1、Bronchiectasis支气管扩张Si Ting WangFaculty of Nursing GuangXi Traditional Chinese Medical University Pathophysiology Bronchiectasis支气管扩支气管扩张张 is a disorder characterized by permanent,abnormal dilatation扩张扩张of one or more medium-sized and diameter greater than 2mm proximal bronchi近端支气近端支气管管.Pathophysiolo
2、gic change that result in dilatation is destruction of the elastic tissue弹性组织弹性组织and muscular structures of the bronchial wall支气管壁支气管壁.Etiology病因 The disease process is often believed to start in childhood as an acquired disorder,beginning with respiratory complications secondary to influenza流行性感冒,m
3、easles麻疹,or whooping cough百日咳.Infant bronchial-lung infection婴幼儿期支气管婴幼儿期支气管-肺组织感染肺组织感染is the most common cause of bronchiectasis.Recurring lower respiratory tract infections are another pattern of disease in childhood that may predispose an individual to bronchiectasis.This pattern is typically seen
4、 in the individual who has cystic fibrosis囊肿性纤维化,asthma哮喘,a-1 aitirypsin deficiency 抗胰蛋白酶不足,or immunodeficiency diseases免疫缺陷疾病.Pathologic types病理类型病理类型 Saccular bronchiectasis囊状支气囊状支气管扩张管扩张:occurs mainly in large bronchi and is characterized by cavity-like dilatations.The affected bronchi end in lar
5、ge sacs.Cylindrical bronchiectasis圆柱支气圆柱支气管扩张管扩张:involve in medium-sized bronchi that are mildly to moderately dilated.Pathophysiology病理生理 Almost all forms of bronchiectasis are associated with bacterial infection细菌感染细菌感染.Infections cause the bronchial walls to be weaken,and pockets of infection beg
6、in to form.When the walls of the bronchial system are injured,the mucocilliary mechanism 粘膜粘膜-纤毛防御机制纤毛防御机制 is damaged,allowing bacteria and mucus to accumulate within the pockets.The infection becomes worse and results in bronchiectasis.Classification分类 1.Localized bronchiectasis局部支局部支气管扩张气管扩张:resul
7、ts from focal airway obstruction,or from necrotizing坏死性坏死性or lobar pneumonia大大叶性肺炎叶性肺炎whose bronchiectatic sequelae后遗症后遗症are limited to one area of the lung.Obstructive processes of any kind can predispose an individual to bronchiectasis.The obstruction causes the bronchi支气管支气管and bronchioles细细支气管支气
8、管to distend and balloon out below the level of obstruction.Classification分类 2.Generalized bronchiectasis广泛性支气管扩张广泛性支气管扩张:is multifocal necrotizing 多灶性坏死性多灶性坏死性 bacterial infection,but other condition can predispose persons to the development of bronchiectasis,such as:Congenital先天性factors:altered bro
9、nchial structures such as cysts支气管囊肿and cul-de-sacs盲囊,which lead to pooling of secretion.A variety of immunodeficiency diseases免疫缺陷疾病are associated with recurrent bacterial pneumonia.Some inhalation exposures,particularly to irritant gases such as oxides of sulfur硫氧化物 and nitrogen氮,have been noticed
10、 as causes of bronchiectasis.Clinical manifestation临床表现 The primary manifestations of bronchiectasis varyconsiderably,depending on the extent and locationof the disease process:Chronic cough with production of mucopurulent sputum黏液性脓性痰黏液性脓性痰;the cough is paroxysmal阵发性阵发性and is often stimulated with
11、position changes.*Hemoptysis咯血咯血 Recurrent pneumonia肺炎肺炎 Exertional dyspnea运动性呼吸困难运动性呼吸困难 Fatigue 疲劳疲劳 Weight loss Anorexia厌食症厌食症 Fetid breath恶臭呼吸恶臭呼吸Diagnostic studies辅助检查 An individual with a chronic productive cough with copious sputum(which may be blood streaked血丝血丝should be suspected of having
