Bronchiectasis

Definition
- Bronchiectasis is an abnormal and permanent dilatation of bronchi. It may be either focal, involving airways (lobe, segment, or subsegment of the lung) supplying a limited region of pulmonary parenchyma, or diffuse, involving airways in a widespread distribution.

Pathologic types of Bronchiectasis

 1. Cylindrical Brochiectasis- The bronchi appear as uniformly dilated tubes that ends abruptly at the point that smaller airways are obstructed by secretions. 2. Saccular Bronchiectasis- bronchi having a balloon-liked appearance at the

periphery, ending in blind sacs without recognizable bronchial structures distal to the sacs. 3. Varicose Bronchiectasis- the affected bronchi have an irregular or beaded pattern of dilatation resembling varicose veins.

Risk factors
a. Patients having recurrent LRTI, b. Patients having AIDS c. People who are frequently exposed to noxious agents ( inhalation of toxic gases like ammonia, oxides of sulfur and nitrogen) d. Persons aged 60-80 years (Although limited, epidemiologic studies, again likely from the rise in atypical mycobacterial infections.) e. socioeconomic status

Signs and Symptoms

Chronic cough w/ mucopurulent sputum Hemoptysis Exertional dyspnea Digital Clubbing Fever Rhonchi Wheeze Crackles Anorexia Wt. loss

Complications
- Bronchiectasis decreases the ability of the lung to mobilize secretions, leading to recurrent infection, increased sputum production, and difficulty breathing. Decreased air entry into the lung through the bronchial tubes decreases oxygen availability in the bloodstream, causing shortness of breath with activity and ultimately at rest. This decreased oxygen level over time causes constriction of the pulmonary arteries, resulting in increased pressure in these arteries, referred to as pulmonary hypertension. Overcoming these pressures forces the heart to work harder causing the right ventricle to thicken, a condition called cor pulmonale. Eventually, the right side of the heart (which pumps blood to the vessels of the lung) may fail, resulting in increased fluid accumulation in the legs or abdominal cavity.

Diagnostics Findings

A. Imaging Studies
1. High-resolution CT (HRCT)- a Right-middle lobe involvement HRTC scanning is the criterion alone suggests right-middle standard for the diagnosis of lobe syndrome, an anatomic bronchiectasis. dysfunction, or a neoplastic cause with secondary Additionally, the mechanical obstruction. anatomical distribution of bronchiectasis may be Bronchiectasis caused by CF, M important in helping diagnose tuberculosis, or chronic fungal any associated condition or infections tends to affect the cause of bronchiectasis, as upper lobes, although this is not follows: universal in the former. Bronchiectasis as a result of ABPA also affects the upper infection generally involves the lobes but usually involves the lower lobes, the right-middle central bronchi, whereas most lobe, and the lingula. other forms of bronchiectasis

B. Procedure
1. Bronchography- Bronchography is performed by instilling contrast material via a catheter or a bronchoscope and performing plain radiographic imaging. It should only be performed at facilities and by operators skilled in its use. In current practice, it is only of potential value in confirming the location of focal bronchiectasis and in excluding disease elsewhere in the setting of possible surgical resection. This procedure carries the risk of acute bronchoconstriction. Bronchoscopy is generally not helpful in diagnosing bronchiectasis, but it may be useful in identifying underlying abnormalities, such as tumors, foreign bodies, or other lesions. Bronchoscopy with bronchoalveolar lavage may be used to obtain specimens for staining and culture when a primary infectious etiology or a secondary infection is suspected

