Bronchiectasis Nursing Care and Management: Study Guide

Bronchiectasis is permanent damage, the airways are stretched out and they stay that way, so most of your work is clearing secretions, controlling infection, and teaching the patient to do the same at home.

What is Bronchiectasis?

Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Under the current definition of COPD, it is a separate disease process.

Pathophysiology

Bronchiectasis is usually localized, hitting a segment or lobe, most often the lower lobes. Infection-driven inflammation damages the bronchial wall and strips its supporting structure, leaving thick sputum that obstructs the bronchi. The walls become permanently distended and distorted, which wrecks mucociliary clearance. Retained secretions and obstruction collapse the alveoli distal to the blockage, and inflammatory scarring (fibrosis) replaces functioning lung tissue. Over time the patient develops respiratory insufficiency with reduced vital capacity, decreased ventilation, and an increased ratio of residual volume to total lung capacity, plus ventilation-perfusion mismatch and hypoxemia.

Causes

Bronchiectasis follows several conditions: airway obstruction that permanently distends the wall and impairs mucociliary action, pulmonary infection or long-term infection complications, genetic disorders such as cystic fibrosis that thicken sputum and obstruct the bronchi, and idiopathic causes.

Clinical Manifestations

The hallmark is a chronic cough lasting 2 months or more with copious purulent sputum. Many patients have hemoptysis. Clubbing of the fingers is common because of respiratory insufficiency, and patients have repeated episodes of pulmonary infection.

Complications

Atelectasis (collapse of alveoli), recurrent pneumonia, and empyema (bronchi filling with pus from sputum overproduction).

Assessment and Diagnostic Findings

Bronchiectasis is easy to miss because it mimics simple chronic bronchitis. A prolonged history of productive cough with sputum negative for tubercle bacilli is a strong sign. A CT scan establishes the diagnosis by revealing bronchial dilation.

Medical Management

The objectives are to promote bronchial drainage and to prevent or control infection. Postural drainage is part of every treatment plan, since gravity drainage of the bronchiectatic areas reduces secretions and infection. Chest physiotherapy (percussion and postural drainage) is central to managing secretions.

Pharmacologic Therapy

• Antimicrobial therapy. Guided by sensitivity studies on sputum cultures to control infection.
• Bronchodilators. For patients with reactive airway disease; also assist secretion management.

Surgical Management

Surgery is indicated for patients who keep expectorating large amounts of sputum and have repeated bouts of pneumonia. Options are segmental resection (the diseased segment of a lobe is removed), lobectomy (the diseased lobe is removed), and pneumonectomy (the entire diseased lung is removed, which rarely happens).

Nursing Management

Nursing Assessment

Evaluate current smoking status, current exposure to occupational toxins or pollutants and indoor/outdoor pollution, and the patient's current level of functioning.

Nursing Diagnosis

• Impaired gas exchange related to ventilation-perfusion imbalance.
• Ineffective airway clearance related to increased mucus production.
• Ineffective breathing pattern related to mucus and airway irritants.
• Activity intolerance related to hypoxemia and ineffective breathing patterns.

Nursing Care Planning & Goals

Improve gas exchange, achieve airway clearance, improve breathing pattern, and improve activity tolerance.

Nursing Interventions

• Smoking cessation. Target smoking and other factors that increase mucus and hamper its removal.
• Bronchodilators. Administer as prescribed.
• Postural drainage. Perform with percussion and vibration in the morning and at night as prescribed.
• Antibiotics. Administer as prescribed.
• Activities. Alternate activity with rest periods.

Evaluation

Improved gas exchange, effective airway clearance, improved breathing pattern, and improved activity tolerance.

Discharge and Home Care Guidelines

Push smoking cessation hard, since smoking paralyzes ciliary action, increases bronchial secretions, and inflames the mucous membranes. Teach the patient and family to perform postural drainage, avoid people with upper respiratory or other infections, and recognize the early signs of respiratory infection so treatment starts promptly. Assess nutritional status and put strategies in place for an adequate diet at home.

Documentation Guidelines

Document respiratory rate, character of breath sounds, and presence of cyanosis; frequency, amount, and appearance of secretions; character of cough; relevant history; respiratory pattern; use of respiratory aids; level of activity; vital signs before, during, and after activity; the plan of care and teaching plan; the patient's response to treatment, teaching, and actions performed; progress toward desired outcomes; modifications to the plan of care; and long-term needs.