Bronchiectasis, including after tuberculosis

1Definition

Bronchiectasis is a chronic lung disease in which the bronchi are permanently and abnormally widened, with a daily wet cough, sputum and repeated chest infections.

The widened, scarred airways cannot clear mucus, so mucus pools and becomes infected. This is why airway clearance is the core of physiotherapy.

2Classification and grading

By shape of the airway (Reid)

• Cylindrical (tubular): evenly widened bronchi that do not taper. Mildest.
• Varicose: irregular, beaded widening like varicose veins.
• Cystic (saccular): balloon-like sacs at the ends of bronchi, often with air–fluid levels. Most severe, most sputum.

By extent

• Localised: one lobe or segment (for example after TB, a foreign body or a single severe pneumonia). The S16 middle-lobe and S19 right-lower-lobe cases.
• Diffuse: both lungs (cystic fibrosis, immune deficiency, ciliary disorders).

Severity scores to name

The Bronchiectasis Severity Index and the FACED score combine FEV1, age, infections with Pseudomonas, number of lobes, breathlessness (mMRC) and admissions.

3Causes and risk factors

• Post-infective: tuberculosis (the commonest cause in India; four of the past cases are "post-Koch's" or "post-PTB"), severe pneumonia, measles or whooping cough in childhood.
• Airway blockage: foreign body, tumour, enlarged lymph nodes (for example the middle lobe).
• Cystic fibrosis.
• Primary ciliary dyskinesia: cilia do not beat. Kartagener's syndrome adds sinusitis and a reversed position of the organs.
• Immune deficiency, HIV.
• Allergic bronchopulmonary aspergillosis (ABPA) in asthma.
• Rheumatoid arthritis and other connective tissue diseases; inflammatory bowel disease; repeated aspiration.
• In many patients no cause is found (idiopathic).

4Pathophysiology to impairments

S19 asked "discuss the reasons for her impairments" for 5 marks. The vicious cycle is the answer.

Impairments and their reasons

• Chronic productive cough and copious sputum: pooled mucus in dilated airways.
• Foul-smelling sputum (S19): anaerobic bacteria growing in stagnant mucus.
• Breathlessness and reduced exercise tolerance: airflow obstruction from mucus and narrowed airways, plus deconditioning.
• Haemoptysis: enlarged, fragile bronchial arteries in the inflamed wall.
• Stress urinary incontinence (S19: "laughing or talking ends in cough and stress incontinence"): repeated coughing raises abdominal pressure and weakens the pelvic floor.
• Fatigue, weight loss, low mood: chronic infection and the social embarrassment of cough and sputum.
• Reduced chest expansion and tracheal shift (S21): fibrosis and collapse of a destroyed lobe pull the trachea towards that side.

5Clinical features (3 marks in W20)

• Chronic cough with large amounts of mucopurulent sputum, worse in the morning and when changing position.
• Sputum may separate into three layers in a pot: froth on top, mucus in the middle, pus at the bottom.
• Recurrent chest infections: more sputum, darker sputum, fever, tiredness.
• Haemoptysis, from blood-streaked sputum to large bleeds.
• Breathlessness, wheeze, chest pain, fatigue, weight loss; sinus symptoms.
• Signs: clubbing; coarse crackles over the affected area, which may change after coughing; wheeze; reduced expansion over a fibrosed lobe.
• Bad breath (halitosis) with foul sputum.

6Investigations

7Medical and surgical management

• Airway clearance: every patient with a productive cough should be taught it by a physiotherapist (ERS 2025: strong recommendation).
• Pulmonary rehabilitation for patients with reduced exercise capacity (ERS 2025: strong recommendation).
• Antibiotics: 14 days for exacerbations; long-term (for example macrolides) or inhaled antibiotics for frequent exacerbations; eradication of new Pseudomonas.
• Mucoactive treatment: nebulised hypertonic or normal saline before airway clearance when sputum is hard to clear.
• Bronchodilators if there is airflow obstruction or asthma.
• Treat the cause: TB treatment, immunoglobulin replacement, ABPA treatment.
• Vaccination against influenza and pneumococcus.
• Surgery: lobectomy for localised disease that does not respond to treatment, or for major haemoptysis (see the lung surgery page). Bronchial artery embolisation for bleeding.

