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.
Frequently Asked Questions
What is the hallmark symptom of bronchiectasis? A daily, chronic cough that brings up large amounts of thick, often purulent sputum is the classic sign. Symptoms can take months or years to appear after repeated lung infections (NHLBI).
Is bronchiectasis the same as COPD? No. Bronchiectasis is permanent, irreversible widening of the bronchi. Under the current definition of COPD it is treated as a separate disease process, though the two can coexist.
Why is airway clearance the core of nursing care? The dilated, scarred airways can no longer clear mucus on their own, so retained secretions feed infection and obstruction. Postural drainage, chest physiotherapy, and teaching the patient to clear secretions at home are central to management (NHLBI).
Can bronchiectasis be cured? No. There is no cure, but most people manage it well with stepwise treatment: clearing the lungs, antibiotics for infections, bronchodilators, exercise, and steps to prevent further lung infection (NHLBI).
What teaching matters most at discharge? Push smoking cessation, since smoking paralyzes ciliary action and increases secretions. Teach the patient and family postural drainage, how to avoid people with respiratory infections, and how to recognize early signs of infection so treatment starts promptly.