C. Laboratory test
1. Sputum analysis- A sputum analysis may reinforce the diagnosis of bronchiectasis and add significant information regarding potential etiologies. Once sputum is allowed to settle, the examination may reveal Dittrich plugs, small white or yellow concretions. 2. Culture and Sensitivity-A Gram stain and culture result may reveal evidence of microorganisms, including mucoid Pseudomonas species and Escherichia coli, which suggest CF but are not diagnostic. Chronic bronchial infection with nonmucoid P aeruginosa is becoming much more common in patients with non-CF bronchiectasis. The presence of eosinophils and golden plugs containing hyphae suggests Aspergillus species, although this finding alone is not diagnostic of. Allergic bronchopulmonary aspergillosis (ABPA) Perform a smear and culture of sputum for mycobacteria and fungi. Atypical mycobacterial infection is a common cause of bronchiectasis in the older population, especially in those with underlying structural lung disease. 3. CBC- CBC count is often abnormal in patients with bronchiectasis and may be useful. Typical findings are nonspecific and include anemia and an elevated white blood cell count with an increased percentage of neutrophils. An increased percentage of eosinophils is one criterion for ABPA. Alternatively, polycythemia secondary to chronic hypoxia may be observed in advanced cases.

D. Pulmonary function test

Pulmonary function studies may be abnormal in advanced bronchiectasis, showing a decrease in vital capacity, expiratory flow, and maximum voluntary ventilation and an increase in ventilation-perfusion mismatching with resultant hypoxemia.

Medical Management

 The goals of therapy are to improve symptoms, to reduce complications, to control exacerbations, and to reduce morbidity and mortality. Early recognition is essential in bronchiectasis and associated conditions. Additionally, management of underlying conditions, which may include the use of intravenous immunoglobulin or intravenous AAT therapy, is essential to the overall treatment. Antibiotics and chest physiotherapy are the mainstay modalities. Other modalities (beyond those for specific associated conditions) may include bronchodilators, corticosteroid therapy, dietary supplementation, and oxygen or surgical therapies. Admitting patients with severe exacerbations of bronchiectasis to the hospital and treating them with intravenous antibiotics, bronchodilators, aggressive physiotherapy, and supplemental nutrition is not uncommon.

Surgical Management

 Surgery is an important adjunct to therapy in some patients with advanced or complicated disease.Surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality in patients of any age. In general, surgery should be reserved for patients who have focal disease that is poorly controlled by antibiotics. The involved bronchiectatic sites should be completely resected for optimal symptom control.

Other indications for surgical intervention may include the following: Reduction of acute infective episodes Reduction of excessive sputum production Massive hemoptysis (Alternatively, bronchial artery embolization may be attempted for the control of hemoptysis.) Foreign body or tumor removal Consideration in the treatment of MAC or Aspergillus species infection

Treatment

Therapy has 4 major goals: 1.) Elimination of an identifiable underlying problem 2.) Improved clearance of tracheobronchial secretions 3.) Control of infection, particularly during acute exacerbations 4.) Reversal of airway obstruction

A. Antibiotics- These are the mainstays of treatment of patients with bronchiectasis and infectious exacerbations. The route of antibiotic administration varies with the overall clinical condition, with most patients doing well on outpatient regimens. Some patients benefit from a set regimen of antibiotic therapy, such as therapy for 1 week of every month. The choice of antibiotic is provider dependent, but, in general, the antibiotic chosen should have a reasonable spectrum of coverage, including the most common gram-positive and gram-negative organisms.Treatment of the patient who is more ill or the patient with CF often requires intravenous antiPseudomonas species coverage with an aminoglycoside, most often in combination with an antipseudomonal synthetic penicillin or cephalosporin. Aerosolized tobramycin has been found effective in patients with CF.

B. Expectorants- One of the hallmarks of bronchiectasis is a chronic, thick, viscid sputum production. In bronchiectasis, it is extremely difficult for the body's natural mucociliary clearance mechanisms to adequately clear the sputum produced. Although definitive evidence is lacking, expectorants are expected to increase respiratory tract fluid secretions and to help loosen phlegm and bronchial secretions. By reducing the viscosity of secretions, this increases the efficacy of mucociliary clearance system. Expectorants are often found in combination with decongestants, which may provide some patients additional relief. Ex. Guaifenesin- Contains 600 mg of guaifenesin in a sustainedrelease formulation intended for oral administration. Increases respiratory tract fluid secretions and helps to loosen phlegm and bronchial secretions. Humibid LA and guaifenesin are indicated for patients with bronchiectasis complicated by tenacious mucus and/or mucous plugs. Dosing: Adult:600-1200 mg PO q12h; not to exceed 2400 mg/d Pediatric : <2 years: 12 mg/kg/d PO in 6 divided doses 2-6 years: 300 mg PO q12h; not to exceed 600 mg/d 6-12 years: 600 mg PO q12h; not to exceed 1200 mg/d >12 years: Administer as in adults

