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Bronchiectasis: pathophysiology,presentation and managementNS461 Farley AH ei al (2008) Bronchiectasis: pathophysiology, presentation and management. NursingStandard. 23, 3, 50-56. Date of acceptance: June 30 2008.

SummaryBronchiectasis, although not as common as other respiratory disorders,can be life-limiting and remains a significant problem for many patients,as well as being a considerable challenge for nurses caring for this patientgroup. This article examines the pathophysiology and presentation ofbronchiectasis and identifies various management strategies.

AuthorsAlistair H Farley, Charles Hendry and Carolyn C Johnstone arelecturers in nursing. School of Nursing and Midwifery, University ofDundee, Ninewells Hospital, Dundee. Email: a.h.farley@dundee.ac.uk

KeywordsAirway inflammation; Bronchiectasis; Respiratory system

These keywords are based on the subject headings from the BritishNursing Index. This article has been subject to double-blind review.For author and research article guidelines visit the Nursing Standardhome page at nursingstandard.rcnpublishing.co.uk. For relatedarticles visit our online archive and search using the keywords.

Introduction

Aims and intended learning outcomes

This article aims to increase knowledge andunderstanding of bronchiectasis, and to exploremanagement strategies to enable nurses to carefor patients with the condition and assist them tomaintain an acceptable quality of life. Afterreading this article you should be able to:

> Outline the anatomy and physiology of therespiratory system.

> Describe the changes which occur in therespiratory tract in bronchiectasis.

> Identify and explain the strategies available formanaging patients with bronchiectasis.

> Apply the knowledge gained from reading thisarticle to clinical practice.

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Bronchiectasis is defined as an abnormal dilationof the bronchi (Payne 2006, ten Hacken etal2007). The condition, although not common, canbe life-limiting and may lead to premature death.Bronchiectasis is now less common in developedcountries as a result of improved child health care(Selby 2002), such as universal vaccinationprogrammes against measles, pneumonia andwhooping cough (Perry 2007) and improvedhousing. However, the condition remainscommon in developing countries. Nurses in theUK, particularly those caring for older adults orworking in respiratory care, may encounterpatients with bronchiectasis. As a long-termchronic condition the focus for nurses is onsupporting self-care along with symptommanagement and education (Goodridge 2006).Bronchiectasis is likely to affect many aspects ofa patient's everyday life. Management of thecondition is essential to improve quality of life.

It is important to note that a form ofbronchiectasis occurs in patients with cysticfibrosis. However, this article focuses on patientswith non-cystic fibrosis bronchiectasis.

aUsing a textbook or resource ofyour choice, revise the normalstructure and function of therespiratory system.

•'• w'

Anatomy and physiology

The respiratory tract (Figure 1) consists of thenose, pharynx, larynx, trachea, bronchi,bronchioles and alveoli (Dunn 2005).

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Structurally, the respiratory system is divided intoan upper respiratory tract and a lower respiratorytract. The upper respiratory tract is composed ofthe nose, pharynx and larynx, while the lowerrespiratory tract is composed of the structuresbelow the larynx, namely the trachea, bronchi,bronchioles and alveoli (Thibodeau and Patton2004). The upper respiratory tract warms, filtersand moistens inhaled air before it enters the lowerportions of the respiratory system.

Respiratory mucosa lines the airways of therespiratory system. The lining of the airways iscovered with mucus secreted by goblet cells.Goblet cells are the main producers of mucus inthe small airways, but contribute only a smallproportion of the total mucus production. Mostmucus is produced by mucus glands in the upperairways. Mucus forms a protective blanketcovering the lining of the airways. An average adultproduces 125ml of mucus every day (Thibodeauand Patton 2004). Mucus is propelled from thelower respiratory tract upwards by the actions ofcilia - tiny, hair-like projections - covering theepithelial cells of the respiratory mucosa .Cilia waftmucus and foreign particles upwards and awayfrom the lower portions of the respiratory tract.Mucus is then swallowed. Excess mucus stimulatesthe cough reflex and mucus is then expectorated.

