Bronchiestasis Case Studies Essay

CASE STUDY OF A PATIENT WITH BRONCHIECTASIS
INTRODUCTION
The respiratory system is divided into upper and lower respiratory system. The upper respiratory system refers to the nose, pharynx and associated structure while the lower respiratory system contains the larynx. Bronchiectasis is an uncommon type of chronic obstructive pulmonary lung disease. Bronchiectasis can be categorized as a chronic obstructive pulmonary lung disease manifested by airways that are inflamed and easily collapsible, resulting in air flow obstruction with shortness of breath, impaired clearance of secretions often with disabling cough, and occasionally hemoptysis.
In this case study, a patient is suffering from bronchiectasis. Bronchiestasis is further defined
and the pathophysiological action that take place are during this diease is also highlighted. The physical assessment is done to confirm this diagnosis, therefore, there is also a brief outline of the physical assessment being carried out with the results. Lastly, the drugs are outlined to treat bronchiectasis together with their pharmacokinetics and pharmacodynamics. Also, the effect of one of the drugs on two body system has been discussed.
This assignment will help broaden our knowledge on the uncommon type of chronic obstructive pulmonary disorder.

HEALTH HISTORY
Name: John X.
Age: 42 years
Hospital: CWM
Date of admission: 12th November, 2010
Social History
Race: Fijian
Religion: Christianity
Marital Status: Married
He lives with his father, wife and four children.
He has been a non-smoker for two years but has been smoking since he was 2o years old. He at times drinks alcohol and Kava.
Family History:
Paternal side: grandfather had hypertension and was positive for pulmonary tuberculosis.
Medical History
Principal Diagnosis: Chronic bronchiectasis
Current Medical History
Mr. X was admitted to the hospital upon presenting signs and symptoms of chronic cough (more than 6 years), shortness of breath at rest and while moving about, and production of foul smelling, yellowish, thick sputum. On admission he was conscious, alert, oriented, and had clear speech. He can mobilize but prefers not to. He does not have any allergies and is neither diabetic nor asthmatic. He is currently on chloramphenicol and Ventolin for his treatment regime.

Past Medical History
He was previously admitted a number of times due to the same signs and symptoms and a suspect of being positive for tuberculosis. However, the test was negative. He was prescribed ventolin for shortness of breath.

PATHOPHYSIOLOGY
Bronchiestasis is the abnormal dilation of the bronchial wall muscle due to obstruction.
According to Porth (2005), it is characterized by permanent dilation of the bronchi and the bronchioles caused by destruction of muscle and elastic supporting tissue resulting from a vicious cycle of infection and inflammation. This disease is secondary to chronic infection and obstruction of the bronchial passage. There are many changes that occur such as edema formation, scarring of the tissues in the bronchial wall, inflammation and ulceration. Some of the common causes of bronchiectasis are cystic fibrosis, immune defects, and recurrent infections. All these causative factors impair the airway clearance system together with the host’s defense system and this leads to accumulation of the secretions in bronchi. The body has impaired ability to clear up secretions causes colonization and infection. Since the secretion harbors the microorganisms, it triggers the host’s body defense system to “respond through neutrophilic proteases, inflammatory cytokines, nitric oxide, and oxygen radicals” (www. emedicine.medscape.com) to counteract this reaction. These infections further damage the bronchi and the cycle of infection continues. These processes damage the muscular walls and the elasticity of the bronchial wall. This cause the bronchial walls to dilated and remain dilated since the elasticity is
lost.
In addition, “some of the organism that causes of brochiestasis are Haemophilus influenza, Pseudomonas aeruginosa, Moraxella catarrhalis, Staphylococcus aureus, and Streptococcus pneumonia” (www. www.nhlbi.nih.gov/health/dci/Diseases/brn/brn_whatis.html). These organisms are also the causative agents of many lung diseases such as pneumonia. According to King (2010), there are three types of bronchiectasis: cylindrical, varicose, and saccular. Cylindrical bronchiectasis is when the bronchi are dilated minimally but has straight, regular outlines that end squarely and abruptly. Varicose bronchiectasis has a bulbous appearance with a dilated bronchus and the sites of relative constrictions are scattered with presence of scarring. These are irregular constrictions. Saccular bronchiectasis has ulceration on the bronchial mucosa and has a ballooned appearance that may have air-fluid levels. This are also called cystic bronchiectasis. In order to diagnose the patient a number of tests had to be carried out. Firstly, chest x ray is done to view the lungs and the pleural cavity. This also done to rule out any other disease such as Pneumonia or cardiovascular problems. Secondly, for bronchiectasis patients the “Early Morning Sputum” is done three times to find out the causative agent for the disease and to see which antibiotics are resistant to this organism. Spirometry is also done.

