but restrictive lung impairment can be seen in advanced disease. flexible bronchoscopy may be performed when sputum studies are negative and a focal obstructing lesion is suspected. a chest x-ray is abnormal in most patients with bronchiectasis. computed tomography is recommended to confirm the diagnosis and is also used to describe the distribution and grade the severity of the disease. radiographic findings include airway dilation, bronchial wall thickening, and atelectasis. there are three types bronchiectasis that can be seen on ct scan, namely cylindrical, varicose, and cystic bronchiectasis. bronchiectasis primarily in the middle lobe of the right lung. bronchiectasis secondary to a large carcinoid tumor (not shown) that was completely obstructing the bronchus proximally. dilation of the airways is present. prevention in preventing bronchiectasis, it is necessary to prevent the lung infections and lung damage that can cause it. children should be immunized against measles, pertussis, pneumonia, and other acute respiratory infections of childhood. additionally, parents should stay alert to keep children from inhaling objects such as pieces of food or small toys that may get stuck in small airways. smoking and other toxic fumes and gases should be avoided by all patients with bronchiectasis to decrease the development of infections (such as bronchitis) and further complications. treatments to slow down the progression of this chronic disease include keeping bronchial airways clear and secretions weakened through various forms of airway clearance. aggressively treating bronchial infections with antibiotics to prevent the destructive cycle of infection, damage to bronchi and bronchioles, and more infection is also standard treatment. regular vaccination against pneumonia, influenza, and pertussis are generally advised. a healthy body mass index and regular doctor visits may have beneficial effects on the prevention of progressing bronchiectasis. the presence of hypoxemia, hypercapnia, dyspnea level and radiographic extent can greatly affect the mortality rate from this disease. management a comprehensive approach to the management of bronchiectasis is recommended. it is important to establish whether an underlying modifiable cause, such as immunoglobulin deficiency or alpha-1 antitrypsin deficiency is present. the next steps include controlling infections and bronchial secretions, relieving airway obstructions, removing affected portions of lung by surgery, and preventing complications. airway clearance the goal of airway clearance therapy is to loosen secretions and interrupt the cycle of inflammation and infection. airway clearance techniques improve difficulty breathing, cough, and help patients cough up phlegm and mucus plugs. airway clearance usually uses an inhaled agent (hypertonic saline) with chest physiotherapy, such as high-frequency chest wall oscillation. many airway clearance techniques and devices exist. the choice of a technique or device is based on the frequency and tenacity of phlegm, patient comfort, cost, and the patient's ability to use the technique or device with minimal interference to their lifestyle. the active cycle of breathing technique (acbt), which can be employed with or without a flutter device, is beneficial in treating those with bronchiectasis. mucolytic agents such as dornase alfa are not recommended for individuals with non-cf bronchiectasis. mannitol is a hyperosmolar agent that is thought to hydrate airway secretions, however, clinical trials with it have not demonstrated efficacy. anti-inflammatories the two most commonly used classes of anti-inflammatory therapies are macrolides and corticosteroids. despite also being antibiotics, macrolides exert immunomodulatory effects on the host inflammatory response without systemic suppression of the immune system. these effects include modifying mucus production, inhibition of biofilm production, and suppression of inflammatory mediators. three large multicenter, randomized trials have shown reduced rates of exacerbations and improved cough and dyspnea with use of macrolide therapy. the impact of adverse effects of macrolides such as gastrointestinal symptoms, hepatotoxicity, and increased antimicrobial resistance needs ongoing review and study. inhaled corticosteroid therapy can reduce sputum production and decrease airway constriction over a period of time, helping prevent progression of bronchiectasis. long term use of high-dose inhaled corticosteroids can lead to adverse consequences such as cataracts and osteoporosis. it is not recommended for routine use in children. one commonly used therapy is beclometasone dipropionate. antibiotics azithromycin is a macrolide commonly used in bronchiectasis. antibiotics are used in bronchiectasis to eradicate p. aeruginosa or mrsa, to suppress the burden of chronic bacterial colonization, and to treat exacerbations. the use of daily oral non-macrolide antibiotic treatment has been studied in small case series, but not in randomized trials. the role of inhaled antibiotics in non-cf