Pathophysiology of bronchiectasis

Bronchiectasis is an abnormal inflammatoryresponse of the lungs resulting in airflowlimitations (Downs and Appel 2007). Irreversibledilation of the bronchi occurs (Barker 2002),and is associated with destruction of the muscularand elastic components of the bronchial walls(Emmons 2007). The destruction of thesupportive muscular and elastic components ofthe bronchial walls results in permanentbronchial dilation and inflammation (Pruitt andJacobs 2005). The distended bronchi have atendency to retain secretions (Crowley 1997).The retained secretions become infected,triggering an ongoing and persistent hostinflammatory response (Pryor and Prasad 2002).

The features of such a response includevasodilation, increased capillary permeabilityresulting in movement of fluid from theintravascular compartment to the tissues,increased macrophage activity and localisedoedema. This persistent inflammatory responseleads to a loss of respiratory cilia and progressiveairway obstruction asa result of the oedema andexcess mucus. These changes greatly impairremoval of bronchial secretions (Gould 2006).A cycle of inflammation, infection, damage andfurther inflammation results, leading to furtherdilation and damage to the respiratory passages.

Patients with bronchiectasis may experience

repeated episodes of infection, produce copiousamounts of sputum and become increasinglybreathless (Sharpies ei a/2002). Sputum cultureoften identifies the presence oí Staphylococcusaureus, Haemophilus inßuenzae or Pseudomonasaeruginosa (Selby 2002). Dilation of the airwaysincreases the 'dead space', that is, the volume of aircontained within the respiratory passages that doesnot participate in gas exchange. As a consequence,less air reaches the respiratory surfaces and thepatient experiences breathlessness.

Bronchiectasis is associated with transmuralinfection and inflammation, which is related to therelease of chemical pro-inflammatory mediators.Pro-inflammatory mediators cause airwayinflammation and an increase in airflow limitation(Downs and Appel 2007). Respiratory obstructionoccurs in the presence of prolonged inflammatorysecretions, and micro-organisms contribute toairway damage and recurrent infection (Barker2002). Neutrophils and T lymphocytes are foundin the bronchial mucosa of patients withestablished bronchiectasis (Gaga eia/1998),which highlights the disease's inflammatory nature.

Bronchiectasis usually results from infectionand presents in the middle and older age groups(Maa eia/2007). However, inhalation of a foreignbody, and allergic, auto-immune and chemical lungdamage, can also predispose individuals tobronchiectasis (Mysliwiec and Pina 1999).Congenital disorders such as cystic fibrosis andprimary ciliary dyskinesia can lead to thiscondition (Payne 2006). Primary ciliary dyskinesialeads to the development of bronchiectasis as thecilia are unable to clear the air passages effectively.This results in the retention of secretions and leadsto recurrent infections. Other conditionsassociated with bronchiectasis include allergicbronchopulmonary aspergillosis,immunodeficiency states (Emmons 2007), foreign

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body aspiration and benign airway tumours (Pruittand Jacobs 2005). Typical clinical features ofbronchiectasis are shown in Box 1.

Emmons (2007) states that a chronic productivecough is present in up to 90% of patients withbronchiectasis and that 76%ofpatients producesputum on a daily basis. These disabling featureshave an adverse effect on individuals' physical andsocial activities. Ultimately, disease progression inbronchiectasis leads to hypoxaemia and in someinstances respiratory failure (Selby 2002).

Classification,presentation and diagnosis

Bronchiectasis can be classified according to thepathological or radiographie appearance of theairways (Table 1) (Barker 2002).

Bronchiectasis can present as focal obstructionconcerning a single lobe or section of one lung,or as widespread disease involving much tissueof both lungs (Barker 2002). Focal obstruction isthe most common presentation (Emmons 2007).A more limited presentation, such as in a focallesion, may have a better prognosis.

Clinical features of bronchiectasis

> Anaemia.

> Chest wheeze.

> Copious amounts of sputum.

> Difficulty in breathing.

> Disabling productive cough.

^ Fever.

P Haemoptysis.

> Pieuritic chest pain.

> Repeated chest infections (requiring antibiotictherapy).

> Weight loss.

(Barker 2002)

Classification of

Type

Cylindrical

Varicose

Saccular or cystic

bronchiectasis

Pathological or radiological appearance

Diffuse mucosal oedema, some dilation of the bronchi.

Dilated bronchi alternating wifh areas of constriction,with or without obstructive scarring.

