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Bronchiectasis: pathophysiology, presentation and management

NS461 Farley AH ei al (2008) Bronchiectasis: pathophysiology, presentation and management. Nursing Standard. 23, 3, 50-56. Date of acceptance: June 30 2008.

Summary
Bronchiectasis, 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 patient group. This article examines the pathophysiology and presentation of bronchiectasis and identifies various management strategies.

Introduction

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

Keywords
Airway inflammation; Bronchiectasis; Respiratory system These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

Aims and intended learning outcomes

This article aims to increase knowledge and understanding of bronchiectasis, and to explore management strategies to enable nurses to care for patients with the condition and assist them to maintain an acceptable quality of life. After reading this article you should be able to: > Outline the anatomy and physiology of the respiratory system. > Describe the changes which occur in the respiratory tract in bronchiectasis. > Identify and explain the strategies available for managing patients with bronchiectasis. > Apply the knowledge gained from reading this article to clinical practice.
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Bronchiectasis is defined as an abnormal dilation of the bronchi (Payne 2006, ten Hacken etal 2007). The condition, although not common, can be life-limiting and may lead to premature death. Bronchiectasis is now less common in developed countries as a result of improved child health care (Selby 2002), such as universal vaccination programmes against measles, pneumonia and whooping cough (Perry 2007) and improved housing. However, the condition remains common in developing countries. Nurses in the UK, particularly those caring for older adults or working in respiratory care, may encounter patients with bronchiectasis. As a long-term chronic condition the focus for nurses is on supporting self-care along with symptom management and education (Goodridge 2006). Bronchiectasis is likely to affect many aspects of a patient's everyday life. Management of the condition is essential to improve quality of life. It is important to note that a form of bronchiectasis occurs in patients with cystic fibrosis. However, this article focuses on patients with non-cystic fibrosis bronchiectasis.

a
Using a textbook or resource of your choice, revise the normal structure and function of the respiratory system.

' w'