8Complications and prevention

9PT assessment

• Sputum: daily amount (in teaspoons or cups), colour, smell, thickness, blood; best time and position for clearing.
• Cough effectiveness; breathlessness (mMRC); exacerbations per year; current airway-clearance routine.
• Past TB and treatment; incontinence (ask directly, patients may not mention it); occupation and home.
• Observation: posture, clubbing, breathing pattern, chest shape (flattening over a fibrosed lobe).
• Palpation: chest expansion (reduced over the affected side), tracheal position.
• Auscultation: coarse crackles over the affected lobe; repeat after treatment to check effect.
• SpO₂ at rest and on exercise; 6MWT or shuttle test.
• Outcome measures: sputum weight or volume, Leicester Cough Questionnaire, Quality of Life–Bronchiectasis (QOL-B), St George's Respiratory Questionnaire, 6MWT, mMRC.

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (S19, 5 + 10 marks)

"50 year old lady with history of pulmonary tuberculosis ten years back. She has completed full course of anti-Koch's medication. However it resulted in right lower lobe bronchiectasis. She had intermittent episodes of infection now and then for the last ten years. At present she complains of increased frequency of infective episodes with productive cough with foul smelling sputum. It is difficult for her to even laugh or talk for long as it ends up with cough and stress incontinence. She has dyspnoea on performing accustomed activities. She works as a clerk and wishes to continue with work but is worried if she would be able to. (i) Discuss the reasons for her impairments. (ii) Plan a rehabilitation program for her."

11Problem list and goals

12PT management

1. Daily airway clearance (the core)

• Usually once or twice a day for about 10–30 minutes, more often during an exacerbation. Choose the technique the patient will actually do.
• If ordered, take a bronchodilator before, then nebulised saline (hypertonic or normal) to loosen sputum, then airway clearance, then inhaled antibiotics after.
• Combine a technique with a gravity-assisted position for the affected lobe when tolerated.

Active cycle of breathing technique (ACBT)

1. Breathing control: relaxed, gentle tidal breathing with the lower chest, shoulders relaxed.
2. Thoracic expansion exercises: 3–4 deep breaths in, with a 3-second hold, relaxed breath out. Air gets behind the mucus through collateral channels.
3. Breathing control again.
4. Forced expiration technique: 1–2 huffs from mid-lung volume (a long, medium breath out with the mouth open, as if steaming a mirror), then breathing control. A huff from high lung volume clears the upper airways; then cough when secretions reach them.
5. Repeat the cycle until the chest sounds clear or two cycles bring nothing up.

Other techniques

• Autogenic drainage: controlled breathing at three volumes: low lung volume to "unstick" peripheral mucus, mid volume to "collect" it, high volume to "evacuate" it. The patient breathes out through an open mouth and suppresses coughing until mucus reaches the large airways.
• Positive expiratory pressure (PEP) and oscillating PEP (flutter, Acapella): breathing out against resistance keeps airways open and moves mucus; the oscillating devices also vibrate the airway. Good for independent use at home and at work.
• Postural drainage with percussion and vibration: traditional; use when the patient finds it helpful and has no contraindication.

2. Postural drainage positions (choose the affected lobe)

Principle: put the affected segment uppermost so gravity drains it towards the main bronchus.

Tilt angles differ between books (raising the foot of the bed by about 35–45 cm). The direction of lying is what matters most.

3. Exercise and pulmonary rehabilitation

• Endurance and strength training as in COPD pulmonary rehab (6–12 weeks, at least twice a week supervised). Exercise also loosens sputum.
• Do airway clearance before exercise so the airways are clear.
• Inspiratory muscle training if the breathing muscles are weak.

4. Pelvic floor and other measures

• Pelvic floor muscle training: slow holds (up to 10 seconds × 10) and quick contractions, three times a day; tighten before coughing or huffing ("the knack").
• Breathing control and posture; thoracic mobility exercises.
• Drink enough water to keep sputum thin.

Ergonomic and energy-conservation advice for left lung bronchiectasis with a normal right lung (7 marks in W22)

• Sleep and rest lying on the right side. This puts the diseased left lung uppermost, so it drains, and the healthy right lung lowermost, where it gets more blood flow and better gas exchange.
• Clear the chest in the morning and before work or travel; plan a short huffing break during the day in private.
• Sit upright at work with the desk at elbow height; avoid long slumped sitting, which squashes the lower chest.
• Pace tasks, sit for tasks such as cooking and ironing, keep things within reach, use trolleys and avoid heavy lifting (as in COPD energy conservation).
• Avoid dust, smoke and crowded places during infections; wear a mask.

