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INTRODUCTION

Bronchiectasis is an abnormal, chronic enlargement of the bronchi, the passageways
from the trachea to the alveoli that are the air-exchanging parts of the lungs.
Bronchiectasis generally occurs as a result of infection, although noninfectious
factors may contribute to the development of this condition. Accompanying the
enlargement of the bronchi is their decreased ability to clear secretions.
Failure to clear secretions allows microbes and particles to collect in them, which
leads to more secretions and inflammation that further damage the airways, causing
more dilation in a vicious cycle.
Bronchiectasis can be categorized as a chronic obstructive pulmonary lung disease
manifested by airways that are inflamed and easily collapsible, resulting in air flow
obstruction with shortness of breath, impaired clearance of secretions often with
disabling cough, and occasionally hemoptysis. Severe cases can result in progressive
impairment with respiratory failure
Bronchiectasis most often presents as (1) a focal process involving a lobe, segment,
or subsegment of the lung or (2) a diffuse process involving both lungs. The former is
by far the most common presentation of bronchiectasis, while the latter is most often
associated with systemic illnesses, such as cystic fibrosis (CF), sinopulmonary
disease, or both.
Diagnosis is usually based on a compatible clinical history of chronic respiratory
symptoms, such as daily cough and viscid sputum production, and characteristic
radiographic findings on CT scans, such as bronchial wall thickening and luminal
dilatation.

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Epidemiology

The prevalence of bronchiectasis is unknown largely because the
symptoms are variable and the diagnosis is often not made.

In the pre-antibiotic era, it was estimated to be as common as or more
common than tuberculosis and to be present in 92 percent of cases of
chronic bronchitis.

It occurs in every age group and, in the pre-antibiotic era, it most often
began in childhood .

Among all ages, it has been estimated that about 25 people per 100,000
have bronchiectasis,but this number increases to 272 per 100,000 for those
over 74 years old.

Cases of bronchiectasis are more common in women than men, especially
when it is of unknown cause.

A wide range of causes of bronchiectasis has been reported in adults, but
for more than half of the cases, there is no known cause or association.

It is estimated that between 30 and 35 percent of cases follow a lung
infection that damages the bronchi for the first time .

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DEFINITION
o Bronchiectasis is a condition that is characterized by the permanent dilatation of
the bronchi associated with destruction of elastic and muscular components of
their walls, usually due to chronic infection.
o Bronchiectasis is chronic dilatation of bronchi with impaired drainage of
bronchial secretions leading to persistent infection of the affected segments or
lobes.
o Bronchiectasis is persistent and irreversible dilation and distortion of medium
sized bronchi (5th to 9th generation) by more than 2
o Bronchiectasis is a condition in which damage to the airways causes them to
widen and become flabby and scarred. The airways are tubes that carry air in and
out of your lungs.
o The anatomic distortion of a conducting bronchi, often with permanent dilation
due to elastic and muscular damage to the epithelium, results in bronchiectasis.

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three borders. Each lung is conical in shape. The substance of the lung is of a light. above the level of the sternal end of the first rib. shining. their proportion to the body being. A sulcus produced by the subclavian artery as it curves in front of the pleura runs upward and lateralward immediately below the apex. The apex (apex pulmonis) is rounded.5 to 4 cm. and two surfaces. The lungs are heavier in the male than in the female. in the latter as 1 to 43. and crepitates when handled.. a base. and extends into the root of the neck. indicating the lobules of the organ: each of these areas is crossed by numerous lighter lines.ANATOMY The lungs are the essential organs of respiration they are two in number. but much variation is met with according to the amount of blood or serous fluid they may contain. and marked out into numerous polyhedral areas.. and presents for apex. placed one on either side within the thorax. and separated from each other by the heart and other contents of the mediastinum. owing to the presence of air in the alveoli it is also highly elastic hence the retracted state of these organs when they are removed from the closed cavity of the thorax. as 1 to 37. The right lung usually weighs about 625 gm. porous. reaching from 2. spongy texture it floats in water. the left 567 gm. The surface is smooth. in the former. 4 .

It is in contact with the costal pleura. and the left lung from the left lobe of the liver. the concavity on the base of the right lung is deeper than that on the left. The base of the lung descends during inspiration and ascends during expiration. and presents. being deeper behind than in front. the base is bounded by a thin. concave. Since the diaphragm extends higher on the right than on the left side. between the lower ribs and the costal attachment of the diaphragm. slight grooves corresponding with the overlying ribs. which separates the right lung from the right lobe of the liver. 5 . Laterally and behind. the stomach. convex. of considerable extent. and rests upon the convex surface of the diaphragm. in specimens which have been hardened in situ.—The costal surface (facies costalis external or thoracic surface) is smooth. sharp margin which projects for some distance into the phrenicocostal sinus of the pleura.The base (basis pulmonis) is broad. and the spleen. and corresponds to the form of the cavity of the chest. Surfaces.

the cardiac impression. which accommodates the pericardium. this is larger and deeper on the left than on the right lung. 6 . where the structures which form the root of the lung enter and leave the viscus. inner surface) is in contact with the mediastinal pleura. Above and behind this concavity is a triangular depression named the hilum. It presents a deep concavity. on account of the heart projecting farther to the left than to the right side of the median plane.The mediastinal surface (facies mediastinalis.

Opposite this notch the anterior margin of the left lung is situated some little distance lateral to the line of reflection of the corresponding part of the pleura. the cardiac notch. and is received into the deep concavity on either side of the vertebral column. below. and projects into the costomediastinal sinus.Borders. in which the pericardium is exposed. and overlaps the front of the pericardium. The anterior border (margo anterior) is thin and sharp. an angular notch. The posterior border (margo posterior) is broad and rounded. into the phrenicocostal sinus. The anterior border of the right lung is almost vertical. 7 .—The inferior border (margo inferior) is thin and sharp where it separates the base from the costal surface and extends into the phrenicocostal sinus medially where it divides the base from the mediastinal surface it is blunt and rounded. that of the left presents. below. It is much longer than the anterior border. and projects.