Anatomy and physiology

The respiratory tract (Figure 1) consists of the nose, pharynx, larynx, trachea, bronchi, bronchioles and alveoli (Dunn 2005).
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Structurally, the respiratory system is divided into an upper respiratory tract and a lower respiratory tract. The upper respiratory tract is composed of the nose, pharynx and larynx, while the lower respiratory tract is composed of the structures below the larynx, namely the trachea, bronchi, bronchioles and alveoli (Thibodeau and Patton 2004). The upper respiratory tract warms, filters and moistens inhaled air before it enters the lower portions of the respiratory system. Respiratory mucosa lines the airways of the respiratory system. The lining of the airways is covered with mucus secreted by goblet cells. Goblet cells are the main producers of mucus in the small airways, but contribute only a small proportion of the total mucus production. Most mucus is produced by mucus glands in the upper airways. Mucus forms a protective blanket covering the lining of the airways. An average adult produces 125ml of mucus every day (Thibodeau and Patton 2004). Mucus is propelled from the lower respiratory tract upwards by the actions of cilia - tiny, hair-like projections - covering the epithelial cells of the respiratory mucosa .Cilia waft mucus and foreign particles upwards and away from the lower portions of the respiratory tract. Mucus is then swallowed. Excess mucus stimulates the cough reflex and mucus is then expectorated. Pathophysiology of bronchiectasis Bronchiectasis is an abnormal inflammatory response of the lungs resulting in airflow limitations (Downs and Appel 2007). Irreversible dilation of the bronchi occurs (Barker 2002), and is associated with destruction of the muscular and elastic components of the bronchial walls (Emmons 2007). The destruction of the supportive muscular and elastic components of the bronchial walls results in permanent bronchial dilation and inflammation (Pruitt and Jacobs 2005). The distended bronchi have a tendency to retain secretions (Crowley 1997). The retained secretions become infected, triggering an ongoing and persistent host inflammatory response (Pryor and Prasad 2002). The features of such a response include vasodilation, increased capillary permeability resulting in movement of fluid from the intravascular compartment to the tissues, increased macrophage activity and localised oedema. This persistent inflammatory response leads to a loss of respiratory cilia and progressive airway obstruction asa result of the oedema and excess mucus. These changes greatly impair removal of bronchial secretions (Gould 2006). A cycle of inflammation, infection, damage and further inflammation results, leading to further dilation and damage to the respiratory passages. Patients with bronchiectasis may experience
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repeated episodes of infection, produce copious amounts of sputum and become increasingly breathless (Sharpies ei a/2002). Sputum culture often identifies the presence o Staphylococcus aureus, Haemophilus inuenzae or Pseudomonas aeruginosa (Selby 2002). Dilation of the airways increases the 'dead space', that is, the volume of air contained within the respiratory passages that does not participate in gas exchange. As a consequence, less air reaches the respiratory surfaces and the patient experiences breathlessness. Bronchiectasis is associated with transmural infection and inflammation, which is related to the release of chemical pro-inflammatory mediators. Pro-inflammatory mediators cause airway inflammation and an increase in airflow limitation (Downs and Appel 2007). Respiratory obstruction occurs in the presence of prolonged inflammatory secretions, and micro-organisms contribute to airway damage and recurrent infection (Barker 2002). Neutrophils and T lymphocytes are found in the bronchial mucosa of patients with established bronchiectasis (Gaga eia/1998), which highlights the disease's inflammatory nature. Bronchiectasis usually results from infection and presents in the middle and older age groups (Maa eia/2007). However, inhalation of a foreign body, and allergic, auto-immune and chemical lung damage, can also predispose individuals to bronchiectasis (Mysliwiec and Pina 1999). Congenital disorders such as cystic fibrosis and primary ciliary dyskinesia can lead to this condition (Payne 2006). Primary ciliary dyskinesia leads to the development of bronchiectasis as the cilia are unable to clear the air passages effectively. This results in the retention of secretions and leads to recurrent infections. Other conditions associated with bronchiectasis include allergic bronchopulmonary aspergillosis, immunodeficiency states (Emmons 2007), foreign