bronchiectasis has recently evolved with two society guidelines and a systematic review suggesting a therapeutic trial of inhaled antibiotics in patients with three or more exacerbations per year and p. aeruginosa in their sputum. options for inhaled antibiotics include aerosolized tobramycin, inhaled ciprofloxacin, aerosolized aztreonam, and aerosolized colistin. bronchodilators some clinical trials have shown a benefit with inhaled bronchodilators in certain people with bronchiectasis. in people with demonstrated bronchodilator reversibility on spirometry, the use of inhaled bronchodilators resulted in improved dyspnea, cough, and quality of life without any increase in adverse events. however, overall there is a lack of data to recommend use of bronchodilators in all patients with bronchiectasis. surgery the primary role of surgery in the management of bronchiectasis is in localized disease to remove segments of the lung or to control massive hemoptysis. additionally, surgery is used to remove an airway obstruction that is contributing to bronchiectasis. the goals are conservative, aiming to control specific disease manifestations rather than cure or eliminate all areas of bronchiectasis. surgical case series have shown low operative mortality rate (less than 2%) and improvement of symptoms in the majority of patients selected to receive surgery. however, no randomized clinical trials have been performed evaluating the efficacy of surgery in bronchiectasis. clinical trials results from a phase 2 clinical trial were published in 2018. in a placebo-controlled, double-blind study conducted in 256 patients worldwide, patients who received brensocatib reported prolonged time to the first exacerbation and also reduced rate of yearly exacerbation. prognosis two clinical scales have been used to predict disease severity and outcomes in bronchiectasis; the bronchiectasis severity index and the faced scale. the faced scale uses the fev-1 (forced expiratory volume in 1 second), age of the affected person, presence of chronic infection, extent of disease (number of lung lobes involved) and dyspnea scale rating (mrc dyspnea scale) to predict clinical outcomes in bronchiectasis. the bronchiectasis severity index uses the same criteria as the faced scale in addition to including criteria related to number of hospital admissions, annual exacerbations, colonization with other organisms and bmi (body mass index) less than 18.5. a decreased fev-1, increasing age, presence of chronic infection (especially pseudomonas), a greater extent of lung involvement, high clinical dyspnea scale ratings, increased hospital admissions, a high number of annual exacerbations, and a bmi less than 18.5 lead to higher scores on both clinical scales and are associated with a poor prognosis in bronchiectasis; including increased mortality. epidemiology the prevalence and incidence of bronchiectasis is unclear as the symptoms are variable. the disease affects between 1 per 1000 and 1 per 250,000 adults. the disease is more common in women and in the elderly. in a medicare cohort study in the united states, consisting of adults 65 years and older, the prevalence of bronchiectasis was 701 per 100,000 persons. a similar prevalence rate of bronchiectasis has been reported in other countries including china, germany, the united kingdom, spain and singapore. those with a dual copd and bronchiectasis diagnosis are more likely to be cigarette smokers and more likely to be hospitalized as compared to those with bronchiectasis without copd. it became less common since the 1950s, with the introduction of antibiotics. it is more common among certain ethnic groups such as indigenous people. an estimated 350,000 to 500,000 adults have bronchiectasis in the united states. specifically, children of the indigenous populations of australia, alaska, canada and new zealand have significantly higher rates than other populations. overall, a shortage of data exists concerning the epidemiology of bronchiectasis in asia, africa, and south america. the prevalence and incidence of bronchiectasis has increased greatly in the 21st century. in a medicare cohort analysis, consisting of adults 65 years and older in the united states; the annual rates of diagnosis have increased by 8.7% every year between 2000 and 2007. this large increase in the diagnosis of bronchiectasis may be due to increased recognition of the disease (including more widespread use of ct scans) or it may be due to an increase in the underlying causes of bronchiectasis. history rené laennec, the man who invented the stethoscope, used his invention to first discover bronchiectasis in 1819. the disease was researched in greater detail by sir william osler, one of the four founding professors of johns hopkins hospital, in the late 1800s. it is suspected that osler himself died of complications from undiagnosed bronchiectasis. his biographies mention that he had frequent severe chest infections for many years. the term "bronchiectasis" comes from the greek words bronkhia (meaning "airway") and ektasis (meaning "widening").