PHYSICAL ASSESSMENT
ON ADMISSION
SUBJECTIVE DATA: * Cough- started six years ago, it was a gradual onset. It was moist and productives * Production of sputum- productive, foul smelling and yellowish * Shortness of breath- present at rest and while walking short distance. Most comfortable in a semiflower’s position * Pain: occasional chest pain while coughing * No allergies * Previously hospitalized for the same symptoms

Objective Data: VITAL SIGNS: this provides the baseline reading of the patient and also gives the stability of the patient. * Respiaration rate: 30 breaths/min, hyperventilated * P/ulse rate: 95 bpm, regular * BP: 118/82 mmhg * Temp: 37.9˚C * SpOˇ2 : 91%

EQUIPMENTS NEEDED FOR THE EXAMINING THE RESPIRATORY SYSTEM Stethoscope Ruler Alcohol swap to clean the equipments PREPARATION: Introduction to the patient, and gain his verbal consent of doig the examination. Mainatin privacy by drawing curtains or taking patient to the examination room. Explanation of the procedure to patient to reduce anxiety Inspection Inspection of Posterior Chest and Findings * Identify the landmarks: C7 is the level of apex of the lungs * Determining the lung fields for reference during auscultation andn percussion * Skin color and condition FINDINGS: the skin was well defined, no lesions was present, the skin felt warm at touch with the dorsal side of the hand. There was slight pallor but no cyanosis. * Size and shape. Normal Findings: The posterior chest should have a good well- developed size of the chest in relation to the age. The anteroposterior ratio should bigger than the transverse chest. Inspect the placement of the scapula. Inspect the angle of the ribs. * Neck muscles and trapezius: The patient’s neck muscles were hypertrophied due to forced respiration * Symmetry: FINDINGS: both the sides of the posterior chest was equal. The scapula was equally placed. The spinal process was straight. * Quality of respiration: by placing the palm fo the hand below the scapula with the thumbs facing upward. Folding a small amount of skin in between the thumbs, the patient is asked to breathe deeply. FINDINGS: There was liitle unfolding of the skin which indicated that the patient had difficulty in breathing. However, it was symmetry. PALPATION OF POSTERIOR CHEST * Symmeteric expansion: test is done by placing warmed hands on the posteriolateral chest wall with thumbs at the level ofT9 or T10.
By sliding the hands medially, a small pinch of the skin is folded and the patient is asked to breathe deeply. FINDING: there was a symmetrical expansion of the posterior chest. * Tactile fremitus: is known as the vibrations that can be felt. This is felt using the base of the palm of fingers of one hand and touching the patient’s chest while he repeats the words “ninety nine”. It is started over the lung apex and palpated from one side to the other comparing the vibrations. “Fremitus I gradually decrease as the hand moves down the chest”. (Jarvis, 2004, pg122). FINDING: there is a decreased fremitus due to accumulation of the secretion in the bronchi. * Entire chest wall: using the fingers the chest wall is palpated to look for any tenderness, increased skin temperature and moisture, any masses or lumps. FINDING: there were no masses or lumps, however, the skin felt warm near the T10 spinal cord. PERCUSSION Lung Fields: Starting at the apices and continue to the inter spaces, making side to side comparison throughout the lung region. It is important to avoid the ribs an dthe
scapulae. AUSCULTATION * Breath sounds: The patient is instructed to breathe through the mouth deeply. While standing behind the patient listen to the breath sounds using a stethoscope. FINDING: there was a decresed breath sound indicating abctruction. * Listen to other sounds such as wheezes. THE ANTERIOR CHEST Inspection * Shape and configuration: observe the chest. Ribs should be sloping downwards. The coastal angle was 90˚. * Facial expression: Patient was sitting looking a little strained and tired. He was also breathing with pursed lips in a whistling position. * Colour and condition: this indicates whether the patient is hypoxic. In this the nail beds, skin and lips are assessed. Finding: There was a slight cyanosis. No skin lesion was present. Colour was correlated with the ethnicity. PALPATION * Symmetry: The patient was assessed for the chest symmetry and repirstion. The palm of the hands were placed on the anterolateral wall and thumbs along the costal margins and the patient was asked to breath deeply. Finding: The patient’s chest was symmetrical and had symmetrical expansion on both sides. * Tactile Fremitus: Patient was asked to repeat the words “ninety nine”while the hand was placed on the apices and on other lung filds. Findings: the fremitus was equal on both sides. * Palpation for any tenderness, masss swelling was done and none was found. PERCUSSION Similar to that done on the posterior chest AUSCULTATION * Breath sounds: this was heard using a stethoscope over the lung field. DIAGNOSTIC TESTS AND RESULTS 1. CHEST X-RAY X-ray results show that the lungs are hyperinflated, reticuluar seen bilaterally in the lung bases. There was no pleural cavity and the heart was not enlarged. 2. Full Blood Count. WBC – 10.49 (10^3/uL), RBC – 5.80 (10^6\uL), HCT -45%, HGB – 13.9g/dL, Neutrophyl – 78%, Lyphpcytes – 13.9%, Monocytes – 78%, Baso – 0.2% 3. Urea and Electrolytes U – 3.3, Cr – 68, Na- 138, k 3.9, Cl – 9.7, 4. LFTs – Lver Function Test TB & ALP – 81, AST – 13, ALT – 11, TP – 88, alb- 3 5. Early Morning Sputum Test – identified sergeusm i. Normal respiratory flora ii. Heavy growth of proteus mirabilis Sensitive to Ampilicin\ Choromphenicol \ Cephalotin Resistant to septrin