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High resolution computed tomography (CT) scanning is widely used as a diagnostic tool for bronchiectasis (Barker 2002). It is considered the gold standard in the detection of the body aspiration and benign airway tumours (Pruitt condition (Pryor and Prasad 2002). High resolution CT scanning can identify dilation of and Jacobs 2005). Typical clinical features of an airway lumen, lack of bronchial tapering, bronchiectasis are shown in Box 1. Emmons (2007) states that a chronic productive cysts at a bronchial end, dilation of the airways, thickening of bronchial walls and the presence cough is present in up to 90% of patients with of mucus plugs (Barker 2002). bronchiectasis and that 76%ofpatients produce sputum on a daily basis. These disabling features The pulmonary function test provides have an adverse effect on individuals' physical and information about an individual's lung capacity social activities. Ultimately, disease progression in and volumes. In bronchiectasis, spirometry bronchiectasis leads to hypoxaemia and in some often shows a reduced ratio of forced expiratory instances respiratory failure (Selby 2002). volume in one second (FEV, ) to forced vital capacity (FVC) and a normal or slightly reduced FVC, and a reduced FEVj (Barker 2002). Classification,presentation and diagnosis Patients with mild bronchiectasis may demonstrate normal spirometry. Bronchiectasis can be classified according to the pathological or radiographie appearance of the airways (Table 1) (Barker 2002). Management strategies Bronchiectasis can present as focal obstruction concerning a single lobe or section of one lung, Successful management of the patient's or as widespread disease involving much tissue respiratory symptoms is central to the of both lungs (Barker 2002). Focal obstruction is management of bronchiectasis. The main the most common presentation (Emmons 2007). symptoms, as mentioned previously, include a A more limited presentation, such as in a focal persistent cough (Emmons 2007), excess lesion, may have a better prognosis. production of purulent sputum (Hassan 2006) and breathlessness. The persistent features of the condition may potentially lead to chronic fatigue in the patient. Clinical features of bronchiectasis The chronic nature of bronchiectasis may have a considerable effect on an individual's daily life > Anaemia. (Kapella etal2006). Individuals living with > Chest wheeze. chronic respiratory conditions need to engage in > Copious amounts of sputum. self-care activities particular to their condition. These include the use of inhalers, annual influenza > Difficulty in breathing. immunisation, breathing and aerobic exercises, > Disabling productive cough. and regular contact with healthcare professionals (Cicutto and Brooks 2006). The role of the ^ Fever. professional is essentially one of supporting the P Haemoptysis. individual to live with the condition by providing > Pieuritic chest pain. assessment, advice and education. Respiratory assessment Jevon and Ewens (2001 ) > Repeated chest infections (requiring antibiotic state that accurate respiratory assessment can aid therapy). diagnosis and help to determine appropriate > Weight loss. treatment. For individuals with chronic respiratory (Barker 2002) conditions, there is a need to ensure that they are able to perform a degree of self-assessment as part of their self-management strategies. Cicutto and Classification of bronchiectasis Brooks (2006) add that those with chronic respiratory disorders are motivated to make use of Type Pathological or radiological appearance self-care strategies. They also suggest that there are Cylindrical Diffuse mucosal oedema, some dilation of the bronchi. common factors that encourage the use of self-care strategies, including a desire to feel better, fear of Varicose Dilated bronchi alternating wifh areas of constriction, getting worse, an improved sense of wellbeing and with or without obstructive scarring. the recommendation of the healthcare professional Saccular or cystic Progressive dilation of the bronchi which ends in (Cicutto and Brooks 2006). balloon-like cysts. The severity of breathlessness is a particularly (Adapted from Barker 2002) important 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 is a need to assess breathlessness carefully with a range of questions that explore the effect of the condition on a number of daily activities (Box 2). In terms of healthcare assessment and self-care it is necessary to consider any alterations in the areas questioned as this is likely to signify a change in the individual's clinical condition. Therefore, patients need to develop an awareness of change, however subtle, while healthcare professionals need to revisit the questions during subsequent consultations. During respiratory assessment nurses should be alert to any possible features that may indicate deterioration in the patient's condition. Nurses should also be aware of the need to educate patients to recognise any changes that may signify deterioration in their condition. This will enable appropriate, early intervention. For example, changes in the colour and consistency of sputum may indicate infection (Jevon and Ewens 2001) which, if not treated quickly, could lead to a significant deterioration in the patient's clinical condition. Bronchopulmonary management Prieto et al (2001 ) suggest that the optimum therapeutic management of patients with bronchiectasis includes postural drainage, chest physiotherapy and antibiotic therapy. Chest physiotherapy may not be well tolerated by some patients because of the difficulty in maintaining a suitable position for drainage (Fahy etal 1992, Currie 2004). Patients who are producing 20ml or more of purulent sputum over a 24-hour period despite appropriate antibiotic therapy should be referred for chest physiotherapy (Currie 2004). A combination of postural drainage, a cycle of