Progressive dilation of the bronchi which ends inballoon-like cysts.

(Adapted from Barker 2002)

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High resolution computed tomography (CT)scanning is widely used as a diagnostic tool forbronchiectasis (Barker 2002). It is consideredthe gold standard in the detection of thecondition (Pryor and Prasad 2002). Highresolution CT scanning can identify dilation ofan airway lumen, lack of bronchial tapering,cysts at a bronchial end, dilation of the airways,thickening of bronchial walls and the presenceof mucus plugs (Barker 2002).

The pulmonary function test providesinformation about an individual's lung capacityand volumes. In bronchiectasis, spirometryoften shows a reduced ratio of forced expiratoryvolume in one second (FEV, ) to forced vitalcapacity (FVC) and a normal or slightly reducedFVC, and a reduced FEVj (Barker 2002).Patients with mild bronchiectasis maydemonstrate normal spirometry.

Management strategies

Successful management of the patient'srespiratory symptoms is central to themanagement of bronchiectasis. The mainsymptoms, as mentioned previously, include apersistent cough (Emmons 2007), excessproduction of purulent sputum (Hassan 2006)and breathlessness. The persistent features of thecondition may potentially lead to chronic fatiguein the patient.

The chronic nature of bronchiectasis may havea considerable effect on an individual's daily life(Kapella etal2006). Individuals living withchronic respiratory conditions need to engage inself-care activities particular to their condition.These include the use of inhalers, annual influenzaimmunisation, breathing and aerobic exercises,and regular contact with healthcare professionals(Cicutto and Brooks 2006). The role of theprofessional is essentially one of supporting theindividual to live with the condition by providingassessment, advice and education.Respiratory assessment Jevon and Ewens (2001 )state that accurate respiratory assessment can aiddiagnosis and help to determine appropriatetreatment. For individuals with chronic respiratoryconditions, there is a need to ensure that they areable to perform a degree of self-assessment as partof their self-management strategies. Cicutto andBrooks (2006) add that those with chronicrespiratory disorders are motivated to make use ofself-care strategies. They also suggest that there arecommon factors that encourage the use of self-carestrategies, including a desire to feel better, fear ofgetting worse, an improved sense of wellbeing andthe recommendation of the healthcare professional(Cicutto and Brooks 2006).

The severity of breathlessness is a particularlyimportant consideration. Breathlessness is a less

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specific symptom of bronchiectasis (Perry 2007)but it can have a major effect on daily life. There isa need to assess breathlessness carefully with arange of questions that explore the effectof the condition on a number of daily activities(Box 2). In terms of healthcare assessment andself-care it is necessary to consider any alterationsin the areas questioned as this is likely to signify achange in the individual's clinical condition.Therefore, patients need to develop an awarenessof change, however subtle, while healthcareprofessionals need to revisit the questions duringsubsequent consultations.

During respiratory assessment nurses shouldbe alert to any possible features that may indicatedeterioration in the patient's condition. Nursesshould also be aware of the need to educatepatients to recognise any changes that may signifydeterioration in their condition. This will enableappropriate, early intervention. For example,changes in the colour and consistency of sputummay indicate infection (Jevon and Ewens 2001)which, if not treated quickly, could lead toa significant deterioration in the patient'sclinical condition.Bronchopulmonary management Prieto et al(2001 ) suggest that the optimum therapeuticmanagement of patients with bronchiectasisincludes postural drainage, chest physiotherapyand antibiotic therapy. Chest physiotherapy maynot be well tolerated by some patients because ofthe difficulty in maintaining a suitable positionfor drainage (Fahy etal 1992, Currie 2004).Patients who are producing 20ml or more ofpurulent sputum over a 24-hour period despiteappropriate antibiotic therapy should be referredfor chest physiotherapy (Currie 2004).

A combination of postural drainage, a cycle of

Questions to help assess breathing difficulties

• Can the patient talk with ease?

• Does breathlessness affect the patient's activitiesof daily living?

• How far is the patient able to walk withoutstopping?

• Can the patient climb stairs?

• Does breathlessness affect the patient's job?

• Does the patient have orthopnoea, that isbreathlessness necessitating an upright positionfor relief? If so, how many pillows does he or sherequire to sleep at night?

