergency bronchial artery embolization is now available, from a long-term perspective, patients with massive or recurrent hemoptysis are best treated surgically.
3. Extent of lesions. This is one of the most critical factors in deciding between medical and surgical treatment. Localized lesions can be resected. If lesions are more widespread but vary in severity, with some areas being mild and others severe, resection of the more severe lesions may provide palliative relief. However, if lesions are bilateral and similarly severe, surgery is not an option.
4. Age. Some case analyses suggest that patients over 40 often experience disease remission, with few cases progressing further. Patients over 50 generally have poorer physical condition, comorbidities, and lower tolerance for surgery. Therefore, a more conservative approach to surgery is advisable for patients aged 40–50 and above.
5. Presence of other associated conditions. For example, if bronchiectasis is caused by obstruction from a benign tumor, resection primarily targets the tumor. For bronchiectasis due to pulmonary subcutaneous nodules (often in the upper lobe), the nodular lesions are usually stable and do not require surgery.
6. General health and comorbidities. Patients with severe systemic diseases (e.g., heart, liver, or kidney conditions) or poor cardiopulmonary function who cannot tolerate surgery should only receive medical treatment.
7. Living, working, and medical conditions. If living and medical conditions are good, and work is not overly strenuous, conservative treatment can often maintain disease stability. However, for those engaged in outdoor labor, physically demanding jobs, or students with limited medical access, surgical resection is preferable if disease progression is difficult to manage.
8. Patient and family consent for surgery. Bronchiectasis typically begins in childhood, and both bronchial and lung parenchymal lesions are irreversible. Repeated exacerbations significantly impair quality of life and work capacity. If feasible, resection is ideal. However, with the continuous emergence of new antibiotics, many cases can now be maintained in a "stable state," reducing the need for surgery. Nevertheless, it is incorrect to assume surgery is never necessary. Given that thoracic surgery has become relatively safe and effective, each patient’s case should be individually evaluated to weigh the pros and cons.
Treatment for bronchiectasis includes several components: ① Antibiotics for infection control. ② Treatment of underlying conditions causing bronchiectasis, such as sinusitis. ③ Symptomatic treatment for issues like hemoptysis and excessive purulent sputum. ④ Surgical resection or lung transplantation. ⑤ Respiratory training and physical therapy to improve quality of life and work capacity—often overlooked by clinicians. ⑥ Special cases, such as bronchiectasis due to immunodeficiency or congenital genetic diseases. If the underlying cause cannot be corrected, only general medical treatment is possible.
Medical treatment is the foundation. Even for cases with clear surgical indications, a period of medical treatment is necessary first—some recommend at least six months, as some bronchiectasis cases may normalize after infection control. Surgery is also safer and more effective after acute inflammation subsides. For inoperable cases, long-term medical treatment is required.
(1) Medical Treatment of Bronchiectasis
1. Control infection and alleviate symptoms. Bronchiectasis is a lifelong disease if not surgically treated, with symptoms that come and go, sometimes mild and sometimes severe. Internal medicine treatment should consider when to use medication, what medication to use, and how to use it (dose, route, and duration). If there is no fever, cough has not worsened, and there is only sticky sputum with no significant discomfort for the patient, antibiotics are unnecessary. If the sputum becomes purulent (often after an upper respiratory infection), broad-spectrum antibiotics should be used at standard doses for at least 1–2 weeks until the sputum turns mucoid. Yellow-green purulent sputum indicates progressing inflammation and ongoing lung damage, requiring aggressive medication, but converting the sputum to mucoid is difficult. If the condition has been "stable" but suddenly worsens, aggressive treatment is also needed. For those who frequently have mucopurulent sputum, the effectiveness of antibiotics is questionable. The choice of antibiotics relies on experience and the patient's response to treatment, as sputum culture and drug sensitivity tests are not entirely reliable. In acute infections like pneumonia, tissue congestion leads to high antibiotic concentrations in the lungs and blood, resulting in good efficacy. Chronic suppurative sexually transmitted disease lesions respond poorly to drugs, possibly due to: ① Antibiotics failing to penetrate the bronchial wall into the lumen, while bacteria thrive in the purulent secretions within the lumen. ② Bacteria being inherently insensitive to the drugs, and anaerobic bacteria (causing foul-smelling sputum) also resisting the medication.