C. Inhaled Beta Agonist-Bronchiectasis may cause an obstructive defect on pulmonary function testing that may respond to inhaled betaagonists. Many older patients with bronchiectasis often have a concomitant illness, such as chronic obstructive pulmonary disease, that responds to inhaled beta-agonists. Finally, in the acute infectious bronchitic exacerbation that occurs in patients with bronchiectasis, patients may develop transient obstructive airway physiology that may be improved with an inhaled beta-agonist. Along these same lines, many patients are started on inhaled steroids for long-term airway stabilization, but the efficacy of these medications in bronchiectasis is questionable, and any effect simply may be secondary to the treatment of other concomitant obstructive airway diseases. Ex. Albuterol sulfate -Relatively selective beta2-adrenergic bronchodilator that, when inhaled, has the effect of causing relaxation of bronchial smooth muscle and inhibiting release of mediators of immediate hypersensitivity from cells, especially mast cells. Administered in metered-dose aerosol unit for oral inhalation; indicated for prevention and relief of bronchospasm from any cause, including those observed in patients with bronchiectasis. Dosing: Adult Acute symptoms: 2 inhalations repeated q4-6h Pediatric <12 years: Not established >12 years: Administer as in adults

Nursing Diagnosis
Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction And airway irritants Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work. Deficient knowledge about selfmanagement to be performed at home.

Nursing Management
Administration of measles and pertusis vaccines. Which decrease bronchiectasis caused by these disease. Promote drainage and removal of bronchial mucus Advice patient to rest for 8 to 10 hrs Increase fluid intake at least 1000 -2000 ml Monitor respiratory status , including rate and patterns of respiration, breath sounds, signs and symptoms of respiratory distress and pulse oximetry. Promote use of lung expansion techniques (e.g deepbreathing exercise, incentive spirometry) as prescribe. Deep-breathing exercises and incentive spirometry promote maximal lung expansion. Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extreme of temperature and fumes bronchial irritants can cause bronchial constriction and increase mucus production, which then interferes with airway clearance.

Prognosis
- Overall, prognosis is thought to be good, with about 80% of patients having no further deterioration of lung function on the basis of bronchiectasis alone. Early recognition and adequate treatment can help control bronchiectasis and decrease symptoms. Life- long awareness of the need for treatment may allow people with bronchiectasis to minimize complications and maximize life expectancy. The outlook depends upon the underlying reason for developing bronchiectasis. Congenital causes of bronchiectasis, like cystic fibrosis, may have a worse prognosis than acquired diseases.

P. Aeruginosa, H. influenza S. Aureus, Klebsiella, adenovirus Mycobacterium avium complex

Enters the body Rupturing of bronchial blood vessels

Produces Pigments, protease, and other toxins

Activation of inflammatory response: 1. Released of Histamine 2. Released of Arachidonic acid

Cellular necrosis

Injury in the P. stratified Ciliated columnar epithelium And smooth muscles

Bleeding

Hemoptysi s Production of mucus Impairment of Mucociliary clearance Loss of elastic tissue and Replacement of fibrous tissue

Macraphage, monocytes, Endothelial cells, others

Pus

Pooling of foul purulent mucus

Weakening of the bronchial wall

Released of pyrogenic cytokines: IL-6, IL-1, TNF, IFN

Initiation of coughing reflex

Colonization of pathogens Chronic Dilatation Inciting further infection

coughing

Narrowing Hypothalamus

Inc. airway pressure

Fever
Rhonchi, wheeze, crackles Body saves energy On defense mechanism and not on food Obstruction impaired ventilation

Dec. oxygenation

Hypercapnia

Hypoxia Anorexia

Respiratory acidosis

Stimulation of chemoreceptors Digital clubbing

Wt. loss
inc. stimulation of resp. muscles Cyanosis Dyspnea

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