• Do certain activities precipitate breathlessness?

• Does the patient have oxygen at home?

{Jevon and Ewens 2001)

breathing, forced expiration and directed coughare sufficient to enhance mucus clearance (Currie2004). A cycle of breathing as described by Currie(2004) consists of four deep breaths with relaxedexpiration, which is followed by a pause to allowthe patient to relax. The patient then engages indiaphragmatic breathing with one or two forcedexpirations. This is followed by a further pausefor gentle breathing to loosen secretions, whichare easily cleared by one or two coughs. This cycleof breathing is repeated as often as necessary.Postural drainage depends on gravity to assist inthe removal of mucus from the airways andshould be performed several times a day.

How would you recogniseincreased sputum retention in apatient? What interventions couldyou use to assist the patient toexpectorate sputum?

PosturaldrainageNèttina (2005) suggests thatbronchial hygiene using postural drainage withpercussion and/or vibration to loosen secretionshelps with mucus clearance. Inflatable vests ormechanical vibrators have been applied to thechest of patients with bronchiectasis with somesuccess, and are now more popular than chestcupping and the use of percussion (Barker 2002).High frequency chest wall oscillation is dependenton a device to exert external forces on the chestwall to help lessen the viscosity of mucus presentand to help move secretions. As previouslymentioned, this upward movement of secretionsis assisted by increased activity and action of thecilia, which are encouraged by chest walloscillation (Pruitt and Jacobs 2005). An inflatablevest is worn and attached to an air pulse deliverysystem. Therapy should last for approximately20 minutes twice daily (Pruitt and Jacobs 2005).Chest physiotherapy The role of physiotherapistsin the management of patients withbronchiectasis is paramount. Overall, the benefitsof physiotherapy are numerous, including earlyclearance of sputum from the lungs. This reducesthe volume of sputum left in the lungs, which inturn reduces the availabilityof sputum for colonisation by bacteria anddecreases the stimulus for an inflammatoryresponse. In a long-term condition such asbronchiectasis, self-administered chestphysiotherapy may be helpful in maintaininggood respiratory function. Nurses andphysiotherapists need to consider the mostappropriate strategies for teaching patients andtheir relatives to perform chest physiotherapy.

Nèttina (2005) encourages daily physicalactivity, which will assist in the mobilisation of

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mucus and hence help clear the airways. Thepatient's state of hydration should be monitoredand well maintained as this can help reduceviscosity of secretions and make expectorationeasier (Nèttina 2005). The nurse's role is to assistthe patient to understand why these aspects ofself-care are important and to teach and supportindividuals to learn the necessary skills.Antibiotic fAerapy Antibiotic therapy is centralto the treatment of patients with bronchiectasis.Antibiotics can be administered intramuscularly,intravenously, subcutaneously, orally or bynebuliser. Early administration of antibiotics isrecommended for suspected exacerbations ofbronchiectasis (Barker 2002) and while durationof treatment with antibiotics has not beenestablished, a course of no less than seven to tendays seems prudent (Barker 2002). Nebulisedantibiotics are recommended for patients withsevere bronchiectasis whose disease is progressiveand resistant to treatment (Currie 1997).

Short courses of antibiotics are usuallyprescribed to convert purulent (yellow or green)sputum to mucoid (white or clear and viscous)or no sputum (Currie 2004). Prolonged coursesof antibiotics may be used to maintain sputumas mucoid or absent, or to reduce or preventexacerbations and prevent disease progression(Currie 2004). Antibiotics should be changed ifsputum remains unresponsive to oral antibioticsafter one to two weeks of treatment (Currie 2004).Airway inflammation Airway inflammation canbe reduced with the use of corticosteroids (Selby2002). Regular use of inhaled corticosteroids mayimprove lung function (Ram etal2007) andreduce sputum volume (King 2007). However, thecurrent evidence base for practice is limited as onlya small number of studies and no randomisedcontrolled trials have been conducted in this area.

The actions of corticosteroids lessen theinflammatory response, which can reduce theamount of tissue damage over time.Corticosteroid therapy can be used during anacute exacerbation where a tapered approach touse can be employed. Airway inflammation, ifuntreated, can lead to airflow obstructionnecessitating bronchodilator therapy (Selby2002). The adverse effects of long-termcorticosteroid use should be considered.

