A nurse-led initiative has demonstrated that nebulised hypertonic saline can help patients with bronchiectasis to clear secretions, improving their quality of life
In this article…
- Developing a safe drug challenge and monitoring service for nebulised hypertonic saline
- Auditing data from the service
- Using findings from the data to further improve the service
Helen Pyne is an advanced practitioner in respiratory medicine, Salford Royal Foundation Trust.
Pyne H (2011) Hypertonic saline for bronchiectasis. Nursing Times; 107: 30/31, 21-22.
Despite intervention, some patients with bronchiectasis struggle to clear secretions. An advanced practitioner in respiratory medicine at Salford Royal Foundation Trust identified nebulised hypertonic saline (HTS) as a treatment that could potentially improve service provision. She developed and evaluated a safe drug challenge and monitoring service for nebulised HTS.
Keywords: Bronchiectasis, Respiratory medicine, Hypertonic saline
- This article has been double-blind peer reviewed
5 key points
- Bronchiectasis is caused by irreversible dilatation, thickening and sac-like formations in the bronchial walls
- It can result in recurrent bacterial chest infections and symptoms such as breathlessness, cough, wheeze and chest pain
- Reducing infective exacerbation is an essential part of management
- Patients with bronchiectasis have a mean FEV1 annual decline of 50-55ml, similar to that seen in COPD
- Despite therapies, some adults with bronchiectasis, mucous plugging or bronchial sepsis have troublesome hypersecretions
Bronchiectasis is caused by irreversible dilatation, and thickening and sac-like formations in the bronchial walls (Fig 1). This results in secretions that are difficult to clear, causing recurrent bacterial chest infections and symptoms such as cough, breathlessness, wheeze and chest pain. It impacts significantly on quality of life.
Patients with bronchiectasis have a mean forced expiratory volume in 1 second (FEV1) annual decline of 50-55ml, which is similar to that seen in patients with COPD. In patients with bronchiectasis, the decline in FEV1 is fastest when there is pseudomonas colonisation, frequent exacerbations or raised inflammatory markers. As such, reducing infective exacerbation is an essential part of management.
Treatment is aimed at controlling infection and improving bronchial hygiene. Standard interventions include mucolytics; inhaled steroids; inhaled short-acting beta2 agonists; immunology blood tests for analysis of functional antibody levels; and vaccination or immunology referral where appropriate. Other interventions include respiratory physiotherapy techniques, with or without a flutter valve; general hydration; exercise; sport; singing; pulmonary rehabilitation; inspiratory muscle training; surgical extirpation (removal); and lung transplantation.
Despite standard interventions, some patients struggle to clear secretions. Nebulised hypertonic 7% saline (7% HTS) has been shown to enhance sputum clearance for these patients (Kellett et al, 2005). The mechanism for hyperosmolar agents is not well understood, but most likely relates to improved mucus rheology, which concerns deformation and flow of matter, increased ciliary motility and enhanced cough clearance. Conversely, a theory developed from in vitro study data suggests that low mucus salinity, rather than underhydration, contributes to mucus retention.
Developing a nurse-led service
Having identified nebulised HTS as a potential treatment, we reviewed the evidence. Most of the research relates to cystic fibrosis but one examined the impact of 7% HTS on non-cystic fibrosis bronchiectasis in adults. However, 7% HTS was not licensed for this indication, had a short shelf life, was expensive and supply could be unreliable.
The respiratory pharmacist sourced a product from PARI pharmaceuticals called Mucoclear – a preloaded nebule with 4ml of 6% HTS. This is licensed for use in this group of patients and easy to administer, has reported reliable supplies, a long shelf life, is relatively inexpensive and can be prescribed on FP10.
We met the drug company representative to discuss practical issues, then applied to add the drug to the hospital and primary care trust formulary. The next step was to develop guidelines along with a tailored assessment and evaluation tool, which were evaluated first by the team, then through clinical governance at directorate level. We designed a patient information booklet, which included advice on sputum clearance techniques and managing an air compressor and nebuliser unit.
HTS can cause significant paroxysmal bronchospasm, so a supervised challenge was required in a safe environment. Patients were invited to a one-hour appointment in a well-ventilated room to try the treatment and learn about the equipment. They then administered the HTS at home once a day for two months and were reviewed in a 15-minute clinic appointment. The co-
ordinator of the nebuliser service was involved and available to patients for advice and equipment replacement; her number was put in the information booklet.
