Case study 2 - Bronchiectasis

Question 1

What is bronchiectasis?

Answer 1

• irreversible airway dilation (of bronchi) associated with chronic airway inflammation and infection.

Question 2

why may haeomoptisis occur in patients with bronchiectasis

Answer 2

• blood vessels damaged causing bleed
• due to chronic coughing

Question 3

What is Coles Viscious Cycle?

Answer 3

• 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)

Question 4

What are the risk factors of bronchiectasis?

Answer 4

• repeated infections
• immunodefiency
• cystic fibrosis

Question 5

what are the symptoms of bronchiectasis?

Answer 5

• increase sputum production
• shortness of breath
• chronic cough
• fatigue

Question 6

What do NICE guidelines say about bronciectasis

Answer 6

• sputum sample should be taken to be tested
• first choice of antibiotics is Amoxicilin
• comprise self management plan where possible ACBT can be given.

Question 7

What is pneumonia?

Answer 7

infection in alveoli

Question 8

Types of pneumonia?

Answer 8

• Bacterial
• Hospital acquired
• Legionnaires’ disease
• community acquired
• fungal pneumonia
• aspiration pneumonia

Question 9

what is virus + bacteria?

Answer 9

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

Question 10

what are the accessory muscles used in respiration?

Answer 10

• scalenes
• sternocleidomastoid

Question 11

What are the lobes of the lungs?

Answer 11

• right upper lobe
• right middle lobe
• right lower lobe
• left upper lobe
• left lower lobe

Question 12

what fissures are there in the lungs?

Answer 12

• horizontal fissure (seperating the RUL + RML)
• oblique fissure (seperating the RML + RLL)
  -oblique fissure (seperating LUL + LLL)

Question 13

Explain the structure of the lungs

Answer 13

• mouth/nose, trachea, bronchi (primary, secondary + tertiary), bronchioles, alveoli
• left + right lobes of lungs

Question 14

What happens in gaseous exchange?

Answer 14

• oxygen diffuses into capillaries down concentration gradient
• forms oxy-haemoglobin
• has large surface area due to capillaries
• is very thin so lots of diffusion

Question 15

Explain bacterial pneumonia

Answer 15

• 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.

Question 16

What does lethargic mean

Answer 16

increased fatigue levels

Question 17

what must you take into consideration when treating Amiel

Answer 17

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)

Question 18

what is the normal value for ph levels in ABG

Answer 18

• 7.35-7.45
• if too low = acidosis
• if too high = alkanosis

Question 19

what is the normal value for HC03 (bicarbonate) levels in ABG

Answer 19

• 22-26 mmol/L
  -if lower then PaCO2 then respiratory
• if higher then PacO2 then metabolic

Question 20

what is the normal value for PaCO2 (partial pressure of carbon dioxide) levels in ABG

Answer 20

• 35-45 mmHg
• if higher then bicarbonate then respiratory

Question 21

what is respiratory acidosis?

Answer 21

• 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

Question 22

what are symptoms of respiratory acidosis?

Answer 22

• shortness of breath
• cyanosis
• headaches
• fatigue
• lethargic
• anxiety

Question 23

what are normal spo2 levels in people with bronchiectasis

Answer 23

• appropriate to maintain a saturation of >92%.

Question 24

what do you look for in a chest x-ray?

Answer 24

• trachea position
• white is solid (bones or blockages)
• black is air
• diaphragm
• check if it is anterior supine or posterior image
• clavicle location

Question 25

What would you do for assessment of secretion retention?

Answer 25

- 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

Question 26

What would you do for treatment of secretion retention?

Answer 26

- 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

Question 27

What evidence is there for treating secretion retention right lower lobe using ACBT

Answer 27

- 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

Question 28

What evidence is there for treating secretion retention using postural drainage

Answer 28

- Bott et al 2009, British Thoracic Society - Recommend postural drainage being aware of precautions - side-lying of lobes affected

Question 29

What would you do for assessment of decreased chest expansion

Answer 29

- 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)

Question 30

what would you do for treatment of decreased chest expansion?

Answer 30

- 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.

Question 31

What evidence is there for treating decreased chest expansion using ACBT

Answer 31

- 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.

Question 32

How would you assess decreased exercise tolerance?

Answer 32

- 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)

Question 33

How would you treat decreased exercise tolerance?

Answer 33

- 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.

Question 34

What evidence is there for mobilzing patient with respiratory acidosis?

Answer 34

- 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

Question 35

types of mechanical ventilation

Answer 35

- Volume-limited assist control ventilation (VAC) - Pressure-limited assist control ventilation (PAC) - Synchronized intermittent mandatory ventilation with - pressure support ventilation (SIMV-PSV)