الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Bronchiectasis is still a problem in some developing countries. Bronchiectasis is one of the most important causes of hemoptysis, and source of hemoptysis may be bronchial or non bronchial arteries.
In cases of bronchiectasis, blood circulation in the bronchi can increase and may represent as much as 30% of cardiac output. Enlargement of the bronchial vessels is associated with the development of granulation tissue during the course of the inflammatory changes in the wall. In patients with chronic pulmonary parenchymal inflammation, preexisting connections between the bronchial and pulmonary arteries become functional at the pre- and postcapillary levels, often creating a source of hemoptysis.
The current thesis aimed to study the vascular changes that occur in bronchiectasis using MDCTA, arterial blood gases, and pulmonary function tests in 25 patients, 14 of them were with hemoptysis (3 were with frank hemoptysis) & 11 patients were without hemoptysis.
All studied patients were submitted to: complete history taking, full clinical examination, routine laboratory workup, MDCTA to study bronchial arteries, pulmonary function tests, arterial blood gases both on room air & on 100% oxygen, to calculate shunt fraction, and bubble contrast echocardiography to detect I-P shunt.
Statistical analysis of the anthropometric parameters revealed the following
- Mean age in the studied patients was 41.7±16.44 years, there was insignificant difference between patients with hemoptysis & those without hemoptysis as regard age.
- There was female predominance in the studied patients (56%), there was insignificant difference between patients with hemoptysis & those without hemoptysis.
- Mean age of onset was 29.64±15.80 years, there was insignificant difference between group of patients with hemoptysis & those without hemoptysis.
- Mean BMI was 21.90±4.39 Kg/m2, there was insignificant difference between both groups as regard the BMI, and there were insignificant correlations between BMI and the extent, severity and combined score of bronchiectasis per patient.
Study of bronchial arteries by MDCTA revealed the following
- There were 57 bronchial arteries detected by MDCTA, 30 were right sided, while 27 were left. There was insignificant difference, between patients with hemoptysis, and those without hemoptysis as regard the side of bronchial arteries.
- Forty-eight (84.2%) bronchial arteries arose from the descending aorta at levels of T5-T7 (45.6% from descending aorta at the level of T6-T7, 38.6% at the level of T5-T6), and 9 (15.8%) bronchial arteries arose from the aortic arch. There was insignificant difference between both groups as regard the level of origin.
- Thirty-seven out of 57(64.9%) bronchial arteries (21 right and 16 left) were traceable from their origin to the hilum. There was significant difference, between both groups as regard the traceability.
- This implies that MDCTA provides information to guide selection of the bronchial arteries (arteries of traceability) in the interventional procedure.
- The diameter of the studied bronchial arteries ranged from 1.3mm to 4.5mm (average 2.28mm). Bronchial artery diameter was significantly larger in patients with hemoptysis than patients without hemoptysis.
- These results implicate that dilated bronchial arteries, may be a source of hemoptysis. Therefore, in a patient who had an episode of hemoptysis, knowledge that the bronchial artery is enlarged is a useful information for diagnosis & treatment planning.
- In the present study, there were peribronchial collaterals only in 2 cases (patient number 7 & 12). Both patients, were with blood streaked sputum, shunt fraction was 20.1% and 17.4% respectively and bubble contrast echo was negative in both.
Study of lung parenchyma by MDCTA revealed the following
- Both lungs were divided into 6 lobes, each lobe could have a maximum score of 3 (0, 1, 2, 3) for the extent and severity, then the patients were assessed, and a maximum possible score was 6 x 3 =18. Then combined score (severity & extent) was calculated out of 36.
- As regard the extent of bronchiectasis, score 3 was the most frequent (56.6%), followed by score 2 (20%). There was insignificant difference, between both groups as regard the extent of bronchiectasis.
- As regard the severity of bronchiectasis, score 3 (cystic) was the most frequent (62%), followed by score 2 (15.3%). There was insignificant difference, between patients with hemoptysis, and those without hemoptysis.