There is disagreement regarding the duration of medication. Some believe that a 2-week course is sufficient for effectiveness, while others advocate for 6–10 months of treatment to reduce lung damage from inflammation and prevent fibrosis. Research in this area remains limited. Since the vast majority of cases seen clinically are chronic sexually transmitted diseases, long-term medication cannot prevent lung damage, and treatment can be discontinued once symptoms resolve.
2. Postural Drainage Bronchiectasis often occurs in the dependent parts of the lungs, where drainage is poor. While healthy individuals rely on coughing to expel mucus, patients with bronchiectasis have damaged bronchial cartilage and impaired mucus clearance mechanisms, making coughing ineffective for complete mucus expulsion. X-ray examinations reveal that coughing causes complete collapse of the proximal bronchi, trapping mucus. Therefore, postural drainage utilizing gravity is recommended to direct peripheral mucus toward the larger bronchi near the hilum for easier expulsion. Based on the orientation of the bronchi, the patient should assume the appropriate position, take deep breaths, and cough out the mucus after 10–15 minutes. This should be performed several times a day, combined with chest percussion and other physiotherapy methods. For patients producing more than 30ml of mucus daily, drainage should be done both morning and evening.
3. Treatment of Hemoptysis Hemoptysis is a common symptom of bronchiectasis and a major life-threatening complication. It often occurs without clear triggers and may not correlate with other symptoms such as fever or purulent sputum. Minor hemoptysis can usually be controlled with rest, sedatives, and hemostatic agents. For massive hemoptysis, bronchial artery embolization may be performed. Bronchoscopy (preferably rigid) can be used to apply ice water locally or to occlude the bleeding site with gauze strips or a Fogarty catheter.
4. Other Therapies During acute infections, rest, nutrition, and supportive care are essential. Bronchodilators may be beneficial if pulmonary function tests show airway obstruction and improvement in FEV1 after administration. If no improvement is observed, a trial of prednisone may be considered, but it should be discontinued if subjective symptoms do not improve. In rare cases involving immunosuppression, human immunoglobulin may be used.
（II）Surgical Treatment
1. Surgical Indications
（1）Localized lesions with significant symptoms or recurrent pulmonary infections are the primary indications. Complete resection of the affected lung tissue can yield excellent outcomes.
（2）Bilateral involvement with severe disease on one side and mild disease on the other, where symptoms primarily arise from the severely affected side. The severely affected side can be resected, and if symptoms persist on the contralateral side, medical therapy can be pursued.
（3）Bilateral localized severe lesions, such as those presenting with massive hemoptysis. The more severely affected side should be resected first. If the contralateral lesions remain stable, observation and medical therapy are advised. If progression occurs, resection may be reconsidered.
(4) Emergency resection for massive hemoptysis. Currently, bronchial artery embolization is available, and most cases can first be managed with this method to stop bleeding before converting to elective surgery. For patients who previously underwent bronchial angiography with clearly identified lesions, emergency resection for hemoptysis can also be performed given current technical capabilities. However, if no prior bronchial angiography was performed and the lesion location and extent are unknown, the surgery becomes very difficult. Some determine the resection approach based on signs (such as rales on auscultation), chest X-rays, and incidental findings from bronchoscopy, but this is not very reliable. Fiberoptic bronchoscopy can visualize the bleeding source, but when hemoptysis is severe, the examination carries risks. Once the bronchoscope is inserted, the lens may quickly become contaminated, rendering visualization impossible. If the bronchial tree is filled with blood everywhere, or if no specific bronchus is seen gushing blood shortly after suctioning, localization becomes impossible. Sometimes blood is observed in the main bronchus, but this does not necessarily indicate lesions throughout one lung. The bronchial lumen is very small, and the bronchial wall is lubricated by secretions, so after bleeding, blood easily flows to lower positions (such as the dorsal segment of the lower lobe or the entire lower lobe in a supine position), leading to misjudgment. In summary, unless absolutely necessary, emergency lung resection is best avoided due to the high technical demands of anesthesia. After thoracotomy, it is sometimes found that most of the lung is filled with blood, appearing purplish-red, making it impossible to determine the resection boundaries, potentially resulting in excessive tissue removal. After lung resection, the remaining lung may expand poorly or become infected due to aspirated blood, leading to higher complication and mortality rates for emergency surgeries.
(5) For patients with extensive bilateral lesions, deteriorating general condition and pulmonary function, ineffective medical treatment, estimated survival time not exceeding 1–2 years, and age under 55, bilateral lung transplantation may be considered. Human allogeneic lung transplantation was successfully performed in 1983, and by 1998, over 8,000 cases had been conducted worldwide, with bronchiectasis accounting for a certain proportion of the indications. The one-year survival rate can reach 79–90%, which is quite satisfactory for a patient on the verge of death.