12、bronchiectasis.Characteristic findings in the health history such as childhood diseases complicated by respiratory infections or chronic bronchitis are significant.Chest X-ray may show streaky infiltrates.Bronchoscope支气管镜支气管镜may be useful in identifying the source of secretions or sites of hemoptysi
13、s in the individual with chronic productive cough.Sputum collection痰液收集痰液收集may provide with additional information regarding the severity of impairment and the presence of active infection.Pulmonary function肺功能测试肺功能测试test may be abnormal in advanced bronchiectasis.A complete blood count血细胞计数血细胞计数may
14、 be normal or show evidence of anemia and leukocytosis.Therapeutic management治疗方案1.Antibiotics抗生素抗生素are the major form of treatment and should be given on the basis of sputum culture痰培养痰培养result.2.Maintaining good hydration is important to liquefy secretions.Encourage daily drinking water of not les
15、s than 1500 2000ml.3.Postural drainage体位引流体位引流is vital to facilitate expectoration of sputum咳痰咳痰.4.The individual should reduce exposure to excessive air pollutants and irritants,avoid cigarette smoking and obtain pneumococcal肺炎球菌肺炎球菌and influenza vaccinations流感疫苗接种流感疫苗接种.5.Surgical resection of par
16、ts of the lungs may be done if conservative treatment is not effective;surgical in not available when there is diffuse or widespread involvement.Nursing managementAcute and chronic intervention1.An important nursing goal is to promote drainage引流引流and removal of bronchial mucus支气管黏液支气管黏液.2.Some indiv
17、iduals require elevation of the foot of the bed by 4 to 6 itches to facilitate drainage.Postural drainage体位引流体位引流should be done on the affected parts of the lungs患侧肺部患侧肺部.3.The patients should be taught effective deep-breathing exercises深呼吸练习深呼吸练习and effective ways to cough.4.Administration of the p
18、rescribed antibiotics抗生素抗生素,bronchodilators支气管扩张剂支气管扩张剂or expectorants is important祛痰剂祛痰剂.Nursing management 护理措施Acute and chronic intervention5.Bed rest may be indicated during the acute phase of the illness,chilling and excess fatigue should be avoided.6.Good nutrition is important but may be diff
19、icult to maintain because the patient is often anorexic.Oral hygiene to cleanse the month and remove dried sputum crusts may improve the patients appetite.7.Adequate hydration to help liquefy secretion,thus the patient should be instructed to drink at least 3L of fluid daily.However,generally the pa
20、tient should be counseled to use low-sodium fluids to avoid systemic fluid retention.Nursing management护理措施Acute and chronic intervention8.The patient with bronchiectasis should avoid ultrasound nebulizers超声雾化吸入超声雾化吸入 because they often induce bronchospasm支气管痉挛支气管痉挛.It is important that the patient
21、medicate with an inhaled bronchodilator 10 to 15 minutes before to prevent bronchoconstriction.9.The patient and family should be taught to recognize significant manifestation to be reported to the health care providers,these manifestation include increased sputum production,grossly bloody血腥痰sputum,
22、increasing dypsnea呼吸困难,fever,chills发烧,and chest pain.HemoptysisHemoptysisis the expectoration(coughing up)of blood or of blood-stained sputum from the bronchi,larynx,trachea,or lungs.500mlor 100500ml/time:massive volume。Nursing management护理措施Hemoptysis care咯血的护理咯血的护理1.Promote personal and special en