By impairment

13Precautions, contraindications and stop criteria

14Education, lifestyle and home programme

• Do airway clearance every day, even on good days. Increase it when you have more sputum.
• Keep a sputum diary; know your action plan for exacerbations (more sputum, darker colour, fever).
• Stop smoking; avoid smoke and dust.
• Exercise every day; it helps you clear sputum and stay fit.
• Clean nebulisers and devices daily; wash hands.
• Do pelvic floor exercises daily.
• Get influenza and pneumonia vaccines.

15Prognosis and discharge criteria

Prognosis varies widely. It is worse with Pseudomonas infection, frequent exacerbations, low FEV1, many lobes involved and low body weight. Daily airway clearance and exercise reduce symptoms and exacerbations.

Discharge from an episode of physio: independent and confident with the chosen airway-clearance technique and positions; daily exercise routine; knows the action plan; pelvic floor programme in place.

16Exam corner

Past questions (MUHS, 2016–2026)

• S16 Q3(b), 5 + 5 + 5 marks35-year-old male labourer, middle lobe bronchiectasis, cough with sputum and breathlessness. Functional diagnosis; short- and long-term goals; physiotherapy management.
• S19 Q3(a), 5 + 10 marksThe worked example in section 10.
• S20 Q3(a), 5 + 5 + 5 marks40-year-old male tailor, post-Koch's bronchiectasis of the right lung, copious mucopurulent sputum, breathless on exertion; attending pulmonary rehab for a week. Impairments, activity and participation; short- and long-term management.
• S21 Q3(a), 7 + 8 marks34-year-old male smoker, post-PTB bronchiectasis, mMRC 3, copious sputum; heterogeneous opacities throughout with the trachea shifted to the left. ICF and physiotherapy management.
• W24 Q3(a), 15 marks35-year-old man with post-TB bronchiectasis, recently married; foul-smelling sputum for 2 days; cannot lie on his right side because it brings up more sputum; embarrassed to meet people and feels unwell. Functional diagnosis and physiotherapy. Clue: lying on the right side drains the left lung, so the disease is mainly on the left.
• 7-mark questionsPhysiotherapy for right lower lobe bronchiectasis (W16). ACBT vs autogenic drainage in bronchiectasis (W17). Physiotherapy management of bronchiectasis (W18). Ergonomic and energy-conservation advice, left lung bronchiectasis with a normal right lung (W22). Mucus removal techniques in chronic respiratory disease (W19).
• 3-mark questionClinical features of bronchiectasis (W19, W20).

Technique cards for this topic: airway clearance, ACBT and autogenic drainage, postural drainage, PEP devices, pulmonary rehabilitation.

Keywords to underline

permanent dilatation vicious cycle post-tuberculous airway clearance ACBT forced expiration technique autogenic drainage oscillating PEP gravity-assisted position affected lobe uppermost pelvic floor action plan

Answer skeleton: bronchiectasis long answer

1. Restate: age, job, cause (TB), lobe, sputum, breathlessness grade, X-ray detail.
2. [ICF or reasons, 5–7] ICF diagram; vicious cycle diagram; reason for each impairment.
3. [Short-term, 5] Airway clearance plan for that lobe: technique, positions, dose; nebulisation; breathing control; pelvic floor if leakage.
4. [Long-term, 5–8] Pulmonary rehab doses; home routine; devices; energy conservation; action plan; outcome measures.

Draw these

• The vicious cycle (section 4)
• The drainage position for the lobe in the question (section 12)
• The ACBT cycle as a loop: breathing control → expansion → breathing control → huff

Viva questions

1. Why is TB a common cause of bronchiectasis in India?
2. What is the difference between a huff and a cough?
3. How do you drain the middle lobe?
4. Name six contraindications to head-down tilt.
5. Why do bronchiectasis patients develop stress incontinence?
6. Which side should a patient with left lung disease lie on, and why?

Linked practical spots

• Chest X-ray: tram lines and ring shadows; trachea pulled to the side of a fibrosed lung.
• Devices: flutter, Acapella, PEP mask, nebuliser.