Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose, and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis.
The primary etiology in the development of ordinary acquired Bronchiectasis is inflammatory destruction of the elastic tissue, smooth muscle, and cartilage of bronchial walls usually due to severe preceding infection(s). Fewer cases are caused by genetic or immune deficiencies or result from inhalation injury.
Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:
- Bronchopulmonary infection— Mycobacterium species, bacterial (e.g., Staphylococcus aureus, Bordetella pertussis, Klebsiella pneumoniae, H. influenza ), viral (e.g., measles, HIV, adenovirus, influenza), fungal (histoplasmosis, coccidiomycosis), recurrent aspiration pneumonia.
- Bronchial obstruction—foreign body aspiration, lung or bronchogenic neoplasm, airway nodules, hilar adenopathy (e.g., sarcoidosis), mucus impaction (e.g., allergic bronchopulmonary aspergllosis), broncholith, external compression by vascular aneurysm.
- Immunodefi ciency states—hypogammaglobulinemia, IgG subclass deficiency, selective IgA deficiency.
- Other congenital syndromes—cystic fibrosis, alpha1-antitrypsin deficiency, primary ciliary dyskinesia (e.g., Kartagener’s syndrome), Young’s syndrome (azoospermia and chronic sinopulmonary infections).
- Inhalation injury—smoke, ammonia, sulfur or nitrogen dioxide.
- Rheumatologic disease—rheumatoid arthritis, Sjogren’s syndrome
- Anatomic defects—bronchomalacia, Swyer-James syndrome, bronchial cartilage deficiency (Williams-Campbell syndrome), tracheobronchomegaly (Mounier-Kuhn syndrome)
- Hemoptysis occurs in nearly 50% of patients with bronchiectasis (Mysliwiec & Pina, 1999); major pulmonary hemorrhage and death from exsanguination are rare (Swartz, 1998).
- Empyema, lung abscess, and pneumothorax are serious but rare complications of acute infections in bronchiectasis (Luce, 1994).
- Progressive respiratory insuffi ciency and cor pulmonale complicate severe bronchiectasis associated with deteriorating pulmonary function and hypoxemia.
TREATMENT FOR BRONCHIECTASIS
a. Medical interventions
- Inhaled bronchodilators may be helpful in diffuse small airway disease; beta adrenergic agents dilate airways and improve ciliary activity (Swartz, 1998).
- Antimicrobial therapy for treatment of acute infectious exacerbations is based on results of sputum gram stain and culture.
- Corticosteroids reduce the airway infl ammatory response in bronchiectasis.
- Oxygen therapy is prescribed as indicated for patients with hypoxemia at rest, during sleep, and/or with activity.
- Gamma globulin replacement for immunoglobulin defi ciency may be effective in reducing the frequency and severity of sinopulmonary infections (George et al., 1995).
- Effective reduction and removal of bronchial secretions by a variety of available methods is critical in patients with bronchiectasis. The approach selected should be based upon an individual’s self-care abilities, motivation, breath control, neuromuscular status, preferences, needs, and financial resources (Langenderfer, 1998).
- Effective cough
- Percussion and postural drainage
- Autogenic drainage
- Positive expiratory pressure (PEP) therapy
- Flutter valve
- Vest therapy
- Humidifi cation (by cold water, jet nebulizers) as an adjunct to chest physiotherapy enhanced sputum production (Conway, Fleming, Perring, & Holgate, 1992).
- Aerosolized recombinant human DNase may lyse the DNA that causes the sputum to be highly viscous. Initial studies for cystic fibrosis are promising, but this therapy is not FDA approved in non-CF bronchiectasis (O’Donnell, Barker, Ilowite, & Fick, 1998; Wills et al., 1996).
- Non-invasive intermittent positive pressure ventilation (NIPPV) is an alternative to tracheostomy for respiratory failure due to advanced bronchiectasis.
b. Surgical intervention
- Surgical resection
- Lung or heart-lung transplantation
Nursing diagnosis Bronchiectasis
Nursing diagnosis for Bronchiectasis determine from data that we collect from nursing assessment and from the test diagnostic results.
Nursing assessment for Bronchiectasis
Patient’s history of recurrent bronchopulmonary infections and symptoms of chronic productive cough are hallmark features of bronchiectasis. Pain and dyspnea are also common.
- The history of acute, even if delayed, onset of bronchiectasis can sometimes be traced to a defi nite illness, pneumonia, or aspiration event in patients with postobstructive or infectious bronchiectasis. Those patients with underlying congenital or immune disorders usually demonstrate a more insidious disease onset (Luce, 1994).
- Cough is present in 90% of patients (Nicotra et al., 1995).
