An overview of treatment and management of patients with bronchiectasis
Peres, A. (2009) The nurse’s role in managing bronchiectasis. Nursing Times; 105: 13, early online publication.
In a previous article on bronchiectasis, Alan Peres defined bronchiectasis, its pathophysiology and clinical manifestations, and how nurses may assess patients presenting with it (Peres, 2008). This article provides an overview of treatment and the role of the nurse in providing and managing the care of patients with this condition.
Keywords: Bonchiectasis, Respiratory nursing, Host defence
Alan Peres, RGN, is a senior staff nurse, Foulis Ward, Royal Brompton and Harefield NHS Trust, London.
Bronchiectasis is a destructive lung disease characterised by abnormal chronic dilatation of the bronchi, associated with persistent or intermittent inflammation of lung tissue. It can occur following infection or after an insult to the airways such as aspiration of gastric contents or smoke inhalation (Shoemark et al, 2006; Sapey and Stockley, 2004) (Box 1).
Box 1. Causative factors in bronchiectasis
- Congenital defects of bronchial wall
- Abnormal mucociliary clearance (primary ciliary dyskinesia, cystic fibrosis)
- Post-infection (tuberculosis, whooping cough, non-tuberculous mycobacteria)
- Impaired immune response (common variable immune deficiency (CVID), HIV)
- Excessive immune response (allergic bronchopulmonary aspergillosis, lung transplant rejection)
- Obstruction of bronchial lumen (internal or compression), such as tumour or foreign body
- Inflammatory pneumonitis (aspiration of gastric contents, inhalation of toxic gases)
- Fibrosis (sarcoidosis, radiation treatment)
The vicious cycle used to describe bronchiectasis is a useful model to understand disease progression and its treatment (Fig 1). It is often difficult to identify what happens first in that process, as the interplay of all factors leads to the progression of the disease.
The treatment of bronchiectasis involves pharmacological and non-pharmacological interventions and a multiprofessional team approach.
Managing sputum clearance
Secretions accumulate in the lungs because the airways are dilated and mucociliary clearance is impaired.
This is treated by regular physiotherapy exercises, such as postural drainage and breathing exercises, that help the patient expectorate sputum.
Patients are taught these exercises by a physiotherapist and are then encouraged to undertake their routine at least once daily and more often during an infective exacerbation.
There is a lack of evidence supporting the use of long-term physiotherapy but expert opinion supports long-term use (King et al, 2006; Rosen, 2006).
Adherence to physiotherapy is often poor, mainly because of the commitment and time required for this intervention.
During periods of infection, the patient may expectorate large volumes of sputum which can be offensive.
Patients may require support to manage this and prevent cross-infection. Nurses should be alert to the need for regular clean sputum pots, tissues and good oral hygiene.
It is important to monitor hydration and replace fluid loss associated with increased sputum production.
If sputum is thick and difficult to expectorate, patients may benefit from nebulised sodium chloride solution to help liquefy secretions.
Another strategy is ultrasonic nebulisation, in which the size of droplets is smaller than in jet nebulisers. This facilitates the hydration of secretions and smaller droplets can be inhaled further down in the airways.
Evidence supporting the use of mucolytics such as carbocisteine and acetylcysteine is poor, although some patients and clinicians believe they help expectoration (Rubin, 2007; Crockett, 2001).
In patients with airway reversibility, short-acting bronchodilators should be taken before physiotherapy to facilitate airway opening and drainage of sputum. Long-acting beta2 agonists, inhaled corticosteroids and nebulised antibiotics should be taken after treatment, when there are fewer secretions in the airways, thereby increasing effectiveness of treatment as the drug reaches the airways (Wilson, 2003; Currie, 1997).
Managing bacterial infection
It is imperative that patients with bronchiectasis have their sputum cultured regularly to identify organisms colonising the lungs, so species known to be particularly pathogenic - such as Pseudomonas aeruginosa and Stenotrophomonas maltophilia - can be eradicated as soon as possible. This information is also useful for nurses when deciding which patients will require isolation to avoid cross-infection. Bacterial infection requires prompt treatment with antibiotic therapy.
Patients may be treated with oral antibiotics while intravenous antibiotics are used to treat more acute exacerbations. Nebulised antibiotics are frequently used between exacerbations, but may also be prescribed during an acute episode.
Some patients may require prophylactic antibiotics, with a few receiving regular, pulsed courses of intravenous antibiotics every 8-12 weeks (Boyton, 2008; Evans and Greenstone, 2003). This involves the administration of regular courses of antibiotics regardless of whether the patient has an active infection.
Patients can self-administer intravenous antibiotics at home. This requires safety considerations, for example, ensuring that they are competent in self-administration via the chosen intravenous administration device and are able to care for the device.
Diffuse bronchiectasis may be caused by impaired host defences, for example, common variable immune immunodeficiency and HIV (see Box 2).
Box 2. CVID (Common variable immunodeficiency)
Common variable immunodeficiency is a syndrome characterised by low plasma levels of gammaglobulin, leading to recurrent bacterial infections of the upper and lower respiratory tract and various immunologic abnormalities. These infections are a direct result of the deficiency in antibody production – specifically immunoglobulin G (IgG).