Referrals were accepted from all respiratory team members once all standard therapies had been exhausted; patients were invited to clinic within four weeks. We agreed inclusion and exclusion criteria. Patients with bronchiectasis, mucous plugging and bronchial dilatation identified on high resolution computer tomography scanning (HRCT) or bronchoscopy were included, as were those with recurrent chest infections and hypersecretions or thick, difficult-to-clear secretions with no structural changes on HRCT. Patients with haemoptysis without infection or who had reacted to hypertonic saline were excluded.
Auditing the service
After 18 months, we audited data. Sixty patients had been challenged to the drug therapy. Of those, 41 (68%) completed two months of self-administration and returned for a review. Baseline data for each patient was compared with two-month review levels. Ten (17%) patients experienced bronchospasm causing coughing bouts, increased breathlessness and chest tightness immediately post challenge; they did not continue with the therapy. All recovered quickly and no delayed reactions were reported.
Two (3%) patients stopped administration during the initial phase because of problems with short-term memory, vision and dexterity. Five (8%) stopped due to increased symptoms or lack of benefit. One (2%) died of unrelated causes before review. One (2%) experienced a hypersensitivity reaction but requested a re-challenge during an infective exacerbation and now uses it intermittently during exacerbations.
The baseline tests were spirometric lung function and oxygen saturation levels; these were repeated immediately and 30 minutes post challenge. A visual analogue 10-point scale for indication of effort required for sputum clearance and a Juniper mini-asthma quality of life questionnaire were also completed, and patient-reported sputum quantity recorded. Tests were repeated at two months, when patients’ perceptions of their condition was also recorded. The follow-up was completed by 15 men and 26 women; the median age of the men was 62 years (range 31-70) and that of the women 63 years (range 38-82) – very different from those with cystic fibrosis.
Seven patients had normal range spirometry at baseline. Six had irreversible severe airflow obstruction because of COPD. All these patients were included in the analysis to prevent post-hoc subdivision analysis. A paired t-test found a statistically significant improvement in FEV1 and forced vital capacity. The clinical significance was borderline but, for some patients, the change was dramatic.
Visual analogue scale
A 10-point visual analogue scale was adapted from the Borg perception of breathlessness scale. All patients reported an increase of at least one point on the scale at follow-up. There was a mean rise of three points within a range of 1-10 points.
Nearly half (49%) of patients reported a rise in sputum expectorated daily. This is notoriously poorly estimated by people so we told the patients about the British Thoracic Society’s recommended measurement method and advised them to note daily sputum quantity over two months on a chart.
One patient reported a daily increase from 120ml to 220ml. Another had no phlegm before or after administration but experienced a dramatic improvement after three large mucous plugs were dislodged.
Juniper mini-asthma questionnaire
Quality of life rose in 59% of patients. The mean unit increase overall was 0.6; 0.5 is considered significant. For the patients with an improvement in quality of life, there was a mean 1.0 unit increase.
Ten patients had a baseline oxygen saturation level of 95% or below, which had risen by 2% or more, with a range of 2-7%.
Patient perception of condition
All but one patient reported an improvement as significant to life changing; the patient reporting no improvement had an infected exacerbation requiring therapy.
Evolution of the service
Patients who had experienced an infective exacerbation requiring antibiotic therapy before the challenge often noted a dramatic reduction in their sputum quantity. As they tended to experience a hypersensitivity reaction, they met the exclusion criteria. If symptoms reoccurred it was agreed they could be referred in future.
People with asthma who did not administer prophylactic-inhaled steroids regularly were likely to experience a hypersensitivity reaction so were also excluded. Those with significantly impaired short-term memory, vision or dexterity who lived alone were more likely to struggle with administration. They were not completely excluded – we advised a discussion about the practicalities of administration with the referrer.
We altered the assessment tool as a result of the experience gained over time. Initially, it was tailored to the research tool to ensure patient safety, but the repeated spirometric lung function testing did not provide any additional information so it was reduced to a baseline test that was repeated immediately and 30 minutes post challenge.
Despite standard therapies, some adults with bronchiectasis, mucous plugging or bronchial sepsis have troublesome hypersecretions. Two-thirds of our patients reported a significant improvement in symptoms using 6% HTS and, for some, this was life changing. This audit suggests that Mucoclear is a viable option, but controlled clinical trials are needed.
Kellett F et al (2005) Evaluation of nebulised hypertonic saline (7%) as an adjunct to physiotherapy in patients with stable bronchiectasis. Respiratory Medicine; 99: 1, 27-31.