Fissures and Lobes of the Lungs .—The left lung is divided into two lobes, an
upper and a lower, by an interlobular fissure, which extends from the costal to the
mediastinal surface of the lung both above and below the hilus. As seen on the
surface, this fissure begins on the mediastinal surface of the lung at the upper and
posterior part of the hilus, and runs backward and upward to the posterior border,
which it crosses at a point about 6 cm. below the apex. It then extends downward
and forward over the costal surface, and reaches the lower border a little behind its
anterior extremity, and its further course can be followed upward and backward
across the mediastinal surface as far as the lower part of the hilus. The superior lobe
lies above and in front of this fissure, and includes the apex, the anterior border,
and a considerable part of the costal surface and the greater part of the mediastinal
surface of the lung. The inferior lobe, the larger of the two, is situated below and
behind the fissure, and comprises almost the whole of the base, a large portion of
the costal surface, and the greater part of the posterior border other fissure separates
the superior from the middle lobe. It begins in the previous fissure near the
posterior border of the lung, and, running horizontally forward, cuts the anterior
border on a level with the sternal end of the fourth costal cartilage on the
mediastinal surface it may be traced backward to the hilus. The middle lobe, the
smallest lobe of the right lung, is wedge-shaped, and includes the lower part of the
anterior border and the The right lung, although shorter by 2.5 cm. than the left, in
consequence of the diaphragm rising higher on the right side to accommodate the
liver, is broader, owing to the inclination of the heart to the left side; its total
capacity is greater and it weighs more than the left lung.anterior part of the base of
the lung.

The Root of the Lung (radix pulmonis)—A little above the middle of the
mediastinal surface of each lung, and nearer its posterior than its anterior border, is its
root, by which the lung is connected to the heart and the trachea. The root is formed by
the bronchus, the pulmonary artery, the pulmonary veins, the bronchial arteries and veins,
the pulmonary plexuses of nerves, lymphatic vessels, bronchial lymph glands, and areolar
tissue, all of which are enclosed by a reflection of the pleura. The root of the right lung
lies behind the superior vena cava and part of the right atrium, and below the azygos vein.
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That of the left lung passes beneath the aortic arch and in front of the descending aorta;
the phrenic nerve, the pericardiacophrenic artery and vein, and the anterior pulmonary
plexus, lie in front of each, and the vagus and posterior pulmonary plexus behind each;
below each is the pulmonary ligament.
The chief structures composing the root of each lung are arranged in a similar manner
from before backward on both sides, viz., the upper of the two pulmonary veins in front
the pulmonary artery in the middle and the bronchus, together with the bronchial vessels,
behind. From above downward, on the two sides, their arrangement differs, thus:
On the right side their position is—eparterial bronchus, pulmonary artery, hyparterial
bronchus, pulmonary veins, but on the left side their position is—pulmonary artery,
bronchus, pulmonary veins. The lower of the two pulmonary veins, is situated below the
bronchus, at the apex or lowest part of the hilus .

Divisions of the Bronchi.
Just as the lungs differ from each other in the number of their lobes, so the bronchi differ
in their mode of subdivision.
The right bronchus gives off, about 2.5 cm. from the bifurcation of the trachea, a branch
for the superior lobe. This branch arises above the level of the pulmonary artery, and is
therefore named the eparterial bronchus.
All the other divisions of the main stem come off below the pulmonary artery, and
consequently are termed hyparterial bronchi. The first of these is distributed to the middle
lobe, and the main tube then passes downward and backward into the inferior lobe, giving
off in its course a series of large ventral and small dorsal branches. The ventral and dorsal
branches arise alternately, and are usually eight in number—four of each kind. The
branch to the middle lobe is regarded as the first of the ventral series.
The left bronchus passes below the level of the pulmonary artery before it divides, and
hence all its branches are hyparterial it may therefore be looked upon as equivalent to that
portion of the right bronchus which lies on the distal side of its eparterial branch. The first
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branch of the left bronchus arises about 5 cm. from the bifurcation of the trachea, and is
distributed to the superior lobe. The main stem then enters the inferior lobe, where it
divides into ventral and dorsal branches similar to those in the right lung. The branch to
the superior lobe of the left lung is regarded as the first of the ventral series.

Structure.—The lungs are composed of an external serous coat, a subserous areolar
tissue and the pulmonary substance or parenchyma.
The serous coat is the pulmonary pleura it is thin, transparent, and invests the entire organ
as far as the root.
The subserous areolar tissue contains a large proportion of elastic fibers; it invests the
entire surface of the lung, and extends inward between the lobules.
The parenchyma is composed of secondary lobules which, although closely connected
together by an interlobular areolar tissue, are quite distinct from one another, and may be
teased without much difficulty in the fetus.
The secondary lobules vary in size those on the surface are large, of pyramidal form, the
base turned toward the surface those in the interior smaller, and of various forms. Each
secondary lobule is composed of several primary lobules, the anatomical units of the
lung. The primary lobule consists of an alveolar duct, the air spaces connected with it and
their bloodvessels, lymphatics and nerves.
The intrapulmonary bronchi divide and subdivide throughout the entire organ, the
smallest subdivisions constituting the lobular bronchioles. The larger divisions consist of:
(1) an outer coat of fibrous tissue in which are found at intervals irregular plates of
hyaline cartilage, most developed at the points of division;
(2) internal to the fibrous coat, a layer of circularly disposed smooth muscle fibers, the
bronchial muscle; and
(3) most internally, the mucous membrane, lined by columnar ciliated epithelium resting
on a basement membrane.
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however. are distributed to the bronchial glands and upon the walls of the larger bronchial tubes and pulmonary vessels. The bronchial arteries supply blood for the nutrition of the lung they are derived from the thoracic aorta or from the upper aortic intercostal arteries. independently of the pulmonary arteries and bronchi. as some of it passes into the pulmonary veins. where they form a capillary network The bronchial vein is formed at the root of the lung. receive all the blood supplied by the artery. Finally they open into the left atrium of the heart. the radicles coalescing into larger branches which run through the substance of the lung. It ends on the 11 . After freely communicating with other branches they form large vessels. the cells of which are united at their edges by cement substance. from which branches are given off to form a second plexus in the mucous coat this plexus communicates with small venous trunks that empty into the pulmonary veins. beneath the pleura. It does not. with scattered alveoli. bronchial veins. accompanying the bronchial tubes.Each bronchiole divides into two or more respiratory bronchioles. polygonal. partly in the superficial. with a greater number of alveoli connected with them. The alveoli are lined by a delicate layer of simple squamous epithelium. receiving superficial and deep veins corresponding to branches of the bronchial artery. With each atrium a variable number (2–5) of alveolar sacs are connected which bear on all parts of their circumference alveoli or air sacs. Others are distributed in the interlobular areolar tissue. the atria. and end partly in the deep. Lastly. conveying oxygenated blood to be distributed to all parts of the body by the aorta. and each of these again divides into several alveolar ducts. Between the squames are here and there smaller. and accompany them to the hilus of the organ. which also possess alveoli. some ramify upon the surface of the lung. Each alveolar duct is connected with a variable number of irregularly spherical spaces. nucleated cells. Those supplying the bronchial tubes form a capillary plexus in the muscular coat. and. which ultimately come into relation with the arteries and bronchial tubes. The pulmonary veins commence in the pulmonary capillaries.

and on the left side in the highest intercostal or in the accessory hemiazygos vein. Small ganglia are found upon these nerves. Nerves. The filaments from these plexuses accompany the bronchial tubes. supplying efferent fibers to the bronchial muscle and afferent fibers to the bronchial mucous membrane and probably to the alveoli of the lung. formed chiefly by branches from the sympathetic and vagus.right side in the azygos vein. The lungs are supplied from the anterior and posterior pulmonary plexuses. 12 .