Compare and contrast the use ofinhaled versus oral corticosteroidsin the management of bronchiectasis.

Chest infections Chest infections are common inpatients with bronchiectasis. Chest infections canprecipitate a rapid deterioration in the patient'scondition. Chronic colonisation withPseudomonas aeruginosa is associated with arapid decline in lung function and thereforelonger-term deterioration (Martinez-Garcia etal2007). Pseudomonas infections are usuallytreated with fluoroquinolone antibiotics (Barker2002), but like many bacterial agentsPseudomonas aeruginosa is developing resistanceto many common antibiotics. Todar (2008)suggests the use of gentamicin and carbenicillinin combination. Patients with frequent chestinfections may require long-term prophylacticantibiotic therapy (ten Hacken et al 2007).The use of antibiotics needs to be combined withbronchodilator therapy, anti-inflammatory drugsand physiotherapy, as outlined above.

To protect the patient from unnecessaryinfections, immunisations against influenza virusand pneumococcal pneumonia are recommended(Currie 2004, Nêttina 2005). Theseimmunisations will help protect against influenzaover the winter months and can prevent the onsetof more serious illnesses. The pneumococcalvaccine is usually only required once and a singledose protects against pneumococcal infection forup to ten years (Scottish Government 2007).Smoking cessation Patients should be taught torecognise factors that may contribute to orexacerbate their condition. Lifestyle issues shouldbe considered. For example, smoking cessation is acrucial factor if disease progress is to be slowed, andis a mainstay of management (Emmons 2007).Second-hand smoke must also be avoided as thisis also a recognised lung irritant (Perry 2007).Pulmonary function is reduced by cigarettesmoking, which also accelerates obstructiveimpairment. Nurses should help patients to stopsmoking and/or refer individuals to appropriatehealthcare professionals and services. Avoidanceof smoking (active and passive) will reduce the rateof bronchial tissue destruction and deterioration(Perry 2007).

What smoking cessation supportis available to patients in yourpractice area? Collate thisinformation into a fact file that youcan keep in your clinical area forfuture reference.

Long-term oxygen therapy Patients with poorrespiratory function may require long-termoxygen therapy (Perry 2007). This is indicatedwhen there is a sustained worsening of a patient'sclinical condition.

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Curative interventions Overall, management ofbronchiectasis is largely aimed at care rather thancure as the only curative interventions are lobarresection and bilateral lung transplantation(Mysliwiec and Pina 1999), both of which carryconsiderable risk for patients. For lobectomy, thedisease must be sufficiently localised to allow forcomplete removal of diseased tissue. Curativeprocedures may be used when, in spite of beingtreated with other conservative methodsincluding antibiotic therapy, the patient remainssymptomatic (Emmons 2007). For bilateral lungtransplantation to be considered, life expectancymust be less than two years and there must be noother significant co-morbidities (Currie 2004).

Acute deterioration

Treatment aims to maximise functional abilityand avoid acute exacerbations of bronchiectasis.However, should an exacerbation occur a quickand appropriate response is essential. O'Donnelletal (1998) suggest that four out of nine clinicalfeatures indicate an acute exacerbation ofbronchiectasis (Box 3). Patients with an acuteexacerbation require different therapies, includingoral antibiotics. Patients may require intravenousantibiotics if oral therapy is ineffective (Fani etal2007). Antibiotics can be used to treat acuteexacerbations as well as prevent exacerbationscaused by bacterial colonisation (ten Hacken etal2007), which result in airway inflammation and

Features of acute exacerbation of broncbiectasis

• Change in sputum production.

• Increased breathlessness.

• Increased cough.

• Temperature higher than 38°C.

• Increased wheezing.

• Malaise, fatigue, lethargy or decreased exercise tolerance.

• Reduced pulmonary function.

• Changes on chest X-ray.

• Changes in chest sounds.

(Payne 2006)

tissue damage. In addition, introduction of,or increase in, bronchodilator and corticosteroidtherapies may be indicated.

Appropriate choice of antibiotics will have to beconsidered, especially if there has been no responseto the initial course of treatment. Therefore asputum culture is an important part of thediagnostic assessment. Antibiotics are generallyprescribed based on the organisms and sensitivitiesidentified in sputum cultures (Fani etal2007).

