Asthma

AsthmaAsthma

AsthmaAsthma DefinitionDefinition

AsthmaAsthma DefinitionDefinition

Reactive airway disease Chronic inflammatory lung disease

Inflammation causes varying degrees of Inflammation causes varying degrees of obstruction in the airwaysobstruction in the airways

Asthma is reversible in early stages

Triggers of AsthmaTriggers of AsthmaTriggers of AsthmaTriggers of Asthma

AllergensAllergens ExerciseExercise Respiratory InfectionsRespiratory Infections Nose and Sinus problemsNose and Sinus problems Drugs and Food AdditivesDrugs and Food Additives GERDGERD Emotional StressEmotional Stress

Early and Late Phases of Responses of Early and Late Phases of Responses of AsthmaAsthma

Early and Late Phases of Responses of Early and Late Phases of Responses of AsthmaAsthma

Fig. 28--1

AsthmaAsthmaPathophysiologyPathophysiology


Bronchospasm Airway inflammation



Early-Phase ResponseEarly-Phase Response PPeaks 30-60 minutes post exposure, subsides 30-

90 minutes later Characterized primarily by bronchospasm Increased mucous secretion, edema formation,

and increased amounts of tenacious sputum Patient experiences wheezing, cough, chest

tightness, and dyspnea



Late-Phase ResponseLate-Phase Response Characterized primarily by inflammationCharacterized primarily by inflammation Histamine and other mediators set up a self-

sustaining cycle increasing airway reactivity causing hyperresponsiveness to allergens and other stimuli

Increased airway resistance leads to air trapping in alveoli and hyperinflation of the lungs

If airway inflammation is not treated or does not resolve, may lead to irreversible lung damage

Factors Causing Airway Obstruction in Factors Causing Airway Obstruction in AsthmaAsthma

Factors Causing Airway Obstruction in Factors Causing Airway Obstruction in AsthmaAsthma

Fig. 28--3

Summary of Pathophysiologic Summary of Pathophysiologic FeaturesFeatures

Summary of Pathophysiologic Summary of Pathophysiologic FeaturesFeatures

Reduction in airway diameter Increase in airway resistance r/t

Mucosal inflammation Constriction of smooth muscle Excess mucus production

AsthmaAsthmaClinical ManifestationsClinical Manifestations


Unpredictable and variable

Recurrent episodes of wheezing, breathlessness, cough, and tight chest



Expiration may be prolonged from a inspiration-expiration ratio of 1:2 to 1:3 or 1:4

Between attacks may be asymptomatic with normal or near-normal lung function



Wheezing is an unreliable sign to gauge severity of attack

Severe attacks can have no audible wheezing due to reduction in airflow

“Silent chest” is ominous sign of impending respiratory failure



Difficulty with air movement can create a feeling of suffocation Patient may feel increasingly anxious Mobilizing secretions may become difficult



Examination of the patient during an acute attack usually reveals signs of hypoxemia Restlessness Increased anxiety Inappropriate behavior Increased pulse and blood pressure Pulsus paradoxus (drop in systolic BP during

inspiratory cycle >10)

AsthmaAsthmaComplicationsComplications

AsthmaAsthmaComplicationsComplications

Status asthmaticus Severe, life-threatening attack refractory

to usual treatment where patient poses risk for respiratory failure

AsthmaAsthmaDiagnostic StudiesDiagnostic Studies


Detailed history and physical exam Pulmonary function tests Peak flow monitoring Chest x-ray ABGs



Oximetry Allergy testing Blood levels of eosinophils Sputum culture and sensitivity

AsthmaAsthmaCollaborative CareCollaborative Care


Education Start at time of diagnosis Integrated into every step of clinical care

Self-management Tailored to needs of patient Emphasis on evaluating outcome in terms of

patient’s perceptions of improvement



Acute Asthma EpisodeAcute Asthma Episode O2 therapy should be started and monitored

with pulse oximetry or ABGs in severe cases Inhaled -adrenergic agonists by metered

dose using a spacer or nebulizer Corticosteroids indicated if initial response is

insufficient



Acute Asthma EpisodeAcute Asthma Episode

Therapy should continue until patient• is breathing comfortably • wheezing has disappeared• pulmonary function study results are

near baseline values



Status asthmaticusStatus asthmaticus Most therapeutic measures are the same as

for acute Increased frequency & dose of

bronchodilators Continuous -adrenergic agonist nebulizer

therapy may be given



Status asthmaticusStatus asthmaticus IV corticosteroids Continuous monitoring Supplemental O2 to achieve values of 90% IV fluids are given due to insensible loss of

fluids Mechanical ventilation is required if there is

no response to treatment

AsthmaAsthma Drug TherapyDrug Therapy

AsthmaAsthma Drug TherapyDrug Therapy

Long-term control medications Achieve and maintain control of persistent

asthma

Quick-relief medications Treat symptoms of exacerbations

AsthmaAsthmaDrug TherapyDrug Therapy


BronchodilatorsBronchodilators -adrenergic agonists-adrenergic agonists

(e.g., albuterol, salbutamol[Ventolin])(e.g., albuterol, salbutamol[Ventolin])Acts in minutes, lasts 4 to 8 hoursShort-term relief of bronchoconstriction Treatment of choice in acute exacerbations