2. Surgical Plan Design
(1) If the lesion is localized and other areas are normal, a segment to the entire lung can be resected. The most common resections are the left lower lobe plus the lingular segment, or the left or right lower lobe and the right middle lobe.
(2) It is not uncommon for the basal segments of the lower lobe to be affected while the dorsal segment remains normal, in which case the dorsal segment can be preserved. However, even if not all basal segments are involved, resection of a single basal segment is generally not performed because the boundaries between segments are unclear, each basal segment is small in volume, forced separation yields limited preserved lung function, and complications significantly increase.
(3) If the superior lingular segment is unaffected, resection of the inferior lingular segment alone can be performed.
(4) For bilateral lesions that are both relatively localized, in young patients with good general condition, simultaneous resection in one operation can be performed using a bilateral anterior thoracotomy or sequential bilateral lateral thoracotomy. If the general condition does not permit, one side can be operated first, and the contralateral side can be addressed 3–6 months later, with the interval determined by the patient’s physical recovery. In some cases, due to complications or significant pulmonary function impairment on the operated side, the contralateral surgery may ultimately not be feasible.
Bilateral bronchiectasis is not uncommon: for example, in cases of massive hemoptysis or recurrent lung infections, treatment is challenging. Since bronchiectasis often begins in childhood, as long as sufficient normal lung tissue can be preserved, staged resections can be performed. There are reports in the literature of three-stage surgeries, ultimately leaving only the left upper lobe and right upper lobe, totaling eight lung segments. Due to the lung’s vast respiratory reserve, even this amount of lung tissue can sustain normal life. The key is to proceed cautiously with each surgery, ensuring no complications occur.
The extent of lung tissue resected in bronchiectasis is entirely based on preoperative bronchography findings. Intraoperative thoracotomy exploration provides only supplementary information. In a significant number of patients, the lung appears normal externally, and palpation reveals no abnormalities, making it impossible to determine the extent of the lesion. Intraoperative pathological changes range from severe to mild, including reduced lung volume, atelectasis, or consolidation; small focal lesions in the lung parenchyma; or lungs with markedly reduced pigmentation, appearing pink and emphysematous, possibly due to childhood illness without respiratory ventilation or inhalation of external dust. Lesions involving the pleura may show adhesions. The hilum almost always shows signs of past inflammation, with enlarged lymph nodes and dense adhesions between tissues. The ipsilateral normal lung often exhibits compensatory emphysema. These intraoperative findings all influence the surgical plan. For example, after resection of the left upper lingular segment and lower lobe, if the remaining lung tissue is unhealthy and minimal in volume, leaving a large residual cavity, a pneumonectomy may sometimes be necessary to avoid severe complications.
3. Preoperative Preparation
(1) Routine laboratory tests, with special attention to sputum culture and drug sensitivity tests.
(2) Pulmonary function tests, blood gas analysis, nuclear imaging, and lung perfusion studies.
(3) Nutritional improvement.
(4) For patients with copious sputum, appropriate antibiotics should be administered. Ideally, surgery should be performed when sputum volume decreases to below 30ml/day and transitions from purulent to mucoid. Antibiotic therapy may need to be prolonged for over two weeks.
(5) Postural drainage for patients with excessive sputum.
(6) Respiratory training and physiotherapy to improve pulmonary function.
(7) If bronchography was recently performed using iodized oil, surgery should be delayed until the oil is cleared. This usually takes a few days, but in some cases, the oil may enter the bronchioles or alveoli and remain for an extended period, making waiting impractical. From a pulmonary function perspective, surgery three days after bronchography has no significant impact.
4. Residual Symptoms After Bronchiectasis Resection: Reasons Include:
(1) Bilateral bronchography with contrast showed poor filling in some branches, which were not identified, leading to incomplete surgical resection and residual bronchiectasis with symptoms.
(2) Originally a bilateral lesion, only the more severely affected side was resected, while the less affected side still had bronchiectasis.
(3) After partial lung resection on one side, the remaining lung overexpands, leading to bronchial distortion, poor drainage, infection, and even the formation of new bronchiectasis.
(4) After lung resection, if the bronchial stump is left too long, secretions may accumulate, or if there is suture irritation at the stump, granulation tissue may form, resulting in cough and hemoptysis.
(5) Underlying factors contributing to bronchiectasis, such as chronic sinusitis, chronic bronchitis, or immune-related defects, were not addressed.
