Introduction
Bronchiectasis a chronic lung condition, defined as the abnormal, irreversible dilatation of the bronchi and bronchioles, where the elastic and muscular tissue is destroyed by acute or chronic inflammation and infection.1, 2 This anatomical definition has been evolved from the original description of ectatic bronchi found in pathological specimens in the year 1819.1 Bronchi, mostly medium sized, are abnormally dilated and bronchial wall shows inflammatory changes. Such changes result from disordered anatomy of bronchial tree, bacterial colonization and chronic host inflammatory response.1, 2, 3
Its characterised by chronic sputum production, recurrent chest infections, and airflow obstruction. Patients suffer from frequent exacerbations and often have significant limitation of activity.1, 2, 3, 4, 5, 6
It was found that bronchiectasis is a relatively common disease among US, European and Australian cohorts, with the mean disease prevalence being approximately 701 per 100,000 population, with the average age group affected being 60-70 years, hence an increasing trend with higher age groups was also noted.7
In India the following features were noted;
Younger age group
P. aeruginosa was the most common organism isolated in sputum culture
Cystic changes was the most common Bronchiectatic pattern was noted in on CT films.
Patients were also found to have severe form of the disease, and suffer from more severe exacerbations.
Patients were poorly evaluated and did not follow a proper treatment regimen.
Therefore there is an increasing need to improve the of care for patients with [WU3] bronchiectasis in India.8
Several etiologies for the occurrence of bronchiectasis have been identified and studied, among which asthma and ABPA have been included.
50 percent of the bronchiectasis cases are idiopathic and for which the aetiology has to be ascertained.
Bronchial asthma is a heterogeneous chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, characterized by recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, these episodes vary in time and intensity and have variable expiratory airflow limitation that is often reversible either spontaneously or with treatment.9
Multiple number of guidelines exist on the treatment of asthma, However significant differences exist across countries.9 A large proportion of patients with asthma have been found to have poor control and inadequate treatment, this is evident among Indian asthmatics who are found to have a higher frequency of exacerbations, poor quality of life and limitation of activity and this results in socioeconomic burden due to poor work force performance and absenteeism from school and work.9, 10, 11
In a resource limited settings like in our country; patient's lack of awareness about the disease, use of alternative forms of therapy without any proven efficacy, physicians not following step-wise standard guidelines in the management of patients, and lack of affordability of inhalers/medications, affects patients survival with the disease and more prone to suffer from exacerbations. One of the important components for the treatment of asthma includes identification and avoiding of precipitating factors along with addition of medications in a step-wise manner.
If left untreated patients could develop complications such as airway remodeling, bronchiectasis, allergic bronchopulmonary aspergillosis (ABPA), etc.9, 10, 11, 12, 13, 14
Studies have been performed to ascertain the relationship between the 2 conditions, and they have found certain features among patients having coexistent bronchiectasis and bronchial asthma, they include:
Lower FEV1 values on
More severe radio logical involvement, with lower lobe involvement, presence of cylindrical bronchiectasis.
More severe and frequent exacerbations, with poor symptom control.
Poor prognosis
Higher airway hyper-responsiveness.
Symptoms of
Upper airway involvement.
Heterogeneous presentation in terms of clinical features and outcome.
Aims and Objectives of the study
The purpose of the study conducted was to estimate the coexistence of bronchial asthma among patients with bronchiectasis, to compare clinical and radiological profile of patients of bronchiectasis with or without bronchial asthma.
Materials and Methods
It is a cross sectional study done among atients diagnosed with bronchiectasis (diagnosed clinical and radiologically) presenting to department of respiratory medicine at Vydehi Institute of Medical Sciences and Research Centre.
Patients were examined and investigated to see if they have coexisting ronchial asthma or not.
The total number of subjects included are 67 according to inclusion and exclusion criteria.
Methods of data collection
Patients who visited department of Respiratory Medicine at Vydehi Institute of Medical Sciences and Research Centre, were diagnosed with bronchiectasis (as per BTS guidelines 2019) and included in the study after taking informed written consent.
Detailed clinical history was taken and clinical examination was done.
Routine investigations were done.