DRUG ACTION Drug therapy is guided at reducing the airway secretions and facilitating their removal through cough and also to inhibit reoccurance of the infection. Usually, in bronchiectasis antibiotics, bronchodilators and anti-inflammatory agents are prescribed. The medications that Mr. X. was prescribed was chloramphenicol (500mg), Ventolin Nebs and salbutamol (5mg). The antibiotic that was given to him was chloramphenicol. According to Kuhn (1991), chloramphenicol is a broad spectrum antibiotic that has activity against both aerobic and anerobic gram positive and gram negative microorganism. The pharmacokinetics is the action of the drugs on body. The absorption of chloramphenicol is the highest when it is taken orally. The oral formula consists of a tasteless and palminate suspension and chloramphenicol base in the capsule. The suspension is not active unless the palminate ester is taken out from it. This process is said to be done in the deudoneum. Then it is absorbed in the bloodstream. The circulating fluid distributes it. This drug is metabolized in the liver and excreted by the kidneys. The pharmacodynamics will explain how the drug would exert their effect on the body. Chloramphenicol binds to the 50S subunit of ribosomes in bacterial cells, which is responsible for catalyzing the formation of bonds between amino acids,. Amino acids are the building blocks for new proteins. By preventing the bacteria from linking amino acids together, chloramphenicol is able to halt the production of bacterial proteins, which keeps the bacteria from replicating and growing. This allows the immune system to destroy the bacterial growth, thus preventing infection.
Ventolin was another drug prescribed to him. Ventolin, also known as albuterol, relaxes the smooth muscles of the bronchi. When this is done, air flow increases in the tract and thus prevents clearing up of secretion. It is either inhaled or taken orally. When it is inhaled it is directly absorbed into the bronchial walls. It is rapidly absorbed after oral administration . The maximum plasma concentrations of about 18 ng/mL within 2 hours, and the drug is eliminated with a half-life of about 5 hours. Ventolin is also

EFFECTS OF VENTOLIN ON TWO BODY SYSTEMS
Ventolin should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension; in patients with convulsive disorders, hyperthyroidism, or diabetes mellitus; and in patients who are unusually responsive to sympathomimetic amines. According to Galbrath & all (2004), sympatomemimetic drugs are drugs that mimic the sympathetic actions Such as the “flight or fight” response.