(6) There may be an occult bronchial fistula, where the bronchial stump communicates with a small abscess cavity. Postoperative cough with yellow sputum may sometimes be due to general respiratory infections and not necessarily related to the original bronchiectasis or surgery. Recurrent hemoptysis, even massive hemoptysis, is occasionally observed after partial lung resection for bronchiectasis. Bronchoscopy often shows a normal bronchial stump, and imaging of the remaining lung may not reveal residual bronchiectasis. We have achieved excellent results using bronchial artery embolization for treatment. Pre-embolization bronchial artery angiography often shows localized hypertrophy of vessels near the hilum, sometimes forming clusters or masses, the cause of which remains to be explored. If embolization fails and other conditions permit, the remaining lung tissue may be resected.
5. Surgical outcomes are closely related to the selection of indications. With strict criteria, the surgical mortality rate is <1%. In experienced centers, there is virtually no surgical mortality. Postoperatively, 80% of patients experience complete resolution of symptoms, 15% show improvement with residual symptoms, and 5% show no improvement or worsening. The relationship between symptom improvement and surgery is sometimes difficult to determine, as some conditions in the remaining lung causing symptoms may have been present preoperatively but were not amenable to surgical treatment.
6. Some issues related to anesthesia and surgery: Double-lumen endotracheal intubation is preferred for anesthesia. Even in patients with minimal preoperative sputum, intraoperative lung manipulation may lead to a sudden outpouring of purulent sputum. Single-lumen intubation may not allow adequate suction, and frequent suctioning can interfere with ventilation. In patients with hemoptysis, double-lumen intubation prevents blood from entering the contralateral side and aids in localizing the bleeding. Once the bronchus of the affected lung is clamped, no further blood should be aspirated. Persistent bleeding suggests hemorrhage from another site.
In pediatric or female patients with smaller airways where double-lumen intubation is not feasible, the prone position may be considered to facilitate sputum drainage. Alternatively, single-lumen intubation can be directed to one side and withdrawn into the main bronchus after clamping the affected bronchus intraoperatively. If the disease involves the pleura with dense adhesions, there are often systemic-pulmonary vascular collaterals, and careful hemostasis and ligation are required during dissection.
In bronchiectasis, pleural adhesions may be absent, but due to recurrent infections, the hilum often has dense, even scar-like adhesions, with various anatomical structures and lymph nodes fused together, leaving no loose connective tissue layer. The degree of bronchial artery dilation and tortuosity in bronchiectasis is among the most severe in common pulmonary diseases. Normally, bronchial artery diameter at the hilum rarely exceeds 1–2 mm, but in bronchiectasis patients, it can reach 5–6 mm based on our extensive bronchial artery angiograms. Special care is needed during hilar dissection. If feasible, the bronchial artery should be ligated at its origin from the main artery (approximately at the level of T5 and T6), or the surrounding soft tissue should be suture-ligated first. In cases of severe hilar adhesions, dissection may start peripherally, leaving the hilar structures to the end. The bronchus, being firm and easily identifiable, can be transected and sutured once the lumen is visualized. Adjacent vessels can be ligated in bundles to avoid injury to vessels of the lung intended for preservation.
Regarding the prognosis of bronchiectasis, there are many reports, but opinions vary greatly due to differences in patient conditions and treatment methods across regions. The natural history of bronchiectasis varies significantly.
The prognosis of bronchiectasis is difficult to estimate, but some observational conclusions have been drawn: ① Bronchiectasis is the final pathological outcome of many different etiologies, and the prognosis varies depending on the underlying disease. For example, cases caused by subcutaneous nodules tend to have a better outcome, while hereditary cystic fibrosis still has a high mortality rate. ② Extensive lesions have a poor prognosis, and worsening conditions are sometimes accompanied by lung heart disease, ultimately leading to death. ③ The use of broad-spectrum antibiotics has significantly reduced bronchiectasis cases in children's hospitals. ④ Although symptoms may gradually improve, chest X-rays may show disease progression. ⑤ The evaluation of surgical treatment outcomes is quite subjective, as surgical criteria vary, follow-up durations differ, and outcomes range from 50% of patients being completely asymptomatic post-operation to 75% showing improvement or significant relief.
To further improve prognosis, it is necessary to rely on a deeper understanding of the disease mechanism, identify the causes of idiopathic bronchiectasis, enhance the management of bronchiectasis caused by specific factors (such as immunodeficiency), and develop methods to prevent bronchiectasis in "high-risk" populations.