In some cases there will be a need to hospitaliseindividuals with an acute exacerbation, and forother patients assessment at home can avoid thephysical and psychological effects of repeated.

References

Barker AF (2002) Bronchiectasis. NewEngland Journal of Medicine. 346,18,1383-1393.

Cicutto LC, Brooks D (2006)Self-care approaches to managing chronicobstructive pulmonary disease: aprovincial survey. Respiratory Medicine.100, 9,1540-1546.

Crowley LV (1997) Introduction toHuman Disease. Fourth edition. Jonesand Bartlett Publishers, Sudbury MA.

Currie DC (1997) Nebulisers forbronchiectasis. Thorax. 52, SuppI 2,S72-S74.

Currie D (2004) Differential Diagnosisof Branchiectasis. www.cysticfibrosismed-icine.com/cfdocs/cftext/bronchiectasis.htm (Last accessed: August 22 2008.)

Downs CA, Appel SJ (2007) Chronicobstructive pulmonary disease: diagnosisand management. Journal of theAmerican Academy of NursePractitioners. 19 3,126-132.

Dunn L (2005) Pneumonia: classification,diagnosis and nursing management.Nursing Standard. 19 42, 50-54.

Emmons EE (2007) Branchiectasis.www.emedicine.com/med/topic246.htm(Last accessed: August 22 2008.)

Fahy JV, Schuster A, Ueki I, BousheyHA, Nadel JA (1992) Mucushypersécrétion in bronchiectasis. The roleof neutrophil proteases. The AmericanReview of Respiratory Disease. 146, 6,1430-1433.

Fani P, Bye MR, Callahan C (2007)Bronchiectasis. www.emedicine.com/ped/topic2468.htm (Last Accessed: August22 2008.)

Gaga M, Bentley AM, Humbert M et al(1998) Increases in CD4-̂ T lymphocytes,macrophages, neutrophils and interleukin8 positive cells in the airways of patientswith bronchiectasis. Thorax. 53, 8,685-691.

Goodridge DM (2006) COPD as alife-limiting Illness: implications foradvanced practice nurses. Topics inAdvanced Practice Nursing e-journal.6,4.

Gould BE (2006) Pathaphysialogy farthe Health Professions. Third edition.Saunders, Philadelphia PA.

Hassan I (2006) Bronchiectasis.www.emedicine.com/radio/topicll6.htm(Last accessed: August 22 2008.)

Jevon P, Ewens B (2001) Assessment ofa breathless patient. Nursing Standard.15,16, 48-53.

Kapella MC, Larson JL, Patel MK, CoveyMK, Berry JK (2006) Subjective fatigue,influencing variables, and consequences inchronic obstructive pulmonary disease.Nursing Research. 55,1,10-17

King P (2007) Is there a role for inhaledcorticosteroids and macrolide therapy inbronchiectasis? Drugs. 67 7, 965-974.

Maa SH, Tsou TS, Wang KY,Wang CH, Lin HC, Huang YH (2007)Self-administered acupressure reduces thesymptoms that limit daily activities inbronchiectasis patients: pilot studyfindings. Journal of Clinical Nursing.16, 4, 794-804.

Martinez-Garcia MA, Soler-Cataluña JJ,Perpiña-Tordera M, Romàn-SànchezP, Soriano J (2007) Factors associatedwith lung function decline in adultpatients with stable non-cystic fibrosisbronchiectasis. Chest. 132, 5,1565-1572.

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long stays in hospital (Schofieid etal 2006).There is limited evidence to support thisapproach for patients with bronchiectasis, butgiven the similarities it could be assumed there isa place for home management for carefullyselected patients.

Patients with severe bronchiectasis mayrequire more aggressive respiratorymanagement. Higher levels of oxygen therapycan be prescribed to reduce respiratory effortand increase the partial pressure of oxygen whilereducing the partial pressure of carbon dioxide.However, in some patients this will beinsufficient and increased ventilatory supportwill be required. Non-invasive positive pressureventilation (NIPPV) has been used for some timein the treatment of patients with chronicrespiratory insufficiency (Preston 2001). The aimis to manage respiratory failure without the needfor intubation. There are two main types ofNIPPV: continuous airway positive pressure, andbilevel positive airway pressure. Readers wishingto learn more about this should refer to Preston(2001 ). Therapy should reduce respiratory effortfor the patient, increase tidal volumes, reducepartial pressure of carbon dioxide and increasepartial pressure of oxygen.