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Expansion of the chest and abdominal walls should be well coordinated. intrathoracic pressures decrease and intraabdominal pressures increase.PHYSIOLOGY Pulmonary Mechanics Successful exchange of gases in the lungs is predicated on efficient ventilation of the lungs. downward movement of the diaphragm on the intact side increases intraabdominal pressures and decreases intrathoracic pressures. When the inward 15 . Although inhalation requires active muscle contraction. Each of these muscle groups acts together to expand the lungs. active contraction of the diaphragm and external intercostal muscles of the ribcage draw air into the lungs. During inhalation. exhalation is normally a passive process and is dependent on the elasticity of the pulmonary tissues. This can be tested with a "sniff test": the subject is asked to sniff while the movement of the diaphragms is evaluated by fluoroscopy or ultrasound. Intercostal contraction results in visible expansion of the chest wall. During inspiration. If the abdomen and chest move in opposite directions. During inhalation. one or the other of these systems is either weak or paralyzed. Tidal respiration is based on cyclical expansion and contraction of the lungs. The auxiliary muscles include the scalenus (which are active during normal inspiration) and the sternocleidomastoid muscles (which are only used with high levels of respiratory effort). The overall strength of the respiratory apparatus can be easily evaluated by measuring the maximum inspiratory and expiratory pressures (PImax and PEmax) that the patients can exert against a fixed obstruction of the mouthpiece. whereas diaphragmatic contraction pushes the abdominal contents downward and outward. Weakness of one or both diaphragms can reduce the ventilatory capacity of the lungs. Furthermore. resulting in an upward movement of the paralyzed side. the left and right diaphragms should move together.

deep or combined shallow and deep breathing. Pnea = breath. This is equivalent to the functional residual capacity (FRC) of the lungs. the lung volume becomes stable at the "resting midposition" of the lungs . 16 . limiting the rate at which they can exhale. this maneuver also reduces the diameter of the bronchi. Diaphragmtic breathing. More time is consequently needed during the expiratory phase and this must be kept in mind when adjusting the inspiratory/expiratory time ratios during mechanical ventilation. ii. Costal breathing. i. Eu = good. It consists of upward and downward movement of the chest due to contraction of the intercostals muscles. It consists of the upward movement of the abdomen due to contraction and descent of the diaphragm. However.The term for the normal pattern of quite breathing is eupnea. Eupnea can consists of shallow.force exerted by the elastic tissues of the lungs matches the outward force of the thorax.- A pattern of deep (abdominal)breathing called “diaphramtic breathing”.- A pattern of shallow (chest)breathing called “costal breathing”. Breathing pattern. Diaphraqgmatic. Loss of elastic tissues within the lungs due to emphysema reduces the ability of patients with this disorder to exhale. Patients with severe intrathoracic obstruction characteristically utilize abdominal muscles to force the diaphragms upward during exhalation. Easy or normal. Costal breathing. The rate and volume of exhalation can be increased by contracting the abdominal and internal intercostal muscles.

3 – 3 lits volume Expiratory reserve ERV Maximal air that can be breathed out after 1 ltr volume quiet expiration.2 lits expiration. Inspiratory vital capacity Forced expiratory volume Functional residual IVC Maximal volume of air inhaled after full FEV expiration Volume of air inhaled in a given period of FRC complete forced expiration.TERMS SYMBOLS Vital capacity VC DESCRIPTION VALUE Maximal volume of 4.5 lits 2200 ml residual expiration TLC Amount of air present in the lungs after a 6000ml maximal deep inspiration Respirsatory minute RMV volume Amount of air breathed in and out of lungs at every minute BIO-MECHANICS: 17 6000 ml .5 litres Air exhaled after forced inspiration. Amount of air remained Iin the lungs at the capacity Total lung capacity 3. Inspiratory reserve IRV After a quiet inspiration 2. Tidal volume TV Volume of air inhaled or exhaled during quiet 500 ml breathing. Residual volume RV Volume of air remaining in lungs after full 1.

with the caudal ribs increasing in lengh until rib. Pump handle movement. Bucket handle movement : - 18 . given the nearly coronal axis at the vertebrae. Chest wall movements.this combined rib and sternal motion that occurs in a predominatetly saggital plane has been termed the “pump handle motion”. 2) Muscles of respiration.the excursion of the manubrium is less that of the body of the sternum.the costocartilage become more horizontal.because of the first rib is shortest. ii.the movement of the ribs pushes the sternum ventrally and superiorly.i.the discrepancy in lengh causes movement of the ms joint. Bucket handle movement Pump handle movement : During inspiration the ribs elevate in the upper ribs most of the movement occurs at the anterior aspect of the rib.the motion of the upper ribs and sternum has its greatest effect by increasing the anteroposterior diameter of thorax.1) Chest wall movements.

The lower ribs have more angled shape ( obliquity increases from rib 1-10 ) and an indirect attachment anteriorly to the sternum. 19 . These factors allow the lower ribs more motion at the lateral aspect of the ribcage. The elevation of the lower ribs has its greatest effect by increasing the transverse diameter of the lower thorax. This motion that occurs in a nearly frontal plane has been termed the “Bucket handle motion” Muscles of respiration : The ventilatory muscles are most accurately classified as either primary or accesory muscles.Elevation of the lower rib about the axis of motion lying nearly in the sagital plane.

