Introduction Bronchiectasis a chronic lung condition, defined as the abnormal, irreversible dilation of the bronchi and bronchioles, where the elastic and muscular tissue is destroyed by acute or chronic inflammation and infection. This anatomical definition has been evolved from the original description of ectatic bronchi found in pathological specimens in the year 1819. 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. Materials and Methods This is a prospective study was conducted in the Department of Respiratory medicine at Tertiary Care Teaching Hospital. Data were collected from inpatients diagnosed with bronchiectasis with or without asthma over a period of 1 year. Patients who had not received a chest HRCT scan examination or who had indecipherable HRCT scan images were excluded. Patients with other diseases (e.g. chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis, α1-antitrypsin deficiency, significant immunodeficiencies and respiratory carcinomas) were also excluded. All aspects of the study were performed in accordance with relevant guidelines and regulations. Results In the present study, 618 BE were analyzed and divided into 2 groups into BE with asthma (n = 144, 23.3%) and those without asthma (n = 474, 76.6%). The characteristics of the patients are shown in Table 1. Among the 518 patients, 242 (53.3.%) were female and the median age of all patients was 65.6 years (IQR, 59.8–71.5 years). BE with asthma had higher BMI (23.8 vs. 100 Patients with asthma had more frequent hospitalizations, outpatient visits, and antibiotic usage compared to those without asthma. Conclusion The presence of bronchiectasis in patients with asthma was associated with greater asthma severity. There are important therapeutic implications of identifying bronchiectasis in asthmatic patients.
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] 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. [2] Its characterised by chronic sputum production, recurrent chest infections, and airflow obstruction. Patients suffer from frequent exacerbations and often have significant limitation of activity. [3] 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. [4]
Therefore, there is an increasing need to improve the care for patients with [WU3] bronchiectasis in India. [5] Several etiologies for the occurrence of bronchiectasis have been identified and studied, among which asthma and ABPA have been included. Percent of the bronchiectasis cases are idiopathic and for which the aetiology has to be ascertained. [6] 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. [7]
Multiple number of guidelines exist on the treatment of asthma, however significant differences exist across countries. [8] 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]
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. [10] 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. [11] If left untreated patients could develop complications such as airway remodeling, bronchiectasis, allergic bronchopulmonary aspergillosis (ABPA), etc. [12].
This is a prospective study was conducted in the Department of Respiratory medicine at Tertiary Care Teaching Hospital. Data were collected from inpatients diagnosed with bronchiectasis with or without asthma over a period of 1 year. Patients who had not received a chest HRCT scan examination or who had indecipherable HRCT scan images were excluded. Patients with other diseases (e.g. chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis, α1-antitrypsin deficiency, significant immunodeficiencies and respiratory carcinomas) were also excluded. All aspects of the study were performed in accordance with relevant guidelines and regulations.
(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).
Diagnosis of bronchiectasis was performed using chest HRCT scans in suspected patients with coughing and expectoration, or long durations of haemoptysis. High-resolution images were obtained during full inspiration at 1-mm collimation and 10-mm intervals from the apex to the base of the lungs. The presence of bronchiectasis was confirmed based on the following criteria: 1) lack of tapering in the bronchi; 2) dilation of the bronchi where the internal diameter was larger than that of the adjacent pulmonary artery; or 3) visualisation of the peripheral bronchi within 1 cm of the costal pleural surface or the adjacent mediastinal pleural surface [6, 7]. An exacerbation is defined as the patient reporting four or more of the following symptoms: change in sputum production, increased dyspnoea, increased cough, fever >38°C, increased wheezing, decreased exercise tolerance, fatigue, malaise, lethargy, reduced pulmonary function, changes in chest sounds or radiographic changes consistent with a new infectious process.
The type of bronchiectasis was defined morphologically. Patients with small areas of bronchiectasis only visible in a single pulmonary segment were excluded, because this sign can appear in a large proportion of the healthy population [8]. Asthma diagnosis was confirmed according to the Global Initiative for Asthma (GINA) guideline at the time of diagnosis. Asthma was diagnosed for patients with symptoms such as episodic breathlessness, wheezing, cough and chest tightness, and whose spirometry showed bronchial reversibility of 12% and 200 mL from the prebronchodilator value or airway hyperresponsiveness as a 20% decrease in forced expiratory volume in 1 s (FEV1) caused by a provocative histamine with a cumulative dose.