breathing, forced expiration and directed cough are sufficient to enhance mucus clearance (Currie 2004). A cycle of breathing as described by Currie (2004) consists of four deep breaths with relaxed expiration, which is followed by a pause to allow the patient to relax. The patient then engages in diaphragmatic breathing with one or two forced expirations. This is followed by a further pause for gentle breathing to loosen secretions, which are easily cleared by one or two coughs. This cycle of breathing is repeated as often as necessary. Postural drainage depends on gravity to assist in the removal of mucus from the airways and should be performed several times a day.

How would you recognise increased sputum retention in a patient? What interventions could you use to assist the patient to expectorate sputum?

Questions to help assess breathing difficulties

Can the patient talk with ease? Does breathlessness affect the patient's activities of daily living? How far is the patient able to walk without stopping? Can the patient climb stairs? Does breathlessness affect the patient's job? Does the patient have orthopnoea, that is breathlessness necessitating an upright position for relief? If so, how many pillows does he or she require to sleep at night? Do certain activities precipitate breathlessness? Does the patient have oxygen at home?

{Jevon and Ewens 2001)

PosturaldrainageNttina (2005) suggests that bronchial hygiene using postural drainage with percussion and/or vibration to loosen secretions helps with mucus clearance. Inflatable vests or mechanical vibrators have been applied to the chest of patients with bronchiectasis with some success, and are now more popular than chest cupping and the use of percussion (Barker 2002). High frequency chest wall oscillation is dependent on a device to exert external forces on the chest wall to help lessen the viscosity of mucus present and to help move secretions. As previously mentioned, this upward movement of secretions is assisted by increased activity and action of the cilia, which are encouraged by chest wall oscillation (Pruitt and Jacobs 2005). An inflatable vest is worn and attached to an air pulse delivery system. Therapy should last for approximately 20 minutes twice daily (Pruitt and Jacobs 2005). Chest physiotherapy The role of physiotherapists in the management of patients with bronchiectasis is paramount. Overall, the benefits of physiotherapy are numerous, including early clearance of sputum from the lungs. This reduces the volume of sputum left in the lungs, which in turn reduces the availability of sputum for colonisation by bacteria and decreases the stimulus for an inflammatory response. In a long-term condition such as bronchiectasis, self-administered chest physiotherapy may be helpful in maintaining good respiratory function. Nurses and physiotherapists need to consider the most appropriate strategies for teaching patients and their relatives to perform chest physiotherapy. Nttina (2005) encourages daily physical activity, which will assist in the mobilisation of
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Chest infections Chest infections are common in patients with bronchiectasis. Chest infections can precipitate a rapid deterioration in the patient's condition. Chronic colonisation with Pseudomonas aeruginosa is associated with a mucus and hence help clear the airways. The rapid decline in lung function and therefore patient's state of hydration should be monitored longer-term deterioration (Martinez-Garcia etal and well maintained as this can help reduce 2007). Pseudomonas infections are usually viscosity of secretions and make expectoration treated with fluoroquinolone antibiotics (Barker easier (Nttina 2005). The nurse's role is to assist 2002), but like many bacterial agents the patient to understand why these aspects of Pseudomonas aeruginosa is developing resistance self-care are important and to teach and support to many common antibiotics. Todar (2008) individuals to learn the necessary skills. suggests the use of gentamicin and carbenicillin Antibiotic fAerapy Antibiotic therapy is central in combination. Patients with frequent chest to the treatment of patients with bronchiectasis. infections may require long-term prophylactic Antibiotics can be administered intramuscularly, antibiotic therapy (ten Hacken et al 2007). intravenously, subcutaneously, orally or by The use of antibiotics needs to be combined with nebuliser. Early administration of antibiotics is bronchodilator therapy, anti-inflammatory drugs recommended for suspected exacerbations of and physiotherapy, as outlined above. bronchiectasis (Barker 2002) and while duration of treatment with antibiotics has not been To protect the patient from unnecessary established, a course of no less than seven to ten infections, immunisations against influenza virus days seems prudent (Barker 2002). Nebulised and pneumococcal pneumonia are recommended antibiotics are recommended for patients with (Currie 2004, Nttina 2005). These severe bronchiectasis whose disease is progressive immunisations will help protect against influenza and resistant to treatment (Currie 1997). over the winter months and can prevent the onset of more serious illnesses. The pneumococcal Short courses of antibiotics are usually vaccine is usually only required once and a single prescribed to convert purulent (yellow or green) dose protects against pneumococcal infection for sputum to mucoid (white or clear and viscous) up to ten years (Scottish Government 2007). or no sputum (Currie 2004). Prolonged courses Smoking cessation Patients should be taught to of antibiotics may be used to maintain sputum recognise factors that may contribute to or as mucoid or absent, or to reduce or prevent exacerbate their condition. Lifestyle issues should exacerbations and prevent disease progression be considered. For example, smoking cessation is a (Currie 2004). Antibiotics should be changed if crucial factor if disease progress is to be slowed, and sputum remains unresponsive to oral antibiotics after one to two weeks of treatment (Currie 2004). is a mainstay of management (Emmons 2007). Second-hand smoke must also be avoided as this Airway inflammation Airway inflammation can is also a recognised lung irritant (Perry 2007). be reduced with the use of corticosteroids (Selby 2002). Regular use of inhaled corticosteroids may Pulmonary function is reduced by cigarette smoking, which also accelerates obstructive improve lung function (Ram etal2007) and reduce sputum volume (King 2007). However, the impairment. Nurses should help patients to stop current evidence base for practice is limited as only smoking and/or refer individuals to appropriate healthcare professionals and services. Avoidance a small number of studies and no randomised of smoking (active and passive) will reduce the rate controlled trials have been conducted in this area. of bronchial tissue destruction and deterioration The actions of corticosteroids lessen the (Perry 2007). inflammatory response, which can reduce the amount of tissue damage over time. Corticosteroid therapy can be used during an acute exacerbation where a tapered approach to What smoking cessation support use can be employed. Airway inflammation, if is available to patients in your untreated, can lead to airflow obstruction practice area? Collate this necessitating bronchodilator therapy (Selby information into a fact file that you 2002). The adverse effects of long-term can keep in your clinical area for corticosteroid use should be considered.
future reference.

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Long-term oxygen therapy Patients with poor respiratory function may require long-term oxygen therapy (Perry 2007). This is indicated when there is a sustained worsening of a patient's clinical condition.
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Curative interventions Overall, management of bronchiectasis is largely aimed at care rather than cure as the only curative interventions are lobar resection and bilateral lung transplantation (Mysliwiec and Pina 1999), both of which carry considerable risk for patients. For lobectomy, the disease must be sufficiently localised to allow for complete removal of diseased tissue. Curative procedures may be used when, in spite of being treated with other conservative methods including antibiotic therapy, the patient remains symptomatic (Emmons 2007). For bilateral lung transplantation to be considered, life expectancy must be less than two years and there must be no other significant co-morbidities (Currie 2004).