The parasternal muscles are considered as primary muscles of ventilation. intercostal muscles and the scalene muscles. ribs and vertebral bodies the fibres travels superiorly to insert insert into a central tendon. arm. the diaphragm is a circular set of muscle fibres that arises from the sternum. costocartilage. Accessory muscles : These muscles assesd with inspiration or expiration in situations of stress such as increased activity or disease. 20 . Which arises from the sternum. Functionally the muscular portion of the diaphragm is divided into the “costal portion” . The external intercostal muscles are activated during inspiration and the internal intercostal muscles are active during exhalation. The scalene muscles attached on the transverse process of c3 – c7 and descend to the upper borders of 1st and 2nd rib. head or pelvis on the trunk. Scalene muscles : The scalene muscles are also primary muscles of quiet ventilation. These muscles all act on the ribcage to promote inspiration. When the trunk is stabilized the accessory muscles of ventilation move the vertebral column. The internal intercostal and external intercostal and the subcostales muscles connect adjacent ribs to one another. Intercostal muscles : The external and internal intercostal muscles are categorized as Ventilatory muscles. The “crural portion” which arises from the vertebral bodies. Diaphragm : The diaphragm is the primary muscle of the ventilation accounting approximately 70-80% of inspiration force during quiet breathing. The scalene muscles also function as stabilizers of ribcage. their action lifts the sternum and the 1st to ribs in the pump handle motion of the upper rib cage.Primary muscles : These include the diaphragm. costo cartilage and ribs.

abdominalis. rectus abdominalis. internal oblique abdominalis.The accessory muscles of inspiration increases the thoracic diameter by moving the rib cage upward and downward. subclavius.are expiratory muscles. external oblique abdominalis. 21 . The accessory muscles of expiration move the diaphragm upward and the thorax downward and inward. pectoralis major. The abdominal muscles are trasversus. trapezius. pectoralis minor. The most common accessory muscles are sternocleidomastoid.

Air-fluid levels within the massively dilated bronchi are seen frequently due to retained secretions. Patients may have only mild symptoms such as a cough.The luminal airway diameter is greater than the diameter of the adjacent vessel. Remember.Saccular/Cystic: This is the most severe form of bronchiectasis. It may occur secondary to infection.TYPES OF BRONCHIECTAISIS: Types of bronchiectasis include: 1-Cylindric/Fusiform/Tubular: Cylindrical bronchiectasis produces "tram-lines" because the distal bronchus has the same lumen size as parent and extends to the lung periphery. or cystic fibrosis. that in contrast to bronchiectasis. This is the most common form of bronchiectasis. ciliary dyskinesia. Cylindrical bronchiectasis with signet-ring appearance. The findings may resemble a cluster of cysts. On HRCT there are thick walled (smooth. It is characterized by progressive dilatation of the bronchi toward the periphery which terminate in cytic cavities resembling balloons. not irregular) bronchi which extend into the peripheral 3 cm of the lung. emphysematous bullae have no discernible walls. with small amounts of sputum production. 2. 22 . and are usually not seen in uncomplicated lung cysts.

23 . Differentiation from cylindrical bronchiectasis is difficult when viewed in cross section. the airway changes are not caused by a primary insult to the airways themselves. In this form of bronchiectasis the bronchial walls are characteristically more irregular and may assume a beaded appearance when in the plane of section (resembling a "varicose" vein).3. but rather as a result of adjacent parenchymal fibrosis. Traction/ Varicose: Unlike most other causes of bronchiectasis. Varicose bronchiectasis with alternating areas of bronchial dilatation and constriction.

whooping cough. and it is sometimes 24 . This may lead to local damage to that airway. but most often begins in childhood as a complication from infection or inhaling a foreign object.  Some inherited conditions.  It is also seen in later life after severe lung infections such as pneumonia in childhood. an inhaled foreign body such as a peanut. a condition called primary ciliary dyskinesia affects the cilia so they do not 'beat' Correctly to clear the mucus. bronchiectasis may be caused by cystic fibrosis. or lung infection in Aids. Cystic fibrosis is another condition that affects the lungs and causes 'bronchiectatic' airways.  Some rare immune problems can also cause lung infections and damage to airways thereby causing bronchiectasis. pneumonia or measles can damage the airways at the time of infection.  Other causes include inhalation of damaging gases. The condition is worsened by smoking.  Less commonly. Some other Causes of Bronchiectasis may be:  Respiratory syncytial virus can cause bronchiectasis in some Childs.AETIOLOGY Bronchiectasis is caused by recurrent inflammation or infection of the airways. following tuberculosis. such as peanuts. Ongoing bronchiectasis may then develop.  Inhaled objects. dust or smoke. can become stuck and block an airway. Acid from the stomach that is regurgitated and inhaled can also damage airways. bronchiectasis was often the result of a serious infection with either measles or whooping cough. may lead to development of bronchiectasis. It may be present at birth. For example.  Severe lung infections such as tuberculosis (TB). Prior to the widespread use of immunizations. Inhaling poisonous gases may also cause damage. Now. viruses that cause influenza (flu) or influenza-like syndromes.

o Recurrent fever. o Abnormal chest sounds. o Fatigue. chills. o There may be frequent bouts of pneumonia or hemoptysis. o Skin discoloration. Some other Symptoms of Bronchiectasis may be: o Cough worsened by lying on one side o Shortness of breath worsened by exercise o Weight loss. bluish. 25 . o Coughing up of blood is also common. o Paleness. o Wheezing.

The arterial vessels within the bronchial walls anastomose with the pulmonary capillaries and this results in the common feature of haemoptysis.Pathology  Bronchial obstruction may be localized (due perhaps to an inhaled foreign body such as a pea nut or broken tooth or obstruction due to a tumor or enlarged gland) or generalized (eg . fusiform.  The bronchial obstruction will cause absorption of air from the lung tissue distal to the obstruction and this area will therefore shrink and collapse. Secretions may collect distal to the obstruction if it is not relieved quickly and these easily become infected.  Several types of obstructions are recognized pathologically: tubular.  The elastic and muscle tissue is destroyed and the mucus lining is replaced by granulation tissue with loss of cilia. with walls becoming weaker and weaker. which will distort and dilate them. This causes traction forces to be exerted upon the more proximal air ways.pneumonia that is slow to resolve owing to whooping cough or measles).  If the obstruction can be cleared and the lung re-expanded quickly then the dilatation is reversible. They will eventually dilate owing to the negative intrapleural pressure.  These infections occur repeatedly. or saccular.  This causes inflammation of the bronchial wall with destruction of the elastic and muscular tissue. Therefore the mucociliary transport mechanism is disrupted and the of mucus out of the lungs is thus hindered. the bronchi become grossly dilated and pockets containing pus are formed.  As the disease advances. 26 .

anorexia. other well-ventilated and perfused alveoli should maintain blood gases at a reasonable level. Chronic sinusitis: . Initially. This is followed by 27 . lassitude and oint pains. it is present only following colds or influenza. but if the disease is allowed to progress in severity the effected segments continually accumulate purulent secretions. although bronchospasm may be a Feature. Clubbing: In about 50per cent of patients fingers and toes become clubbed. It can be life-threatening if severe and may require surgical resection of the affected lung tissue. night sweats. particularly during an exacerbation. The sputum is usually in green. usually in association with an acute infection. resulting in cough and sputum production. Dyspnoea: Shortness of breath is noticeable only if disease is particularly severe and widespread. malaise. The first sign of clubbing is loss of the angle between the nail and the nail bed. Recurrent pneumonia: Characteristically this will affect the same site and is a common feature. often foulsmelling and present fairly large volume. Haemoptysis: This occurs quite commonly. If the bronchiectasis is localized. weight loss. This occur in approximately 70per cent of patients General ill-health: Patients may suffer pyrexia. The cough is particularly troublesome on a change of position and on raising first thing in the morning.Clinical manifestations Cough and sputum: Patients complains of persistent cough with purulent sputum since childhood.

as do shoulder girdle movements. Thoracic Mobility This gradually decreases. and an increase in the soft tissue of the ends of the fingers. forming so.called ‘drumstick’ fingers.curvature of the nail. 28 .