Patients were subjected to PFT or PEFR (If patients were unable to understand/perform PFT) after treating the active infection/exacerbation. Diagnosis of bronchial asthma was made as per GINA 2021 guidelines.
FEV1 change of >12% and 200ml post bronchodilator, or PEFR variability of >10%
If ronchial asthma was diagnosed after performing spirometry/PEFR, The following tests to Rule out ABPA were performed:
(Serum precipitins testing is not available in our hospital and could not be included).
Demographic data, clinical symptoms and signs in detail, all investigations were recorded in case record form.
Occurrence of bronchial asthma in bronchiectasis patients was calculated and the symptomatology and radiological features were compared between the 2 groups (i.e., patients with only bronchiectasis and patients with both bronchiectasis with Bronchial asthma).
Statistical analysis
Data was entered into Microsoft excel data sheet and was analyzed using SPSS 22 version software. Categorical data was represented in the form of Frequencies and proportions. Chi-square test or Fischer’s exact test was used as test of significance for qualitative data.
Continuous data was represented as mean and standard deviation. Independent t test was used as test of significance to identify the mean difference between two quantitative variables.
Graphical representation of data
MS Excel and MS word was used to obtain various types of graphs
P value (Probability that the result is true) of <0.05 was considered as statistically significant after assuming all the rules of statistical tests.
Results and Discussion
This study includes a total of 67 patients who were diagnosed to have bronchiectasis clinically and radio-logically.
Table 1
Distribution of subjects according to bronchialasthma
|
|
N |
% |
|
bronchiectasis Only |
55 |
82.08 |
|
bronchiectasis + bronchial asthma |
12 |
17.91 |
In the study out of the 67 patients included, 55 (82.08 %) were found to have bronchiectasis only, and 12 (17.91 %) were found to have bronchiectasis with bronchial asthma.Table 1
Comparison of clinical profile between 2 groups
Age distribution
Table 2
Distribution of subjects according to age groupbetween two group
The above table shows the age distribution of the patients in the study,
In the bronchiectasis group, majority of the patients were found to belong to the age group 31-40 years, I.e. 16 patients (29.09%)
In the Bronchiectasis with bronchial asthma group, majority of the patients were found to belong to the age group 41-50 years, I.e. 5 patients (41.66%).
The P value 0.488 (Chi square value 4.440, df 5), there was no statistically significant difference found between two groups with respect to age group.
The mean age for onset of symptoms in the bronchiectasis group was 35.89 years, and 24.83 % in the bronchiectasis with bronchial asthma group. Which was significantly lower in the bronchiectasis with bronchial asthma group.Table 2
In the bronchiectasis group the age of onset of symptoms were as follows:
8 patients belonged to the age group < 20 years (14.54%)
27 patients belonged to the age group 21-40 years (49%)
17 patients belonged to the age group 41-60 years (30.90 %)
3 patients belonged to the age group >60 years (5.45%)
In the bronchiectasis and asthma group the age of onset of symptoms were as follows:
4 patients belonged to the age group < 20 years (33.33%)
8 patients belonged to the age group 21-40 years (66.66%)
0 patients belonged to the age group 41-60 years (0 %)
0 patients belonged to the age group >60 years (0%)
Maximum patients in both groups had onset of symptoms at 21-40 years of age.
Gender distribution
Table 3
Distribution of subjects according to genderbetween two group
|
Bronchiectasis only (55 patients) |
Bronchiectasis with bronchial asthma (12 patients) |
|||
|
N |
% |
N |
% |
|
|
Female |
15 |
27.27 |
7 |
58.33 |
|
Male |
40 |
72.72 |
5 |
41.66 |
In the Bronchiectasis only group, majority of the patients were males (40 patients,72.72 %).Table 3
In the Bronchiectasis with bronchial asthma group, majority of the patients were Females (7 patients, 58.33%).
The P value 0.049 (Chi square value 4.309, df 1), there was a statistically significant difference found between two groups with respect to sex.
Cardinal symptoms
Table 4
Comparison of cardinal symptom between two groups.
