Learning Objectives
By the end of this section, you will be able to:
- Discuss pathophysiology, risk factors, and clinical manifestations for bronchiectasis
- Describe the diagnostics and laboratory values in the disease of bronchiectasis
- Apply nursing concepts and plan associated nursing care for the patient with bronchiectasis
- Evaluate the efficacy of nursing care for the patient with bronchiectasis
- Describe the medical therapies that apply to the care of bronchiectasis
Bronchiectasis is a chronic lung condition that results in widened, damaged airways. In the United States, there are approximately 350,000 to 500,000 adults with bronchiectasis. Increased case rates occur in women, adults over sixty, and patients with a structural lack of access to resources.
Pathophysiology
In bronchiectasis, the elastic, supportive structures of the bronchial wall become damaged, and the bronchi abnormally dilate (Figure 11.13). The damage and dilation make it harder to cough up and clear lower airway secretions. When mucus and phlegm remain trapped in the lower airways, bacteria can flourish. Infection and inflammation cause additional damage to the airways and can worsen bronchiectasis. This causes a recurrent cycle of infection, inflammation, and airway damage.
Risk Factors
Risk factors for bronchiectasis include genetic diseases that affect the respiratory tract, including cystic fibrosis and primary ciliary dyskinesia. Previous lung infections and immunosuppression can predispose a person to bronchiectasis. Asthma and connective tissue disorders are also associated with a greater incidence of bronchiectasis. The risk of bronchiectasis is increased with airway obstruction; causes of obstruction can include tumor, aspiration, and COPD. Approximately 40 percent of cases are considered idiopathic, which means the cause is unknown (American Thoracic Society, 2022). Bronchiectasis is more common in female patients and older adults. In adults sixty and older, bronchiectasis is eight to ten times more prevalent when compared with patients fifty years old and younger (Barker, 2023c).
Clinical Manifestations
The primary clinical manifestations of bronchiectasis are cough and sputum production. Signs of infection, including fatigue, chills, fever, and night sweats can occur. During an acute infection, the sputum may increase and change color. Patients may report shortness of breath, chest tightness, hemoptysis (coughing up blood), and unintentional weight loss (American Thoracic Society, 2022).
Assessment and Diagnostics
Diagnosis of bronchiectasis is made based on the presence of patient-reported symptoms in conjunction with imaging tests. Ninety-eight percent of patients with bronchiectasis will report a cough. Bronchiectasis is suspected in patients who report both a cough and sputum production experienced most days of the week. Because a cough and sputum production can occur with other illnesses, imaging is used to identify anatomical abnormalities that are specific to bronchiectasis. Adventitious lung sounds present in bronchiectasis commonly include crackles, but wheezes may also be present (Barker, 2023c).
To formally diagnose bronchiectasis, imaging is needed. A chest x-ray will commonly show nonspecific abnormalities, such as dilated, thickened airways or atelectasis, which is a condition that causes a partial or complete collapse of the lung. A CT scan is needed for definitive diagnosis, however. A CT scan provides evidence of anatomical abnormalities that confirm the diagnosis and identifies which parts of the lungs are affected. Lung function tests, such as spirometry and a six-minute walk, may be used once diagnosis is established. Lung function tests are not used to diagnose bronchiectasis, but to evaluate lung function, disease trajectory, and response to treatment (Barker, 2023c). When infections are present or suspected, additional testing is required. Sputum may be sent for Gram stain and culture; viral testing can evaluate for viruses like flu or COVID-19 (Barker, 2023b).
Nursing Care of the Patient with Bronchiectasis
When providing nursing care to a patient with bronchiectasis, areas of focus include preventing complications and managing symptoms. With comprehensive prevention strategies, modifiable risk factors for developing complications can be addressed, potentially leading to better outcomes.
Recognizing Cues and Analyzing Cues
The nurse providing care to a patient with bronchiectasis recognizes and analyzes subjective and objective assessment data to provide safe care. Subjective data includes shortness of breath, chest pain, and signs of infection, such as chills, feeling warm, and night sweats. Monitor vital signs because of the risk of infection and respiratory compromise. Subtle changes in vital signs, especially respiratory rate, oxygen saturation, and temperature, are especially important to monitor and track. The nurse performs auscultation, noting the location and character of any adventitious lung sounds. A cough will often be present, and the patient should be questioned about its frequency and characteristics. It is important to note the volume and character of any mucus produced, including the presence of visible blood.
Environmental irritants can worsen bronchiectasis. The nurse should ask the patient about exposure to air pollution, smoke, and secondhand smoke. If the patient smokes or vapes, inquire about frequency, years of use, and duration. Because preventable respiratory illnesses can worsen bronchiectasis, inquire about the patient’s immunization status.