Patients present with a history of recurrent or persistent lobar pneumonia. One useful distinction is that of focal versus diffuse disease. Bronchiectasis occurs in several suppurative lung diseases. carcinoma. The latter occurs in chronic granulomatous infections. The differential diagnosis of bronchiectasis is one of the most challenging in pulmonary medicine. Bronchiectasis involving a single lobe or segment of the lung typically results from focal bronchial obstruction or severe lobar pneumonia. Bronchiectasis can be confirmed with chest radiographs and HRCT. autoimmune diseases. or Klebsiella species.DIFFERENTIAL DIAGNOSIS: The typical history that suggests bronchiectasis is chronic cough with mucopurulent secretions. or lymph nodes (as occurs in middle lobe syndrome). S aureus. immunodeficiency disorders. Bronchial obstruction proximal to the region of bronchiectasis may be secondary to a foreign body. Multilobar disease is usually secondary to diffuse infections such as influenza. broncholith. P aeruginosa. to toxic inhalation. or to defects in host defense. and congenital diseases 29 .

This painless test creates precise images of your airways and other structures in your chest. or chest CT scan. This CT scan shows areas of both cystic bronchiectasis and varicose bronchiectasis. It can show how much your airways are damaged and where the damage is.INVESTIGATIONS Diagnostic Tests and Procedures: Chest Computed Tomography Scan: The most commonly used test to diagnose bronchiectasis is a chest computed tomography scan. 30 . A chest CT scan gives more detailed pictures than a regular chest x ray.

 A sputum culture: Lab tests of a sample of your sputum can show whether you have bacteria (such as the bacteria that cause tuberculosis) and fungi. A chest x ray may show areas of abnormal lung and thickened. Other Tests: You also may have other tests. and how well your lungs 31 .Chest X Ray: You also may have a chest x ray. They also can show whether you have an infection or low levels of certain infection-fighting blood cells. irregular airway walls. how much air you can breathe in and out. Cystic and cylindrical bronchiectasis of the right lower lobe on a posterior-anterior chest radiograph. such as your heart and lungs. how fast you can breathe air out. This painless test creates pictures of the structures in your chest. such as:  Blood tests: These tests can show whether you have an underlying condition that can lead to bronchiectasis.  Lung function tests: These tests measure the size of lungs.

Bronchoscopy is a procedure used to look at the insides of the airways. You'll be given medicines to numb the upper airway and to help you relax during the procedure.  A sweat test or other tests for cystic fibrosis. 32 . flexible tube with a light on the end is inserted through your nose or mouth into your airways. a long. This time should not exceed 20minutes and is greatly prolonged in patients with ciliary dysfunction. During this procedure. Ciliary function test: A screening test can be performed in patients suspected of having a cilary dysfunction syndrome by assessing the time taken for a small pellet of saccharin placed in the anterior chamber of nose to reach pharynx. If there is bleeding. If ciliary function is thought to be impaired. It is also possible to assess ciliary function by measuring ciliary beat frequency using biopsies taken from nose. the ciliary ultrastructure should also be determined by electron microscopy. It provides a video image of your airways. Lung function tests help show how much lung damage you have. Bronchoscopy can show whether something is blocking your airways.deliver oxygen to your blood. narrow. Bronchoscopy: If bronchiectasis doesn't respond to treatment. this procedure can show where the bleeding is coming from. when the patient can taste it. This tube is called a bronchoscope.

Other modalities (beyond those for specific associated conditions) may include bronchodilators. azithromycin85 or c larithromycin86  a second-generation cephalosporin.g.  tetracycline. corticosteroid therapy.g- staphylococcus aureus ) . -Ceftazidime by intravenous injection or infusion (100150mg/kgdaily in divided dose). SURGICAL 3. dietary supplementation Antibiotic therapy is as follows: o Antibiotics have been the mainstay of treatment for more than 40 years. -Oral.  Acceptable choices for the outpatient who is mild to moderately ill include amoxicillin.(e. depending on the clinical situation. the duration is 7-10 days.  trimethoprim-sulfamethoxazole.  a newer macrolide e.  one of the fluoroquinolones. 33 .ciprofloxacin (250-750mg twice daily). o Inhaled nebuliser or continuous oral therapy may be used for chronic sepsis and more resistant pathogens.MANAGEMENT 1. In general.. PHYSIOTHERAPY CONSERVATIVE MANAGEMENT Antibiotics and chest physiotherapy are the mainstay modalities. and aerosolized antibiotics are used. o Oral. o Intravenous treatment is indicated for severe infections. CONSERVATIVE 2. parenteral.In acute exacerbation. broad-spectrum antibacterial agents are generally preferred.

-The oral antibiotics of choice are the same as those mentioned previously. o Inhaled corticosteroids. 34 . alternating antibiotics for 7-10 days with antibiotic-free periods of 7-10 days. such as an  aminoglycoside  gentamicin. including -beta-agonists and anti-cholinergic. presumably reversing bronchospasm associated with airway hyperreactivity and improving mucociliary clearance. some patients with chronic bronchial infections may need regular antibiotic treatment to control the infectious process.  a third-generation cephalosporin. may be indicated. or a long-term daily dose of antibiotics Bronchodilator therapy is as follows:  Bronchodilators. o Leukotriene inhibitors and nonsteroidal anti-inflammatory agents have all been examined. -Potential regimens include daily antibiotics for 7-14 days of each month. Anti-inflammatory medication therapy is as follows: The rationale is to modify the inflammatory response caused by the microorganisms associated with bronchiectasis and subsequently reduce the amount of tissue damage. tobramycin and  an antipseudomonal synthetic penicillin.may help some patients with bronchiectasis. or  a fluoroquinolone. -Treatment with inhaled bronchodilators may be appropriate. parenteral antibiotics. o Oral corticosteroids.For patients with moderate-to-severe symptoms. Additionally.