In the bronchiectasis only group, majority of the patients had cough as a cardinal symptom (total 54 patients, 98.18%). Other symptoms like sputum production (Total 46 patients 83.63%), chest pain (24 patients 43.63 %) and hemoptysis (29 patients, 52.72%) were more common in the bronchiectasis group.Table 4
In the bronchiectasis with bronchial asthma group, 12 patients (100%) had breathlessness as a cardinal symptom, and 12 patients (100%) had sputum production as a cardinal symptom. Symptom of Wheeze (8 patients, 66.66%) was more common in this group.
P value was significant only on comparing symptom of breathlessness and wheezing between 2 groups, I.e. 0.013 and 0.001 respectively, which was more predominant in the bronchiectasis with bronchial asthma group.
Constitutional symptoms
Table 5
Comparison of Constitutional symptoms between two groups
In the bronchiectasis only group, majority of the patients had fever (i.e. 18 patients, 37.72%).Table 5
In the bronchiectasis with bronchial asthma group majority of the patients had weight loss as a cardinal symptom (i.e. 6 patients, 50%).
There is no statistical significant difference on comparing the constitutional symptoms between the 2 groups.
Atopy symptoms
Table 6
Comparison of atopy symptoms betweentwo groups
Avoid unnecessary capital letters
In the bronchiectasis group, majority of the patients had running nose as a symptom of atopy (I.e. 9 patients 16.36 %).Table 6
In the bronchiectasis with bronchial asthma group, majority of the patients also had running nose as a symptom of atopy (i.e. 8 patients 66.66 %)
There is a statistical difference between 2 groups, while comparing the symptoms of running nose, sneezing and itching. The P value being 0.001, 0.003, 0.001 respectively, which were more commonly found to occur amongst the patients belonging to bronchiectasis with bronchial asthma group.
Exposure history
Table 7
Comparison of exposure history between two groups.
In the bronchiectasis group majority of the patients had exposure to smoke and dust (16 patients in each group, 29.09% in each group).Table 7
In the bronchiectasis with bronchial asthma group majority of the patients had exposure to dust (9 patients 75 %).
While comparing the exposure history between 2 groups, only exposure to fumes and dust was found to be statistically significant, i.e. P value being: 0.005 and 0.006 respectively. Which was found to be more common among the patients belonging to the bronchiectasis with asthma group.
Co morbidities
Table 8
History of old TB was found to be in majority, I.e. 26 patients (47.27%) in the bronchiectasis group.Table 8
H/o Pneumonia was found to be in majority in the bronchiectasis with bronchial asthma group i.e. 5 patients (41.66%)
On comparison of comorbidities between the 2 groups, There was a significant difference in Past history of pneumonia between the 2 groups (P value being 0.007). With history of pneumonia being more common in the bronchiectasis with bronchial asthma group.
In the bronchiectasis group, 7 patients (i.e.12.72%) had history of use of ICS.
In the bronchiectasis with bronchial asthma group, 2 patients (i.e. 16.66%) had history of use of ICS.
There is no statistical significant difference on comparing the percentage of use of ICS between the 2 groups.
Vitals and respiratory system findings
Table 9
Comparison of SpO2 and RR between twogroup
|
|
Bronchiectasis only |
Bronchiectasis with bronchial asthma |
P value |
||
|
Mean |
SD |
Mean |
SD |
||
|
SpO2 |
95.78 |
3.8 |
94.33 |
6.1 |
0.293 |
|
RR |
20.2 |
1.01 |
19.9 |
1.5 |
0.403 |
In the bronchiectasis group, majority of the patients had a mean SpO2 of 95.78 (SD 3.8) and mean respiratory rate of 20.2 (SD 1.01).Table 9
In the bronchiectasis with bronchial asthma group, majority of the patients had a mean Spo2 of 94.33 (SD 6.1) and mean Respiratory rate of 19.9 (SD 1.5)
Table 10
Comparison of Respiratory System finding betweentwo group
In both the groups majority of the patients had crackles as a respiratory system finding I.e. 26 patients, 47.27% in the bronchiectasis group, and 9 patients 75 % in the bronchiectasis with bronchial asthma group.Table 10
While comparing the respiratory system findings between the 2 groups, there was no significant statistical difference.