Clinical Safety and Procedures (QSEN)
Teamwork and Collaboration
The care of patients with bronchiectasis can be complex and requires a strong, collaborative, interprofessional team. Medications may be nebulized or inhaled. A nebulizer converts liquid medication into a fine mist. The mist is inhaled through a mask or mouthpiece. A nebulizer is often used to treat those with severe respiratory conditions. An inhaler is a handheld device that delivers a premeasured dose of medication in the form of a spray or powder, and is often used to open the airway passages. Inhalers should be administered prior to nebulizers for optimal absorption of the medications. Respiratory therapists may administer the medication or reinforce teaching with the nurse, patient, and family. Successful airway clearance strategies may require the cooperation of nursing staff, physical therapists, respiratory therapists, and physicians. Similarly, oxygen administration can require close communication between physicians, nurses, and respiratory therapists to ensure oxygenation goal (usually > 92 percent) is met.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Signs of active infection and inadequate oxygenation are a high priority. When a patient reports symptoms, such as fever and purulent sputum, the nurse should communicate these findings to the provider. Nursing interventions based on a provider order may include administering antipyretics, preparing a patient for CT scan, obtaining a sputum sample for Gram stain and culture, and administering antibiotics. Some patients with bronchiectasis may require supplemental oxygen. The nurse collaborates with respiratory therapy and the provider to identify SpO2 targets and optimize oxygenation. Additionally, the nurse works together with the patient and respiratory therapy on airway clearance strategies, including chest physical therapy, positive expiratory pressure devices, and wearable percussion vests. If a large volume of blood is present in sputum, hemoptysis can be an emergency. Nursing interventions may be related to suctioning and airway clearance, oxygen administration, or preparing the patient for a procedure to stop the bleeding.
Educational topics include immunizations and strategies to avoid environmental irritants. The nurse may provide coaching and resources on smoking cessation. Additional teaching may reinforce how to identify signs of infection and airway clearance strategies and devices.
Evaluation of Nursing Care for the Patient with Bronchiectasis
Evaluate the efficacy of nursing care by assessing the patient’s respiratory status. The nurse considers if indicators of infection, adventitious lung sounds, and cough have improved. Consider activity tolerance and oxygen requirement. The absence of vaccine-preventable infections is a goal.
Link to Learning
Nurses or respiratory therapists will often provide chest physiotherapy (CP) to optimize clearing of the airway. Watch this video for a chest physiotherapy demonstration.
Medical Therapies and Related Care
Effective treatment of bronchiectasis requires collaboration with the interprofessional team, including physicians, respiratory therapists, and pharmacists. Often, a variety of interventions will be necessary to provide symptom relief and prevent disease progression. In addition to being a potential trigger for the initial development of bronchiectasis, lung infections can also worsen existing cases. Key points for treatment include:
- Treatment with antibiotics is necessary for bacterial infections.
- Antibiotics may be oral, intravenous, inhaled, or nebulized.
- Antiviral medications can be used when a viral infection is present.
- Some patients with recurrent exacerbations may be prescribed a preventive antibiotic.
- Some types of fungal infections cause inflammation that can lead to bronchiectasis; in these cases, antifungal medications and steroids are prescribed.
- A key component of nonpharmacologic therapy for bronchiectasis is avoiding substances that irritate the respiratory tract. Patients are instructed on smoking cessation (including vaping) and to avoid other irritants like cleaning products, dust, and smoke. Some patients may be advised to wear masks to avoid environmental triggers.
- Airway clearance interventions can improve a patient’s ability to clear mucus. These include chest physical therapy, which can improve drainage and mobilization of mucus; positive expiratory pressure devices, which let the patient breathe in easily but create resistance as they exhale, slowing down the breath and causing the patient to increase the force of exhalation; and wearable chest wall high frequency oscillation vests, which provide movement and percussion that helps mobilize secretions.
- Nebulized hypertonic saline is used to thin mucus.
- When immunodeficiencies are present, treatment with immune globulin may prevent bronchiectasis or delay disease progression. An immune globulin is a product that may be administered intravenously or subcutaneously to provide necessary antibodies to strengthen the immune system.
- Treating dysphagia or reflux that causes aspiration pneumonia can limit disease progression.
- In patients with major hemoptysis related to severe lung damage, procedures to stop the bleeding may be necessary.
- In advanced cases, surgical removal of the damaged section of lung can be performed.
- Lung transplantation is sometimes necessary (Barker, 2023b).
Treatment is often complex, challenging, and prolonged. Coordinated care that encompasses psychosocial support is essential.
Link to Learning
The nurse or respiratory therapist will incorporate positive expiratory devices to encourage an increase in the force of expiration to assist with clearing mucus from the airway. Watch this video for a demonstration of a positive expiratory pressure device in use.