35 .Although evidence tends to support some benefit from the use of these agents. In CF patients a meta-analysis suggests that it improves lung function. In non-CF patients. Azithromycin has known anti-inflammatory properties and long-term use has been studied in patients with both CF and non-CF bronchiectasis. On inhaled corticosteroids are beneficial to patients with bronchiectasis compared with a placebo. while another study showed improvement in quality-of-life scores.aeruginosa infections. azithromycin has been shown to decrease exacerbations and improve spirometry and microbiologic profiles. particularly patients with associated P. especially in those patients colonized with Pseudomonas. findings are not universally definitive.

or double-lung transplantation has been used as treatment of severe bronchiectasis. In general. surgery should be reserved for patients who have focal disease that is poorly controlled by antibiotics. Although there is conflicting evidence regarding the efficacy of surgery when compared to conservative treatment. bronchial artery embolization may be attempted for the control of hemoptysis. 36 . Single. consider patients with CF and bronchiectasis for lung transplantation when forced expiratory volume in 1 second (FEV1) falls below 30% of the predicted value. Surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality in patients of any age. In general.SURGICAL MANAGEMENT: Surgery is an important adjunct to therapy in some patients with advanced or complicated disease. The involved bronchiectatic sites should be completely resected for optimal symptom control. Other indications for surgical intervention may include the following: * Reduction of acute infective episodes * Reduction of excessive sputum production * Massive hemoptysis (Alternatively. predominantly when related to CF.) * Foreign body or tumor removal * Consideration in the treatment of Aspergillus species infections.

Complications of surgical intervention include empyema. and persistent atelectasis. which may be as low as 1% in the surgical treatment of segmental or even multisegmental bronchiectasis. Patient selection plays an important role in preoperative mortality rates. Female patients and younger patients may need to be considered even sooner. hemorrhage. 37 . prolonged air leak.

Fever 2.early morning 4. Head ache. SUBJECTIVE ASSESSMENT : Name Age Gender Occupation Chief complaints HISTORY OF PATIENT: Past history Present history Medical history Personal history Family history Socio economic history Environmental history II. OBJECTIVE ASSESSMENT: Observation: Breathlessness Dyspnea Cough Sputum Wheeze Other symptoms: 1. Peripheral edema 38 . High fever with sweating 3.PHSYIOTHERAPY ASSESSMENT : I.

Temperature:98.General observation: vital signs: 1. Add ( or ) Adventious 39 . Pulse rate: 12-16/min 4.4 2. Blood pressure: 128/80mm of hg Pulse deficit: Pulse paradox: Body weight: body mass index-kg/m2 Observation of chest: Land marks of heart and lung shape Shape Chest deformities: Chest movements: Breathing patterns: ON PALPATION. - Pain - Tenderness - Warmth - Swelling ON PERCUSSION: - Dull sounds - Hyper resonant ON AUSCULTATION: Sounds Breath sounds I. Normal II. Heart rate: 60-100/min 3. Abnormal III.

b. X-rays b. Pulmonary function test g.G d. E. S2 sounds INVESTIGATIONS: a. Bronchovesicular. b. ciliary function test Differential daignosis : 40 . Wheeze 1. c. Analysis e. heart sounds a. A. Ronchi c. S1 sounds b.G. Bronchial. c. Vesicular. Cracked rales / crepitus sounds b. Decreased sounds. Absence of sound Added or adventitious sound : a. Extra pulmonary sounds 2. Bronchial sounds. Abnormal breath sounds : a.Normal : a. voice sounds 3. Sputum examination c.B.C. Stress test f.

Goal Plan Progress note : Discharge summary: PHYSIOTHERAPY AIMS: The principal aims of physiotherapy in bronchiectasis are: To remove secretions and clear lung fields. To promote good general health and maintain or improve exercise tolerance.Provisional diagnosis : Management: Short term – Goal Plan Long term --. To teach an appropriate sputum clearance regimen. 41 . To educate the patient in the pathology and management of the condition. To teach the patient how to fit in home treatment within his or her llifestyle.

PHYSIOTHERAPY MANAGEMENT: In early stage :  Postural drainage  Coughing  Humidification  Relax position  Breathing exercises Segmental Diaphragmatic In later stage :  Inspiratory muscle traing  Exercise tolerance  Home program Postural Drainage and Chest Physiotherapy: Postural drainage therapy (PDT) is a component of bronchial hygiene therapy. and turning and is sometimes accompanied by chest percussion and/or vibration. It consists of postural drainage. Postural drainage therapy is often used in conjunction with aerosol administration and other respiratory care procedures.  Postural drainage and percussion.  Chest physiotherapy. Cough or airway clearance techniques are essential components of therapy when postural drainage is intended to mobilize secretions. positioning.  Percussion and vibration. 42 .

by the effect of gravity. or an optimum frequency. Standard positions are modified as the patient's condition and tolerance warrant. 43 . with the bed at any degree of inclination (as indicated and tolerated). and to normalize functional residual capacity based on the effects of gravity and external manipulation of the thorax. Postural Drainage Postural drainage is the drainage of secretions. Regular turning can be to either side or the prone position. from one or more lung segments to the central airways (where they can be removed by cough or mechanical aspiration). No convincing evidence demonstrates the superiority of one method over the other. clapping. the superiority of either manual or mechanical methods. Patients may turn themselves or they may turned by the caregiver or by a special bed or device. This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained. Percussion Percussion is also referred to as cupping. The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung. Turning Turning is the rotation of the body around the longitudinal axis to promote unilateral or bilateral lung expansion and improve arterial oxygenation. Positions should generally be held for 3 to 15 minutes (longer in special situations). No conclusive evidence supports the efficacy of vibration. Vibration Vibration involves the application of a fine tremorous action (manually performed by pressing in the direction that the ribs and soft tissue of the chest move during expiration) over the draining area. Each position consists of placing the target lung segment(s) superior to the carina. and tapotement.Postural drainage therapy is designed to improve the mobilization of bronchial secretions and the matching of ventilation and perfusion.

half lying Techniques apply . Position.Postural drainage positions : Upper lobe. patient lies flat and quarter turn from prone Techniques apply.1) Anterior segment. supine lying Techniques apply. directly over the nipple Posterior segment. forward lean sitting Techniques apply. Position. Position. one quartern turn from prone 44 .- Apical Anterior Posterior Apical . directly above the scapula Anterior segment. Right side Position. directly under clavicle Posterior segment. right scapula Left side Position.