23、vironment to decrease anxiety from disease.2.Keeping the patient at rest,position for maximal aeration of lung fields,the bleeding lung should be placed in the dependent position,so that blood is not aspirated into the unaffected lung.3.When helping patient cough,use whatever position best ensures c
24、ooperation and minimizes energy expenditure.4.Using suction as ordered,when its needed.with massive bleeding,endotracheal intubation气管内插管气管内插管and mechanical ventilation机械通气机械通气may be needed to control airway and maintain adequate gas exchange.5.If there is massive bleeding which is prone to be suffo
25、cated,preparing for endotracheal intubation气管内插管气管内插管,as order.6.Monitor and document vital sigh,bleeding characteristic to gauge therapys effectiveness and detect possible progression.咯血的护理咯血的护理1.促进个人和特殊的环境，减少焦虑。促进个人和特殊的环境，减少焦虑。2.保证病人休息和正确体位，能够最大限度促使肺野的通气。保证病人休息和正确体位，能够最大限度促使肺野的通气。小小量咯血应静卧休息，大量咯血者需
26、绝对卧床休息。肺出血时应量咯血应静卧休息，大量咯血者需绝对卧床休息。肺出血时应协助患者在患侧卧位，协助患者在患侧卧位，从而使血液不能被吸入健侧。从而使血液不能被吸入健侧。3.当帮助病人咳嗽时，选择任何合适的位置，最好确保病人能够当帮助病人咳嗽时，选择任何合适的位置，最好确保病人能够配合的同时最大限度地减少能量和体力的消耗。配合的同时最大限度地减少能量和体力的消耗。4.及时为病人漱口，擦净血迹，保持口腔清洁，舒适，防止口腔及时为病人漱口，擦净血迹，保持口腔清洁，舒适，防止口腔异味刺激，再度引起咯血。异味刺激，再度引起咯血。5.如果需要，遵医嘱使用吸引。当患者出现大出血，可能需要气如果需要，遵医嘱
27、使用吸引。当患者出现大出血，可能需要气管内插管和机械通气，以控制呼吸道和保持足够的气体交换。管内插管和机械通气，以控制呼吸道和保持足够的气体交换。6.如果有大量出血，患者很容易被窒息，因此，必须遵医嘱准备如果有大量出血，患者很容易被窒息，因此，必须遵医嘱准备气管插管。气管插管。7.监测并记录生命体征，出血的情况，用于衡量治疗的效果和发监测并记录生命体征，出血的情况，用于衡量治疗的效果和发现疾病可能的进展。现疾病可能的进展。8.遵医嘱用止血药，抗生素，祛痰剂，支气管舒张药。遵医嘱用止血药，抗生素，祛痰剂，支气管舒张药。大咯血可使用垂体后叶素。大咯血可使用垂体后叶素。剧烈咳嗽者给予小剂量镇静剂。剧
28、烈咳嗽者给予小剂量镇静剂。烦躁不安者适当选用镇静剂如地西拌，烦躁不安者适当选用镇静剂如地西拌，禁用吗啡，派替啶禁用吗啡，派替啶以免抑制呼吸。以免抑制呼吸。asphyxia窒息If the patient present stressed精神紧张,restless坐卧不安and dull complexion面色晦暗,poor in hemoptysis,it is often choking sign窒息先兆.If the patient suddenly become dread表情恐怖,chest tightness胸闷,shortness of breath气促,cyanosis发绀of
29、 mouth and lip.sweating,or loss of consciousness意识丧失,etc.,indicating that asphyxia窒息 has occurred,it should be urgently addressed.Nursing care for asphyxia1.First aid items are ready,closely monitor patients with aura suffocation.2.When signs of asphyxia present,immediately place the patient on Tren
30、delenburg position,with head to one side,purcuss the back quitely in order to discharge blood clot.If necessary,tracheal intubation or tracheostomy should be well prepared.3.Inform patients can not breath,so as not to induce laryngospasm.4.Timely clear blood clots in mouth and nasal,or quickly conne
31、cted with a suction catheter into nasal tracheal suction to remove blood clots within the respiratory tract.5.If necessary,cooperating with doctor to perform endotracheal intubation or a bronchoscope under direct vision draw blood clots.6.After blood clot removed,if the patient has not resumed spont
32、aneous breathing,artificial respiration should be held to provide with high flow oxygen,or uesing respiratory stimulants.7.Close observation of disease,monitoring blood gas analysis and coagulation mechanisms to guard against the possibility of choking again.窒息的护理1.备好急救物品，密切监测病人有无窒息先兆。备好急救物品，密切监测病人有
33、无窒息先兆。2.当窒息发生或有窒息征象时，立即采取当窒息发生或有窒息征象时，立即采取头低脚高体位，头低脚高体位，头偏向一侧头偏向一侧，轻扣背部，排出血块，必要时做好气管，轻扣背部，排出血块，必要时做好气管插管或气切的准备。插管或气切的准备。3.告知病人咯血时不能屏气，以免诱发喉头痉挛。告知病人咯血时不能屏气，以免诱发喉头痉挛。4.及时清除口，鼻腔内血凝块，或迅速用鼻导管接吸引及时清除口，鼻腔内血凝块，或迅速用鼻导管接吸引器插入气管内抽吸，以清除呼吸道内的积血。器插入气管内抽吸，以清除呼吸道内的积血。5.必要时配合医生行气管插管或气管镜直视下吸取血块。必要时配合医生行气管插管或气管镜直视下吸取血块。6.血块清除后，若病人自主呼吸尚未恢复，应行人工呼血块清除后，若病人自主呼吸尚未恢复，应行人工呼吸，给高流量吸氧或遵医嘱应用呼吸中枢兴奋剂。吸，给高流量吸氧或遵医嘱应用呼吸中枢兴奋剂。7.密切观察病情，监测血气分析和凝血机制，警惕再次密切观察病情，监测血气分析和凝血机制，警惕再次窒息的可能。窒息的可能。
