Case study 2 - Bronchiectasis Flashcards
What is bronchiectasis?
- irreversible airway dilation (of bronchi) associated with chronic airway inflammation and infection.
why may haeomoptisis occur in patients with bronchiectasis
- blood vessels damaged causing bleed
- due to chronic coughing
What is Coles Viscious Cycle?
- shows that there is a decrease in cilia, mucocilary clearance (hairs in airways helping to remove secretions).
- This results in a colonization (increase) of bacteria, leading to chronic inflammation and frequent infection.
- This increase in mucus leading to infection, becomes the cycle (Chandrasekaran et al, 2018)
What are the risk factors of bronchiectasis?
- repeated infections
- immunodefiency
- cystic fibrosis
what are the symptoms of bronchiectasis?
- increase sputum production
- shortness of breath
- chronic cough
- fatigue
What do NICE guidelines say about bronciectasis
- sputum sample should be taken to be tested
- first choice of antibiotics is Amoxicilin
- comprise self management plan where possible ACBT can be given.
What is pneumonia?
infection in alveoli
Types of pneumonia?
- Bacterial
- Hospital acquired
- Legionnaires’ disease
- community acquired
- fungal pneumonia
- aspiration pneumonia
what is virus + bacteria?
Bacteria are single cells that can survive on their own, inside or outside the body.
- Viruses cause infections by entering and multiplying inside the host’s healthy cells
what are the accessory muscles used in respiration?
- scalenes
- sternocleidomastoid
What are the lobes of the lungs?
- right upper lobe
- right middle lobe
- right lower lobe
- left upper lobe
- left lower lobe
what fissures are there in the lungs?
- horizontal fissure (seperating the RUL + RML)
- oblique fissure (seperating the RML + RLL)
-oblique fissure (seperating LUL + LLL)
Explain the structure of the lungs
- mouth/nose, trachea, bronchi (primary, secondary + tertiary), bronchioles, alveoli
- left + right lobes of lungs
What happens in gaseous exchange?
- oxygen diffuses into capillaries down concentration gradient
- forms oxy-haemoglobin
- has large surface area due to capillaries
- is very thin so lots of diffusion
Explain bacterial pneumonia
- caused by various bacteria.
- most common is Streptococcus pneumoniae.
- in this case the patient has bronchiectasis, with lower cilia more sputum is retained causing increased infection risk.
What does lethargic mean
increased fatigue levels
what must you take into consideration when treating Amiel
he is feeling lethargic, therefore may be a risk of hypotension, so ensure you take it slowly and check on patient (maybe place pulse oximeter or bp on)
what is the normal value for ph levels in ABG
- 7.35-7.45
- if too low = acidosis
- if too high = alkanosis
what is the normal value for HC03 (bicarbonate) levels in ABG
- 22-26 mmol/L
-if lower then PaCO2 then respiratory - if higher then PacO2 then metabolic
what is the normal value for PaCO2 (partial pressure of carbon dioxide) levels in ABG
- 35-45 mmHg
- if higher then bicarbonate then respiratory
what is respiratory acidosis?
- likely that Amiels ph levels are below 7.35 and PaCO2 levels are higher then bicarbonate levels in blood.
- increased carbon dioxide in blood
- the body is unable to remove enough carbon dioxide through breathing
- medulla oblangata in brain and chemoreceptors detect decrease PH and try to level it leading to hypoventilation
what are symptoms of respiratory acidosis?
- shortness of breath
- cyanosis
- headaches
- fatigue
- lethargic
- anxiety
what are normal spo2 levels in people with bronchiectasis
- appropriate to maintain a saturation of >92%.
what do you look for in a chest x-ray?
- trachea position
- white is solid (bones or blockages)
- black is air
- diaphragm
- check if it is anterior supine or posterior image
- clavicle location
What would you do for assessment of secretion retention?
- sputum sample which links to NICE guidelines
- auscultation of lungs listening for affected area, likely to be lower lobes due to atelectasis
- assess cough strength
- tactile fremitus
What would you do for treatment of secretion retention?
- teach ACBT techniques (forced expiratory, thoracic expansion and diaphragmatic breathing)
- if they are unable to clear use yanker suction?
- postual drainage for affected lobes (lie Amiel on left side to drain secretions).
- chest percussion
- nebuliser if secretions are thick
- re-position patient in bed
What evidence is there for treating secretion retention right lower lobe using ACBT
- Zisi et al 2022
- explain aim, method, findings, conclusion
- ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion.
- Amiel will therefore be able to clear secretions
What evidence is there for treating secretion retention using postural drainage
- Bott et al 2009, British Thoracic Society
- Recommend postural drainage being aware of precautions
- side-lying of lobes affected
What would you do for assessment of decreased chest expansion
- tactile fremitus feeling for equal chest epansion (likely to feel decreased in anterior + posterior lower lobes due to atelectasis)
- palpation of accessory muscles feeling for hypertorphy
- observe respiratory rate, likely to be decreased due to respiratory acidosis (hypoventilation)
- use dyspnoea scale (rate of perceived exertion)
what would you do for treatment of decreased chest expansion?
- ACBT (forced expiratory, thoracic expansion and diaphragmatic breathing) Reduce sputum retention and in turn reduce dyspnoea, shown from the systematic review.
- Thoracic expansion technique and diaphragmatic breathing has been shown to have a positive impact compared to other methods such as flutter device, which is also expensive.
What evidence is there for treating decreased chest expansion using ACBT
- Zisi et al 2022
- explain aim, method, findings, conclusion
- ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion and in relieving symptoms such as dyspnoea.
- will help to increase chest expansion and decrease dyspnoea.
How would you assess decreased exercise tolerance?
- use dyspnoea scale/rate of percieved exertion
- respiratory rate
- 30 second sit to stand - for his age 58 should be able to do 18. (use borg scale before and after or dyspneoa (breathlessness) scale)
How would you treat decreased exercise tolerance?
- marches on spot, sit and rest
- progress to mobilise patient with WZF to sit on in chair
- Teach ACBT to ensure breathing pattern is maintained and risk of pulmonary complication decreased
- outcome measure using dyspnoea scale used.
What evidence is there for mobilzing patient with respiratory acidosis?
- Bailey et al 2007
- explain aim, method, findings, conclusion
- early activity is feasible and safe in respiratory failure patients.
- therefore, mobilising Amiel is important to help increase exercise tolerance and decrease risk of muscle weakness
types of mechanical ventilation
- Volume-limited assist control ventilation (VAC)
- Pressure-limited assist control ventilation (PAC)
- Synchronized intermittent mandatory ventilation with
- pressure support ventilation (SIMV-PSV)