The variables collected in this study included the following: general and anthropometric information (i.e. age, sex, body mass index and smoking history); history of respiratory illness (i.e. pertussis, tuberculosis and anaphylactic rhinitis); lung signs (moist or dry rales); serological indicators (e.g. C-reactive protein, erythrocyte sedimentation rate, albumin and immunoglobulin (Ig)); pulmonary function test results (e.g. predicted and absolute values of FEV1 and forced vital capacity (FVC) and FEV1/FVC ratio); and microbiological detection of sputum samples. Sputum samples were accepted if they contained 25 leukocytes per low-powered field. Bronchiectasis exacerbations were recorded in patients within 1 year of their discharge from the hospital, using telephone or face-to-face interviews.
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. The statistical packages SPSS (version 29.0) were used for statistical analysis and drawing graphs, respectively.
In the present study, 618 BE were analyzed and divided into 2 groups into BE with asthma (n = 144, 23.3%) and those without asthma (n = 474, 76.6%). The characteristics of the patients are shown in Table 1. Among the 518 patients, 242 (53.3.%) were female and the median age of all patients was 65.6 years (IQR, 59.8–71.5 years). BE with asthma had higher BMI (23.8 vs.100 Impacts of Asthma on Bronchiectasis
Table 1: Baseline Characteristics
Characteristic |
BE with Asthma (n = 164) |
BE without Asthma (n = 454) |
P Value |
Age (years) |
67 (61–73) |
65 (60–71) |
0.146 |
Sex (Female, %) |
100 (61.0%) |
242 (53.3%) |
0.157 |
BMI (kg/m²) |
23.8 (21.0–25.7) |
22.5 (20.3–25.0) |
0.020 |
Smoking History |
|
|
0.151 |
- Never-smoker (%) |
115 (70.1%) |
287 (63.2%) |
|
- Current- or ex-smoker (%) |
49 (29.9%) |
167 (36.8%) |
Table 2: Functional Parameters
Parameter |
BE with Asthma (n = 164) |
BE without Asthma (n = 454) |
P Value |
FEV1% Predicted |
58.2 ± 15.3 |
67.5 ± 12.8 |
0.003 |
FEV1/FVC Ratio |
0.54 ± 0.10 |
0.64 ± 0.12 |
<0.001 |
Modified Reiff Score |
5 (3–9) |
5 (3–9) |
0.406 |
Sputum Volume (mL) |
20 (10–30) |
10 (5–20) |
0.015 |
Table 3: Comorbidities
Comorbidity |
BE with Asthma (n = 164) |
BE without Asthma (n = 454) |
P Value |
History of pneumonia (%) |
70 (42.7%) |
175 (38.5%) |
0.017 |
COPD (%) |
65 (39.6%) |
145 (31.9%) |
0.005 |
History of measles (%) |
34 (20.7%) |
85 (18.7%) |
0.037 |
Pseudomonas isolation (%) |
18 (11.0%) |
48 (10.6%) |
0.324 |
Parameter |
BE with Asthma (n = 164) |
BE without Asthma (n = 454) |
P Value |
Sputum Volume (mL) |
20 (10–30) |
10 (5–20) |
0.015 |
Pseudomonas Isolation |
18 (11.0%) |
48 (10.6%) |
0.324 |
Recurrent Exacerbations (%) |
95 (58.0%) |
180 (39.6%) |
<0.001 |
Parameter |
BE with Asthma (n = 164) |
BE without Asthma (n = 454) |
P Value |
Hospitalizations in past year |
|
|
0.012 |
- None |
90 (54.9%) |
310 (68.3%) |
|
- 1–2 |
50 (30.5%) |
105 (23.1%) |
|
- ≥ 3 |
24 (14.6%) |
39 (8.6%) |
|
Outpatient visits (per year) |
5.6 ± 2.3 |
4.3 ± 1.8 |
0.020 |
Antibiotic usage (days/year) |
45 (30–60) |
30 (15–45) |
0.008 |
Parameter |
BE with Asthma (n = 164) |
BE without Asthma (n = 454) |
P Value |
Pseudomonas isolation (%) |
18 (11.0%) |
48 (10.6%) |
0.324 |
Nontuberculous mycobacteria (NTM, %) |
20 (12.2%) |
50 (11.0%) |
0.601 |
Lobe involvement (mean) |
4.1 ± 1.5 |
3.6 ± 1.4 |
0.022 |
Modified Reiff score (median) |
5 (IQR: 3–9) |
5 (IQR: 3–9) |
0.406 |
In the present study, the clinical impacts of asthma in BE were evaluated. BE with asthma had more respiratory symptoms including a larger amount of sputum and more severe dyspnea and lower lung function than those without asthma. Inhalers such as ICS, ICS/LABA, and LAMA and leukotriene receptor antagonists were more frequently used in BE with asthma than in those without asthma. [13] Although significant intergroup differences in radiological extent, disease severity scores, and exacerbation history were not observed, BE with asthma showed significantly poorer quality of life than those without asthma. [14]