Sputum culture sensitivity
Table 11
Comparison of Sputum culture between two group
In both groups, majority of the patients did not have any growth in the sputum culture (I.e 38 patients, 69.09% in bronchiectasis group, and 10 patients, 83.33% in bronchiectasis with bronchial asthma group).Table 11
There was also no statistical significance in sputum culture sensitivity between the 2 groups.
Comparison of spirometry and PEFR variability between two groups
Table 12
Comparison of spirometry and PEFR between twogroups
Table 13
Comparison of FEV 1 % between two groups
Spirometry was done in 46 subjects and PEFR was done in 21 subjects.
In both the groups majority of the patients had obstruction in spirometry (32 patients in bronchiectasis group- 58.18%, and 7 patients in the Bronchiectasis with bronchial asthma group- 58.33%)
PEFR variability was found to be present in 5 patients in the bronchiectasis with bronchial asthma group.Table 13
In both the groups majority of the patients had obstruction in spirometry (32 patients in bronchiectasis group- 58.18%, and 7 patients in the bronchiectasis with bronchial asthma group- 58.33%). Patients the bronchiectasis with bronchial asthma group had a positive BDR in spirometry and PEFR variability.
Etiology
Table 14
Comparison of etiology between two groups
In the bronchiectasis only group, Post TB sequelae was found to be the major etiology (I.e. 27 patients 49.09 %).Table 14
In the bronchiectasis with bronchial asthma group, Post Infection sequelae was found to be the major etiology (I.e. 6 patients 50 %)
On Comparison of etiology between two groups, there was no significant statistical difference between the 2 groups, P value 0.658.
Radiological profile
Table 15
Comparison of X-ray between two groups
In the bronchiectasis group the following findings were identified:Table 15
15 patients (27.27%) had a normal chest radiograph.
24 patients (43.63 %) had unilateral involvement.
The most common pattern of bronchiectasis noted was cystic type (31 patients, 56.36 %)
24 patients, 43.63 %, had other specific features present on chest radiograph.
12 patients, 21.81 % had signs of infection present on chest radiograph.
6 patients (10.9 %) had features of hyperinflation on chest radiograph.
In the bronchiectasis with asthma group the following findings were identified:
0 patients (0%) had a normal chest radiograph.
Majority of the patients had unilateral involvement (8 patients, 66.66 %)
The most common pattern of bronchiectasis noted was cystic type (11 patients, 91.66%)
4 patients, 33.3%, had other specific features present on chest radiograph.
5 patients, 41.66 % had signs of infection present on chest radiograph.
1 patient, 8.33 % had features on hyperinflation on chest x-ray.
On comparing X-ray findings between the 2 groups, there was found to be no statistical difference in terms of side of involvement, type of bronchiectasis, presence of signs of infection, presence of hyperinflation, presence of other additional features.
Table 16
Comparison of CT between two group
In the bronchiectasis group the following findings were identified:Table 16
Majority of the patients had bilateral involvement (28 patients, 50.90 %)
The most common pattern of bronchiectasis noted was cystic type (22 patients, 40 %)
30 patients, 54.54 %, had other specific features present on CT thorax.
29 patients, 52.72 % had signs of infection present on CT thorax.
In the bronchiectasis with asthma group the following findings were identified:
Majority of the patients had bilateral involvement (11 patients, 91.66 %)
The most common pattern of bronchiectasis noted was cystic type (8 patients, 14.54 %)
9 patients, 75 %, had other specific features present on CT thorax.
3 patients, 18.75 % had signs of infection present on CT thorax.
On Comparing CT thorax findings between the 2 groups, There was found to be a statistical difference only in terms of side of involvement (P value being 0.010), There was found to be no statistical difference in terms type of bronchiectasis, presence of signs of infection or presence of other features on CT. Both groups had predominant bilateral involvement.
Conclusion
The study conducted concludes that the prevalence of bronchial asthma in cases of bronchiectasis is significant found be 17.91%. Early suspicion and diagnosis such cases reduces the morbidity and mortality of patients suffering from frequent and severe bronchiectasis exacerbations, associated complications and sequelae, and better treatment options can also be provided.
Study Limitations
In the bronchiectasis and bronchial asthma group, ABPA could not be ruled out due to the following factors:
Non availability of tests Serum IgE, Aspergillus specific IgE and IgG, Serum precipitins.
Loss during follow up.
Article
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