- Daily (often purulent) sputum production occurs in 75% of patients and varies in volume from 10–500 ml (Nicotra et al., 1995).
- Pleuritic chest pain represents distended peripheral airways or distal pneumonitis adjacent to a visceral pleural surface. This symptom occurs in 50% of bronchiectasis patients (Barker, 2002).
- Repeated episodes of fever, pleurisy, and/or sinusitis are also common.
- Weakness, dyspnea, and weight loss are seen in patients during infectious exacerbations or those with extensive disease.
- The St. George’s Respiratory Questionnaire (SGRQ) has been validated as a useful tool for assessment of health-related quality of life in patients with bronchiectasis (Wilson, Jones, O’Leary, Cole, & Wilson, 1997). Test items are divided into three major areas: symptomatology; activity tolerance; and impact of the condition on daily life including employment, need for medications, and sense of control or panic over one’s health.
Physical examination findings are neither sensitive nor specific for bronchiectasis.
- Crackles are the most common adventitious auscultatory finding, followed in frequency by wheezing, rhonchi, and a pleural friction rub (Barker, 2002; Mysliwiec & Pina, 1999; Nicotra et al., 1995).
- Digital clubbing is rare (Barker, 2002; Mysliwiec & Pina, 1999).
- Nasal polyps and sinusitis may also be evident (Luce, 1994).
- Patients may have fetid breath chronically or solely during episodes of purulent sputum production.
- Generalized weight loss and use of accessory muscles accompany severe disease.
Diagnostic Test for Bronchiectasis
- Radiographic imaging studies are the principal diagnostic tools for Bronchiectasis (chest roentgenogram, non-contrast computed tomography (HRCT) and spiral volumetric scans.
- Bronchoscopy is used to examine airways for obstructing tumors or foreign bodies, to evaluate the degree and site of hemoptysis, and to detect or remove inspissated secretions (Barker & Bardana, 1988; George, Matthay, Light, & Matthay, 1995).
- Functional assessment of the bronchiectasis patient includes pulmonary function testing with spirometry and lung volumes, and arterial blood gas analysis.
- Laboratory studies are important in the diagnosis and follow-up of patients:
- The complete blood count with cell differential may reveal leukocytosis or increased neutrophil levels during acute exacerbations; anemia may be present in chronic infections (Swartz,1998).
- Quantitative serum immunoglobulin levels of IgA, IgM, IgE, IgG
- Sputum smear reveals large numbers of white blood cells and both gram-positive and gram-negative organisms
- Sweat chloride testing is used to screen for cystic fibrosis in young adults with no identifiable predisposing cause for bronchiectasis.
- Aspergillus titers are indicated when an Aspergillus organism is cultured or if radiographic exam (chest X-ray or HRCT) demonstrates central bronchiectasis (Barker & Bardana, 1988).
Nursing Diagnosis That Could Be Found In Patient with Bronchiectasis
- Impaired gas exchange related to ventilation–perfusion inequality
- Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications
- Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants
- Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation
- Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns
- Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work
- Deficient knowledge about self-management to be performed at home.
Nursing Care Plans Bronchiectasis
Nursing Care Plans Bronchiectasis. Common nursing diagnosis found in nursing care plans for Bronchiectasis: Impaired gas exchange, Ineffective airway clearance, Ineffective breathing pattern, Self-care deficits, Activity intolerance, Ineffective coping, and Deficient knowledge.
Below is Sample nursing care plans Bronchiectasis:
Bronchiectasis, Patient Teaching & Home Health Guidance
Patient Teaching & Home Health Guidance for Patient With Bronchiectasis. Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis.
Patient Teaching & Home Health Guidance for Patient with Bronchiectasis:
- Instruct on early signs of pulmonary or sinus infection: change in amount or color of sputum or nasal drainage, Hemoptysis, increased Dyspnea, fever, chills, fatigue, headache, chest pain.
- Emphasize importance of completing full course of antimicrobial therapy to prevent relapse or development of resistant strains of organisms; include education on proper delivery of intravenous and/or aerosolized antibiotics.
- Teach patient and significant other effective airway clearance techniques to remove secretions and optimize ventilation. In addition to postural drainage and chest percussion, the patient may be instructed on proper use of the Flutter or PEP devices. The Vest is an alternative to chest percussion.
- Encourage the patient to drink plenty of fluids to thin secretions and aid expectoration
- Educate on avoidance of potential lung irritants: secondhand smoke, dust, noxious fumes, occupational exposures, and respiratory infections.
- Instruct the patient to avoid air pollutants and people with known upper respiratory tract infections.
- Inform patient of variety of pharmacologic and non-pharmacologic smoking cessation strategies and aids.
- If appropriate, advise the patient to stop smoking because it stimulates secretions and irritates the airways.
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