- There was significant correlation, between severity score & extent of bronchiectasis per lobe by MDCTA.
- There was insignificant correlation, between extent of bronchiectasis & shunt fraction, but there was significant correlation, between severity, combined score per patient and shunt fraction.
These significant correlation between shunt fraction and severity of bronchiectasis, implicates that local vascular changes occurring with bronchiectasis, related to severity (type) and combined score (severity & extent).
Plain chest X-ray revealed the following
- Crowding of bronchovascular markings & peribronchial infiltration were the most frequent findings (92%) in chest X-ray.
- There was insignificant correlation, between severity of bronchiectasis by MDCTA and honeycomb appearance in X-ray, but there was significant correlation between severity of bronchiectasis by MDCTA and the peribronchial infiltration in X-ray.
Pulmonary function tests revealed the following
- There were 11(44%) patients with restrictive pattern, 8(32%) patients with obstructive pattern, 5(20%) patients with mixed pattern, and 1(4%) patient was with normal pulmonary functions.
- There were insignificant differences between patients with hemoptysis and those without hemoptysis, as regard FVC%, FEV1%, FEV1/FVC, MMF, and MVV.
- There were insignificant correlations, between FVC or FVC% and severity, extent, and combined score of bronchiectasis per patient, but there were significant correlations between FEV1% and extent, severity and combined score per patient.
- There were insignificant correlations between FVC%, FEV1% and shunt fraction
- These results imply that local vascular changes that occur in bronchiectasis, are related to shunt fraction and to the severity of bronchiectasis.
Arterial blood gases analysis on room air & on 100% oxygen revealed the following
- There was significant difference between patients with hemoptysis, and those without hemoptysis, as regard shunt fraction.
- There was significant negative correlation between PaO2 & shunt fraction, denoting that main cause of hypoxia in bronchiectatic patients in current study was the presence of I-P shunts.
- The great majority of patients with hemoptysis were hypoxic on room air, this can explain the significant difference between patients with hemoptysis, and those without hemoptysis, as regard PaO2-predicted for age.
- There was significant correlation between shunt fraction & diameter of bronchial artery. These results reinforce the hypothesis of budding capillaries in the granulation tissue of areas with organizing pneumonitis, thus increasing the capillary bed supplied by the bronchial arteries, leading to increased flow and hypertrophy & opening of bronchial to pulmonary artery communications.
- There was significant correlation between, shunt fraction & PaO2- PaO2 predicted for age, implying that the main cause of hypoxia in the present study was I-P shunt.
- There were significant correlations between shunt fraction, PaO2, PaO2-predicted for age and severity and combined score per patient.
Bubble contrast echocardiography revealed the following
- There were only 4 positive cases (28.6%) by bubble contrast echo, in one of them, bubble contrast revealed intracardiac shunt. The shunt fraction of these patients was more than 5% of COP.
- These results suggest that, positive bubble contrast echo is predictive for the presence of intrapulmonary shunts, but the test has low sensitivity for detection of shunt.
- There was significant difference between patients with hemoptysis, and those without hemoptysis as regards corpulmonale as detected by echo. The possible aetiological culprits for the development of corpulmonale in patients with bronchiectasis are shunts (as seen in most of patients in the present study) leading to RT ventricular volume overload, also hypoxic pulmonary vasoconstriction increasing the pulmonary vascular resistance.
Electrocardiogram (ECG) revealed the following
- Peaked P wave (P pulmonale) & right axis deviation were the most frequent (60%) ECG findings.
- There was insignificant difference between patients with hemoptysis & those without hemoptysis, as regard P pulmonale. Also there was insignificant difference, between patients with shunt & those without shunt, as regard P pulmonale.
Clubbing
- The higher incidence of clubbing in patients with shunt (as seen in the present study) rather than patients without shunt might suggest that local vascular changes contribute to genesis of clubbing in bronchiectasis