Features of acute exacerbation of broncbiectasis

Change in sputum production. Increased breathlessness. Increased cough. Temperature higher than 38C. Increased wheezing. Malaise, fatigue, lethargy or decreased exercise tolerance. Reduced pulmonary function. Changes on chest X-ray. Changes in chest sounds. (Payne 2006)

Acute deterioration
Treatment aims to maximise functional ability and avoid acute exacerbations of bronchiectasis. However, should an exacerbation occur a quick and appropriate response is essential. O'Donnell etal (1998) suggest that four out of nine clinical features indicate an acute exacerbation of bronchiectasis (Box 3). Patients with an acute exacerbation require different therapies, including oral antibiotics. Patients may require intravenous antibiotics if oral therapy is ineffective (Fani etal 2007). Antibiotics can be used to treat acute exacerbations as well as prevent exacerbations caused by bacterial colonisation (ten Hacken etal 2007), which result in airway inflammation and tissue damage. In addition, introduction of, or increase in, bronchodilator and corticosteroid therapies may be indicated. Appropriate choice of antibiotics will have to be considered, especially if there has been no response to the initial course of treatment. Therefore a sputum culture is an important part of the diagnostic assessment. Antibiotics are generally prescribed based on the organisms and sensitivities identified in sputum cultures (Fani etal2007). In some cases there will be a need to hospitalise individuals with an acute exacerbation, and for other patients assessment at home can avoid the physical and psychological effects of repeated.

References
Barker AF (2002) Bronchiectasis. New England Journal of Medicine. 346,18, 1383-1393. Cicutto LC, Brooks D (2006) Self-care approaches to managing chronic obstructive pulmonary disease: a provincial survey. Respiratory Medicine. 100, 9,1540-1546. Crowley LV (1997) Introduction to Human Disease. Fourth edition. Jones and Bartlett Publishers, Sudbury MA. Currie DC (1997) Nebulisers for bronchiectasis. Thorax. 52, SuppI 2, S72-S74. Currie D (2004) Differential Diagnosis of Branchiectasis. www.cysticfibrosismedicine.com/cfdocs/cftext/bronchiectasis.ht m (Last accessed: August 22 2008.) Downs CA, Appel SJ (2007) Chronic obstructive pulmonary disease: diagnosis and management. Journal of the American Academy of Nurse Practitioners. 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, Boushey HA, Nadel JA (1992) Mucus hyperscrtion in bronchiectasis. The role of neutrophil proteases. The American Review of Respiratory Disease. 146, 6, 1430-1433. Fani P, Bye MR, Callahan C (2007) Bronchiectasis. www.emedicine.com/ped/ topic2468.htm (Last Accessed: August 22 2008.) Gaga M, Bentley AM, Humbert M et al (1998) Increases in CD4-^ T lymphocytes, macrophages, neutrophils and interleukin 8 positive cells in the airways of patients with bronchiectasis. Thorax. 53, 8, 685-691. Goodridge DM (2006) COPD as a life-limiting Illness: implications for advanced practice nurses. Topics in Advanced Practice Nursing e-journal. 6,4. Gould BE (2006) Pathaphysialogy far the 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 of a breathless patient. Nursing Standard. 15,16, 48-53. Kapella MC, Larson JL, Patel MK, Covey MK, Berry JK (2006) Subjective fatigue, influencing variables, and consequences in chronic obstructive pulmonary disease. Nursing Research. 55,1,10-17 King P (2007) Is there a role for inhaled corticosteroids and macrolide therapy in bronchiectasis? Drugs. 67 7, 965-974. Maa SH, Tsou TS, Wang KY, Wang CH, Lin HC, Huang YH (2007) Self-administered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. Journal of Clinical Nursing. 16, 4, 794-804. Martinez-Garcia MA, Soler-Catalua JJ, Perpia-Tordera M, Romn-Snchez P, Soriano J (2007) Factors associated with lung function decline in adult patients with stable non-cystic fibrosis bronchiectasis. Chest. 132, 5,1565-1572.