BE with asthma showed different clinical characteristics, including higher BMI, more respiratory symptoms, and more use of inhaler treatment compared with those without asthma. Similar findings were also observed in a previous research performed in China. [15] However, data regarding the characteristics of bronchiectatic population with asthma are limited. Because bronchiectasis-asthma overlap is not yet clearly defined, the diagnosis of asthma in BE is challenging since it is made at the discretion of attending physicians. [16] However, the present study provided meaningful results showing the clinical characteristics of asthma in terms of bronchiectasis cohorts in actual clinics. However, BE with asthma-like features and patients with long-confirmed asthma history plus concomitant bronchiectasis may be different populations, which was not distinguished in this study. Thus, further studies using various cohorts (bronchiectasis and asthma cohorts) are warranted to characterize bronchiectasis-asthma overlap. [17]
Notably, the existence of asthma was independently associated with a poorer quality of life in BE even when adjusting for potentially confounding factors. In agreement with our results, in a previous study, the EMBARC cohort showed a similar result when the quality of life was measured using a different tool (quality of life-bronchiectasis scale). [18] The present study also provided detailed aspects of quality of life because the score for BHQ each item was evaluated, which supports previous findings. BE with asthma were more hampered by the following than those without asthma: dyspnea, sleep disruption, coughing, tiredness, [19] and much slower in performing tasks. The impaired dyspnea, sleep disruption, and coughing indicate that more attention should be given to the proper control of respiratory symptoms in BE with asthma. Furthermore, the present study results provide insights into pulmonary rehabilitation potentially benefitting tiredness and slow task performance, which may improve quality of life and long-term outcomes in BE with asthma. [20]
Unexpectedly, asthma was not significantly associated with an increased rate of AEs in the prior year in BE. Conversely, identified asthma was considered a relevant risk factor for bronchiectasis exacerbation in previous studies. [21]In studies with asthmatic patients, bronchiectasis was also associated with increased risk of exacerbations. [22] The discordant result of our study might be explained by the following reasons: exacerbation was assessed during a relatively short period (initial questionnaires on exacerbations in a previous year); regional differences in study populations affected different clinical outcomes; a very high proportion of regular asthma-related medications, especially ICS, may have affected the results. Proper therapeutic intervention such as asthma medication in asthma-bronchiectasis overlap patients may reduce the risk of exacerbations requiring antibiotics,3,29 and because we used the definition of AE for bronchiectasis, mild AEs requiring a short-acting beta agonist only might not have been counted. [23]
Notably, BE with asthma showed lower frequency of exacerbation requiring antibiotics than BE without asthma (77.3% vs. 94.1%). Clinicians might prescribe systemic corticosteroids instead of antibiotics when their BE with asthma experience AEs. Currently, biomarkers do not exist to guide the use of antibiotics or corticosteroids for the treatment of BE with asthma. Because identifying therapeutic traits can improve the clinical outcomes of BE, [24] evaluating whether eosinophilic endotypes are higher in BE with asthma than in BE without asthma is important. Because the EMBARC is an ongoing registry, future longitudinal data could help elucidate the exacerbation risk and appropriate treatment strategies when considering eosinophilic endotypes in BE with asthma. [25].
This study provides further evidence of the association between bronchiectasis and severity of asthma. Moreover, it shows that the presence of bronchiectasis in patients with asthma is associated with severe pulmonary insufficiency, higher risk of exacerbations, and a worse prognosis. From the clinical point of view, we conclude that this subgroup of patients may need tailer treatment targeting chronic mucus production and airway bacterial infection, in addition to the recommended treatments for patients with asthma, in order to improve symptoms and to reduce future risks. Moreover, we conclude that more prospective cohort studies should be conducted to identify whether coexistent bronchiectasis should be considered a pathological phenotype of asthma, which may have important predictive value in clinical care