It is important to identify patients with immunoglobulin deficiency so that replacement therapy can be given. This therapy can result in long-term substantial reduction in pneumonic episodes (Garcia et al, 2001).
Managing the inflammatory response
The inflammatory response is treated with corticosteroids by the oral, inhaled or intravenous route.
Systemic corticosteroids should be prescribed with caution because of side-effects associated with their long-term use. Regular blood glucose monitoring is recommended for those on high steroid dosages to detect raised blood glucose levels which are a side-effect of steroid therapy.
Patients are advised to use a mouthwash after using inhaled steroids to prevent the side-effects of a hoarsening voice and oral thrush.
Managing disease progression
With the progression of the disease and the resulting tissue damage, treatment is aimed at preventing further deterioration and compensating for the loss of physiological function associated with the pathological process.
Patients may need oxygen therapy during an exacerbation and some patients benefit from humidified oxygen as this loosens secretions and aids expectorate.
Long-term oxygen therapy may be required as the disease progresses including oxygen concentrators installed at home and portable cylinders so that patients can move around (Young, 2005).
Some patients with bronchiectasis will develop type II respiratory failure, where the arterial carbon dioxide pressure (PaCO2) exceeds 6kPa and arterial oxygen pressure (PaO2) is less than 8kPa on air (British Thoracic Society, 2002). These patients may benefit from a non-invasive ventilator used at night or, more often, during an acute exacerbation (Wedzicha and Muir, 2002).
A sleep study where a patient’s CO2 levels are monitored overnight may be performed before setting up the ventilator, while measurement of arterial blood gases will indicate if the treatment is successful. The patient will need assistance in adjusting to this therapy as they will have to wear a tight-fitting mask and have a relatively complicated piece of medical equipment in the home.
Energy-saving techniques and pacing
Patients benefit from learning to pace themselves using energy-saving techniques such as having short naps during the day. This compensates for the tiredness most patients associate with the increased work of breathing.
Occupational therapists may provide patients with specially adapted equipment, such as bath boards and perch chairs, which are useful in conserving energy and avoiding accidents (Sewell and Singh, 2005).
Patients with bronchiectasis tend to lose weight as the disease progresses and a dietitian can provide patients with dietary advice and nutritional supplements.
Social workers can provide advice on social security and coordinate the provision of community social services, such as visiting carers to help patients to adapt and/or cope with the burden of disease as they become more dependent on others.
The patient with localised bronchiectasis resistant to antibiotic therapy may benefit from surgical dissection of the affected part, while the patient with diffuse bronchiectasis whose life has been affected significantly may be referred for transplantation. Survival data is very limited but suggests around 60% of patients survive the first five years (Beirne et al, 2005).
The role of the nurse
Nurses play a vital role in the multidisciplinary team caring for patients with bronchiectasis.
In primary care, nurses provide information and support about smoking cessation and following up patients who require care including antibiotics, immunisations and blood tests.
The nurse caring for patients with bronchiectasis may be involved in educating the patient following diagnosis and supporting patients and their families to cope and recognise symptoms so as to avoid complications.
Bronchiectasis can result in anxiety associated with negative health perception, and depression appears to be related to the perceived level of exercise impairment and breathlessness in daily life (O’Leary et al, 2002).
Self-image is also a problem as patients report worries about the negative image of coughing and sputum and how attractive they appear to others. The input from a health psychologist or psychiatrist may be required.
Cognitive behavioural therapy has been shown to be useful in dealing with these problems (Parkin et al, 2006).
For most patients, learning to cope with the illness and trying to lead a normal life is a common experience.
The nurse may help by promoting prevention and self-management strategies such as: a healthy diet, exercise and good hygiene habits; identifying and treating exacerbations; and encouraging adherence to treatment.
Patients who attend regular clinic visits, receive regular influenza and pneumococcal vaccinations and maintain a BMI above 20 are more likely to live longer (Onen et al, 2007).
MacLeod (2005) mentions several non-pharmacological interventions for dealing with chronic breathlessness, such as a detailed assessment of dyspnoea in conjunction with breathing retraining.
A study by Lavery et al (2007) suggested that nurses can help patients gain confidence in dealing with perceived obstacles to self-management activities by providing information on access to health care and to support groups such as Breathe Easy (organised by the British Lung Foundation) and encouraging independence in many aspects of care.
Nurses will be involved in providing end-of-life care when patients are either not suitable for transplantation or their deterioration has accelerated. This entails emotional support for the patient and family, providing comfort and alleviating pain, assisting patients with self-care activities and helping patients make arrangements for dying and death.
Because of nurses’ position in the multidisciplinary team, they have the potential to provide care to patients with bronchiectasis including assessing needs and coordinating the input of other healthcare professionals. Bronchiectasis is a disease that is poorly understood but, by educating themselves, colleagues and patients, nurses can greatly improve the care of patients with this condition.
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