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long stays in hospital (Schofieid etal 2006). There is limited evidence to support this approach for patients with bronchiectasis, but given the similarities it could be assumed there is a place for home management for carefully selected patients. Patients with severe bronchiectasis may require more aggressive respiratory management. Higher levels of oxygen therapy can be prescribed to reduce respiratory effort and increase the partial pressure of oxygen while reducing the partial pressure of carbon dioxide. However, in some patients this will be insufficient and increased ventilatory support will be required. Non-invasive positive pressure ventilation (NIPPV) has been used for some time in the treatment of patients with chronic respiratory insufficiency (Preston 2001). The aim is to manage respiratory failure without the need for intubation. There are two main types of NIPPV: continuous airway positive pressure, and bilevel positive airway pressure. Readers wishing to learn more about this should refer to Preston (2001 ). Therapy should reduce respiratory effort for the patient, increase tidal volumes, reduce partial pressure of carbon dioxide and increase partial pressure of oxygen. It is hoped that after a short course of NIPPV the patient will be able to return to normal with limited change to his or her condition. However, frequent exacerbations are a recognised factor

associated with lung decline in adults (MartinezGarcia etal2007). For patients who do experience significant lung decline there may be a need to consider in the long term palliative and ultimately end-of-life care.

James, aged 58 years, is due to be discharged home after an acute worsening of his bronchiectasis. He is to start on home oxygen therapy. Outline a care plan to prepare James and his family for this therapy.

Conclusion
Although the causes of bronchiectasis are varied, the consequences in terms of each patient's experience are the same. Problems patients might experience as a result of bronchiectasis and strategies to support patients to live with this chronic condition have been discussed. Nurses will require a range of knowledge, skills and interventions to assist patients to cope with the everyday challenges associated with exacerbations of this long-term condition NS

Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60.

Mysliwiec V, Pina JS (1999) Bronchiectasis: the 'other' obstructive iung disease. Postgraduate Medicine.'iob. 1, 123-126,128-131. Nttina SiVi (2005) Lippincott Manual of Nursing Practice. Eighth edition. Lippincott Wiiliams and Wilkins, Philadelphia PA. O'Donneii AE, Bari<er AF, Ilowite JS, Fici< RB (1998) Treatment of idiopathic bronchiectasis with aerosolized recombinant human DNase I. rhDNase Study Group. Chest. 113, 5,1329-1334. Payne K (2006) Bronchiectasis. In Scullion JE (Ed) Fundamental Aspects of Nursing Adults with Respiratory Disorders. Quay Books, Dinton. 31-40. Perry iVi (2007) Brcnchiectasis: diagnosis and prognosis. Practice Nursing. 18, 9, 436-441. Preston R (2001) Introducing noninvasive positive pressure ventilation. Nursing Standard 15, 26, 42-45. Prieto D, Bernardo J, iVIatos MJ,

Eugenio L, Antunes iVi (2001) Surgery for bronchiectasis. European Journal of Cardio-thoracic Surgery. 20,1,19-24. Pruitt B, Jacobs M (2005) Clearing away pulmonary secretions. Nursing. 35,7 36-41.

Pneumococco/? www.infoscotland.com/ infoscotland/files/Dr%20Steele%20Pneu moccocal%2Oleaflet.pdf (Last accessed: August 28 2008.) Selby C (2002) Respiratory Medicine: An Illustrated Colour Text Churchill Livingstone, Edinburgh.

Pryor JA, Prasad SA (Eds) (2002) Physiotherapy for Respiratory and Cardiac Problems. Adults and Paediatrics. Siiarpies LD, Edmunds J, Biiton D et al Third edition. Churchill Livingstone, ' (2002) A randomised controlled Edinburgh. crossover trial of nurse practitioner versus doctor ied outpatient care in a Ram FSF, Welis A, Koibe J (2007) bronchiectasis clinic. Thorax. 57, 8, Inhaled steroids for bronchiectasis. 661-666. Cochrane Database of Systematic Reviews. Issue 2. ten Haci<en NH, Wiji<stra PJ, Kerstjens HA (2007) Treatment of bronchiectasis in Schofieid I, Knussen C, Toison D adults. British Medical Journal 335, 7629, (2006) A mixed method study to 1089-1093. compare use and experience of hospital care and a nurse-led acute respiratory Thibodeau GA, Patton i a (2004) assessment service offering home care Structure and Function ofthe Body. to people with an acute exacerbation of Twelfth edition. Mosby, St Louis MO. chronic obstructive pulmonary disease: Todar K (2008) Pseudomonas Aeruginosa. International Journal of Nursing Studies. www.textbookofbacteriology.net/ 43, 4, 465-476. pseudomonas.html Scottish Government (2007) What's (Last accessed: August 11 2008.)

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