45 .

patient lies prone placing pillow under the Abdomen. Techniques apply. Techniques apply. under the right breast Lingular segments. Position. directly below the scapula Anterior segments : Position. over the lower portion of the ribs. patient lies one-quarter turn from supine on left side supporting placing a pillow from shoulder.Middle lobe. Apical broncho pulmonary segments. Position. patient lies on supine pillow under the knees in a 30-40 degrees head down Techniques apply. under the left breast Lower lobe. 46 . Medial and lateral broncho pulmonary segmen position. patients lies one-quarter turn from supine on Right side supported with pillow and in 30 degrees head down position Techniques apply.

mechanical ventilation. Lateral segments(right). drug-induced paralysis)  Poor oxygenation associated with position(eg. lower portion of the ribs. patient lies prone position 45 degrees down Position Techniques apply. neuromuscular disease. (eg. Position. Lateral segment ( left ) : Position - on the right side in a 30-40 degrees head down position Technique apply - over the lateral aspect of the rib cage. on the left side in a30-45 degrees head down position techniques apply. unilateral lung disease)  Potential for or presence of atelectasis  Presence of artificial airway  Postural Drainage 47 . Position. over the lateral aspect of the rib cage.Posterior segments. INDICATIONS:  Turning  Inability or reluctance of patient to change body position.

 Evidence or suggestion of difficulty with secretion clearance  Difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult)  Evidence or suggestion of re-tained secretions in the presence of an artificial airway. or cavitating lung disease  Presence of foreign body in airway. in a patient receiving postural drainage CONTRAINDICATIONS: The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks.  Presence of atelectasis caused by or suspected of being caused by mucus plugging. Positioning All positions are contraindicated for:  Intracranial pressure (ICP) > 20 mm Hg(59. bronchiectasis.60)  Head and neck injury until stabilized  Active hemorrhage with hemodynamic instability  Recent spinal surgery (eg.  External Manipulation of the Thorax  Sputum volume or consistency suggesting a need for additional manipulation (eg. laminectomy) or acute spinal injury  Acute spinal injury or active hemoptysis  Empyema  Bronchopleural fistula  Pulmonary edema associated with congestive heart failure 48 . Listed contraindications are relative unless marked as absolute. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. percussion and/or vibration) to assist movement of secretions by gravity.  Diagnosis of diseases such as cystic fibrosis.

confused. or infiltrates o Deterioration in arterial blood gas values or oxygen saturation Pulmonary problems treated successfully with PDT (eg. bronchiectasis. eye surgery)  Uncontrolled hypertension  Distended abdomen ASSESSMENT OF NEED: The following should be assessed together to establish a need for postural drainage therapy o Excessive sputum production. aneurysms. cystic fibrosis. or anxious patients who do not tolerate position changes  Rib fracture. mucus plugging. o Decreased breath sounds or crackles or rhonchi suggesting secretions in the airway o Change in vital signs o Abnormal chest x-ray consistent with atelectasis. lung abscess) 49 . o Effectiveness of cough. with or without flail chest  Surgical wound or healing tissue  patients in whom increased intracranial pressure is to be avoided (eg. Large pleural effusions  pulmonary embolism  Aged. neurosurgery.

50 . it has been effective in clearance of bronchial secretions improve lung function  Breathing control   Thoracic expansion exercises   Breathing control   Thoracic expansion exercises   Forced expiration technique Breathing control : It is normal tidal breathing using the lower chest with relaxation of upper extremities. ACBT used to mobilize and clear excess bronchial secretions.Active cycle of breathing techniques (ACBT) It is the cycle of breathing control thoracic expansion exercise and force expiration technique.

 Then again diaphragmatic breathing exercises are carries out.  Closed expectoration against closed glottis.  For a cough to be effective. 51 . Huffing: Open expectoration against open glottis Types :  High volume huffing dislodge secretions from proximal airways.Forced expiratory technique : Combination of forced expiration a period of breathing control. Techniques:  Ask the patient to take 3-4 deep breaths. Huff from high lung volume will clear secretions that have reach more proximal airway.  Coughing technique actually the cuff coughing is contraindicated when the secretions is stable the technique coughing are using. there shall be  High pressure during expiration.  Expiration has to be at higher volumes.  High expiratory flow rate. Then diaphragmatic breathing exercise are carried out and then 3-4 huff from mid lung volume to low volume.  If the secretions reach the proximal airways there the patient to made to cough or huff with high lung volume in order to clear the secretions in proximal airways.  Mid lung volume huffing dislodge secretions from mid airways of zone ll  Low lung volume huffing – dislodge secretions from tertiary airways.

 Closure of glottis and trapping of air inside at a power positive pressure of about 30 mmhg  Ask the patient to mimis swallowing in order to increase in the intra thoracic pressure.  For abdominal contraction and internal intercostal muscle contraction.Techniques of cough :  An inspiratory gulp of about 90% of total lung capacity.  Ask the patient to pronounce the alphabet “K” to increase the intra abdominal pressure. 52 .  Forcibly expire against the open glottis costal expansion is crried out to improve ventilation and optimize gaseous exchange.

One pillow must be above the shoulder so thst only the head and neck are supplied. One pillow. High side lying : Position : 5 or 6 pillows are used to rise the patienst shoulder while lying on his shoulder Pillow placement : One pillow placed between the waist and axills to keep the spine straight.the underneath the forearm. 53 .Relaxation position for breathless patient : These relaxation position will assist relaxation of upper chest while encouraging diaphragmatic breathing control during an attack of breath less.

54  Diaphragmatic breathing. Pillow placement : The back must be kept straight. the back should be kept straight . Relaxed standing : The patient can lean back against a wall with the fet placed slightly apart and approximately 30 cms away from it. Forward lean standing : The patient should lean forward with the forearm resting on an object of suitable height such as the windows. banisters.One pillow underneath the pillow in the waist. These patients who are suffering from acute breathlessness during the night : Forward lean sitting : Position. Improve the breathing pattern : Breathing exercises : These are fundamentals interventions for the prevention management of or comprehensive acute pulmonary disorder. the forearms resting on the thighs and the wrists relaxed. One pillow if the knees are bent on top leg place in front of the one beneath.children can sit or kneel with the head and upper chest resting against pillows. Relaxed sitting : This is an obstructive position can be taken up easily. so diaphragmatic movement is not inhibited. or chronic .  Segmental breathing. patient sits on the table leaning forward from the hips with head and upper chest supported on several pillows.  Pursed breathing. The shoulder and arm should be relaxed.  Low frequency breathing.