It is hoped that after a short course of NIPPVthe patient will be able to return to normal withlimited change to his or her condition. However,frequent exacerbations are a recognised factor

associated with lung decline in adults (Martinez-Garcia etal2007). For patients who doexperience significant lung decline there may be aneed to consider in the long term palliative andultimately end-of-life care.

James, aged 58 years, is due to bedischarged home after an acuteworsening of his bronchiectasis. He isto start on home oxygen therapy.Outline a care plan to prepare Jamesand his family for this therapy.

Conclusion

Although the causes of bronchiectasis are varied,the consequences in terms of each patient'sexperience are the same. Problems patients mightexperience as a result of bronchiectasis andstrategies to support patients to live with thischronic condition have been discussed. Nurseswill require a range of knowledge, skills andinterventions to assist patients to cope with theeveryday challenges associated withexacerbations of this long-term condition NS

Now that you have completed thearticle, you might like to write apractice profile. Guidelines to helpyou are on page 60.

Mysliwiec V, Pina JS (1999)Bronchiectasis: the 'other' obstructive iungdisease. Postgraduate Medicine.'iob. 1,123-126,128-131.

Nèttina SiVi (2005) Lippincott Manualof Nursing Practice. Eighth edition.Lippincott Wiiliams and Wilkins,Philadelphia PA.

O'Donneii AE, Bari<er AF, Ilowite JS,Fici< RB (1998) Treatment of idiopathicbronchiectasis with aerosolizedrecombinant human DNase I. rhDNaseStudy Group. Chest. 113, 5,1329-1334.

Payne K (2006) Bronchiectasis. InScullion JE (Ed) Fundamental Aspects ofNursing Adults with RespiratoryDisorders. Quay Books, Dinton. 31-40.

Perry iVi (2007) Brcnchiectasis: diagnosisand prognosis. Practice Nursing. 18, 9,436-441.

Preston R (2001) Introducing non-invasive positive pressure ventilation.Nursing Standard 15, 26, 42-45.

Prieto D, Bernardo J, iVIatos MJ,

Eugenio L, Antunes iVi (2001) Surgeryfor bronchiectasis. European Journal ofCardio-thoracic Surgery. 20,1,19-24.

Pruitt B, Jacobs M (2005) Clearing awaypulmonary secretions. Nursing. 35,7 36-41.

Pryor JA, Prasad SA (Eds) (2002)Physiotherapy for Respiratory andCardiac Problems. Adults and Paediatrics.Third edition. Churchill Livingstone, 'Edinburgh.

Ram FSF, Welis A, Koibe J (2007)Inhaled steroids for bronchiectasis.Cochrane Database of SystematicReviews. Issue 2.

Schofieid I, Knussen C, Toison D(2006) A mixed method study tocompare use and experience of hospitalcare and a nurse-led acute respiratoryassessment service offering home careto people with an acute exacerbation ofchronic obstructive pulmonary disease:International Journal of Nursing Studies.43, 4, 465-476.

Scottish Government (2007) What's

Pneumococco/? www.infoscotland.com/infoscotland/files/Dr%20Steele%20Pneumoccocal%2Oleaflet.pdf (Last accessed:August 28 2008.)

Selby C (2002) Respiratory Medicine:An Illustrated Colour Text ChurchillLivingstone, Edinburgh.

Siiarpies LD, Edmunds J, Biiton D et al(2002) A randomised controlledcrossover trial of nurse practitionerversus doctor ied outpatient care in abronchiectasis clinic. Thorax. 57, 8,661-666.

ten Haci<en NH, Wiji<stra PJ, KerstjensHA (2007) Treatment of bronchiectasis inadults. British Medical Journal 335, 7629,1089-1093.

Thibodeau GA, Patton i a (2004)Structure and Function ofthe Body.Twelfth edition. Mosby, St Louis MO.

Todar K (2008) Pseudomonas Aeruginosa.www.textbookofbacteriology.net/pseudomonas.html(Last accessed: August 11 2008.)

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