BronchodilatorsBronchodilatorsUseful in preventing bronchospasm

precipitated by exercise and other stimuliOveruse may cause rebound bronchospasmToo frequent use indicates poor asthma

control and may mask severity



Bronchodilators (longer acting)Bronchodilators (longer acting)8 – 12 or 24 hr; useful for nocturnal asthma

Avoid contact with tongue to decrease side effects

Can be used in combination therapy with inhaled corticosteroid



Antiinflammatory drugsAntiinflammatory drugs Corticosteroids (e.g., beclomethasone, Corticosteroids (e.g., beclomethasone,

budesonide)budesonide)Suppress inflammatory responseInhaled form is used in long-term controlSystemic form to control exacerbations and

manage persistent asthma



Antiinflammatory drugsAntiinflammatory drugs Corticosteroids Corticosteroids

Do not block immediate response to allergens, irritants, or exercise

Do block late-phase response to subsequent bronchial hyperresponsiveness

Inhibit release of mediators from macrophages and eosinophils



Anti-inflammatory drugsAnti-inflammatory drugs Mast cell stabilizers (e.g., cromolyn, nedocromil)Mast cell stabilizers (e.g., cromolyn, nedocromil)

Inhibit release of histamineInhibit release of histamineInhibit late-phase responseLong-term administration can prevent and reduce

bronchial hyper-reactivityEffective in exercise-induced asthma when used 10

to 20 minutes before exercise



Leukotriene modifiers (e.g. Singulair) Leukotriene – potent bronchco-constrictors

and may cause airway edema and inflammation

Have broncho-dilator and anti-inflammatory effects

AsthmaAsthmaPatient Teaching Related to DrugPatient Teaching Related to Drug

TherapyTherapy


TherapyTherapy

Correct administration of drugs is a major Correct administration of drugs is a major factor in determining success in asthma factor in determining success in asthma managementmanagement Some persons may have difficulty using an MDI

and therefore should use a spacer or nebulizer DPI (dry powder inhaler) requires less manual

dexterity and coordination


TherapyTherapy


TherapyTherapy

Inhalers should be cleaned by removing dust cap and rinsing with warm water

-adrenergic agonists should be taken first if taking in conjunction with corticosteroids

Nursing ManagementNursing ManagementNursing DiagnosesNursing Diagnoses

Nursing ManagementNursing ManagementNursing DiagnosesNursing Diagnoses

Ineffective airway clearance

Anxiety

Ineffective therapeutic regimen management

Nursing ManagementNursing ManagementPlanningPlanning

Nursing ManagementNursing ManagementPlanningPlanning

Normal or near-normal pulmonary function Normal activity levels No recurrent exacerbations of asthma or

decreased incidence of asthma attacks Adequate knowledge to participate in and

carry out management

Nursing ManagementNursing ManagementHealth PromotionHealth Promotion


Teach patient to identify and avoid known triggersUse dust coversUse of scarves or masks for cold airAvoid aspirin or NSAIDs

Desensitization can decrease sensitivity to allergens



Prompt diagnosis and treatment of upper respiratory infections and sinusitis may prevent exacerbation

Fluid intake of 2 to 3L every day



Adequate nutrition Adequate sleep Take -adrenergic agonist 10 to 20

minutes prior to exercising

Nursing ManagementNursing ManagementNursing ImplementationNursing ImplementationNursing ManagementNursing ManagementNursing ImplementationNursing Implementation

Acute Intervention Monitor respiratory and cardiovascular

systemsLung soundsRespiratory ratePulseBP


ABGsPulse oximetryFEV and PEFRWork of breathing

Response to therapy


Nursing InterventionsNursing InterventionsAdminister O2

BronchodilatorsChest physiotherapyMedications (as ordered)Ongoing patient monitoring


An important goal of nursing is to decrease An important goal of nursing is to decrease the patient’s sense of panicthe patient’s sense of panic Stay with patient Encourage slow breathing using pursed lips for

prolonged expiration Position comfortably


The patient must learn about medications and develop self-management strategies

Patient and health care professional must monitor responsiveness to medication

Patient must understand importance of continuing medication when symptoms are not present


Important patient teaching: Seek medical attention for bronchospasm or

when severe side effects occur Maintain good nutrition Exercise within limits of tolerance


Important patient teaching (cont.): Patient must learn to measure their peak flow

at least daily Asthmatics frequently do not perceive changes

in their breathing


Counseling may be indicated to resolve problems

Relaxation therapies may help relax respiratory muscles and decrease respiratory rate


Peak Flow ResultsPeak Flow Results GreenGreen zonezone

Usually 80-100% of personal best Remain on medications


Peak Flow ResultsPeak Flow Results Yellow zoneYellow zone

Usually 50-80% of personal best Indicates caution Something is triggering asthma


Peak Flow ResultsPeak Flow Results Red zoneRed zone

50% or less of personal best Indicates serious problem Definitive action must be taken with health care

provider

Asthma

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