3. 2. To induced relaxed pattern of breathing. 4. To have a controlled pattern of breathing. To improve the efficiency of ventilation. Sustained maximal breathing. To mobilize lung secretions during postural drainage. Diaphragmatic breathing : Uses : 1. 55 .

56 .

fowler’s position.  During the technique the patient should relax shoulder and upper chest quiet the abdominal rise. 57 .  Then the patient to slowly tell all the air our using control expiration. 2. Concentrates on upper abdominal wall and lower lateral ribs.Diaphragmatic breathing exercise gives : 1.  The lower ribs are sinking down and in towards the mid line. Concentrates on forward movement of whole abdominal wall. 1st method : Concentrates on upper abdominal wall and lateral ribs. In COPD costal expansions exercise are gives : 1. Position : semi. 2nd method : Position : Half lying Procedure :  Therapist places both hands on anterior abdominal valve then the patient to breath out gently. To improve ventilation to the lung after relieving bronchospasm. To improve the thoracic cage movements. Procedure :  Patient places hands on anterior central margin or upper abdominal wall and ask the patient to breath out gently as he does. 3.  The air is concentrated and directed to abdomen and it bulges achieve the therapist places hands. To mobilize the secretions. 2. Segmental breathing : In this expansion exercises are includes.  He felt abdomen is sinking down and ask him to breath in through his nose.

58 .

59 . and shoulder girdle when it effect ventilation or postural alignment. Maximal inspiration holds for 3 to 5 second and expiration slowly. Procedure : The patient is instruction to breathe to breathe in expand the upper chest against pressure. bilaterally emphasing deep breathing with a focus of movements of this position of the lower rib cage on thoughts to facilitate diaphragmatic excursion. Before inspiration give up stretch and pressure is relaxed at the end of inspiration. The therapist placed the pattern of hand over the mid axillary line of 7th and 8th rib. Thoracic mobility exercises : Chest mobilization exercises are any exercises that they are designed to maintained ( or ) improve mobility of chest wall trunk. Exercises that combine stretching of these muscle with deep breathing ventilation on that side of the chest and control the expiration. Pressure in applied below the clavicle using the tips of fingers. Apical expansion exercise : Position : Technique : Relaxed half lying ( or ) sitting position.Lateral costal expansion : It is done unilaterally. Procedure : Ask the patient to breath out gently and the therapist applies a firm pressure against chest wall and ask the patient to breath air through nose the pressure maintained during inspiration. Position : Technique : Relaxed half lying ( or ) sitting position.

Specific technique : To mobilize one side of the chest : Postion : Sitting position Procedure : Patient bend away from the right side lengthen hypomobile stricter expands that side of the chest during inspiration. Patient bend forward and the hip and reach for the floor during expiration. the air way add heat and water to the inspired gas and extract heat and water from expired gas. Function : Normally one of the functions of upper respiration tract. Then instruct the patient to bring the elbow together and bend forwards during expiration. To mobilize the upper chest stretch the pectoralis muscle : Position : Procedure : Sitting position in a chair The patient hands closed behind the head . 60 . Progress by having the patient rise the arm on the right side. Patient push the fisted hand into lateral aspect of chest and patient bend towards the right side and breath out. It is a process of moisturing of the air for gases we breath. To enhance expiration . patients horizontally abducts the arms during a deep inspiration. To mobilize the upper chest and shoulders : Position : Procedure : sitting position in a chair Patient reach with both arms over head during inspiration. In addition to exercises therapist may also instruct the patient in posture correction.

Before inspiration give quick stretch is apply and pressure is maintained during inspiration at the end of inspiration pressure is relieved.Barach Belt : Gardon barach belt and diaphragmatic breathing with active abdominal contraction during expiration in design to cause a cephalic displacement of diaphragm. Posterior basal expansion exercise : Position : patient sit and lean forward on pillow slightly bending the rib.If the secretions are very thick and tenacious the patient may be given humidification through nebulizer inhalation with penio oil added to near be oiling water may also be given prior to treatment to remove excess brochial secretions. Gardon . It may be most commonly use respiratory therapy in post operative patient. General : Aerobic exercises Walking Swimming Cycling Jogging Treadmill Gymnastics Specific: Inspective spirometry :Types : Volume oriented incentive spirometry Flow oriented incentive spirometry It is use to encourage the patient to take long slow deep breath and thus prevent athlectasis. Inspiratory muscles training : Inspiratory muscles training is used in pulmonary rehabilitation to increase and endurance of the inspiratory muscles. general and specific training program are used ininspiratory muscle training. 61 .

Explain to the patient that expiration must be relaxed on that contract of abdomen must be avoided. Place your hand over the patient abdominal muscle to detect breath in slowly and deeply then have the patient loosely pure the lips and in able. Pursed-lip breathing : Increased the tidal volume Improve exercise tolerance Develop this pattern of breathing Procedure : patient assumes a comfortable position and relax as much as possible.Technique : Pressure is given unilaterally over the posterior aspect of the lower rip and pressure is relieved at end of inspiration. 62 .

pneumococcal vaccine.  Also.  Avoiding over-sedation from drugs or alcohol and seeking medical care for neurologic symptoms (such as impaired consciousness) or gastrointestinal symptoms (such as difficulty in swallowing and regurgitation or coughing after eating) may help to prevent aspiration.  Inhalation of foreign objects into the airways by children may be prevented by watching what they put in their mouth. smoke.  Influenza vaccines. drops of mineral oil or petroleum jelly should never be placed in the nose because they can be inhaled into the lungs 63 . improved living conditions. and good nutrition have markedly reduced the number of people who develop bronchiectasis. gases.  Avoiding toxic fumes.  Childhood immunizations against measles and whooping cough. and use of appropriate antibiotics early in the course of lung infections help to prevent bronchiectasis or reduce its severity.  Receiving immunoglobulin for an immunoglobulin deficiency syndrome may prevent recurring infections.  More than half the cases of bronchiectasis in children can be accurately diagnosed and promptly treated. and injurious dusts also helps prevent bronchiectasis or reduce its severity.PREVENTION:  Early identification and treatment of conditions that tend to cause bronchiectasis may prevent its development or reduce its severity.

Patient is also advice to take care of personal and environment hygine. health and good diet. The patient is given chest physiotherapy in the early stages itself to improve the condition. postural drainage. if he is chronic smoker. huffing. Hence physiotherapy plays a major role in bringing out a good prognosis. Hence the patient is advice to stop smoking. coughing. manual techniques. 64 . relaxation positions ect. mobility exercises.CONCLUSION According to the treatment i have conclude that prevention is always better than cure. Physiotherapist has main role in treating the bronchiectasis patients. to prevent the condition becoming worse. Chest physiotherapy techniques include breath exercises.