ASTHMA
CHAPTER 24
Dr. Raed Shudifat
Introduction
Asthma is a chronic inflammatory disease of the
airways characterized by 1. Hyper
responsiveness 2. Mucosal edema 3. Mucus
production.
Inflammation leads to episodes or attacks of
:cough, chest tightness, wheezing, and dyspnea.
The most common chronic disease of childhood.
Can occur at any age.
Allergy is the strongest predisposing factor.
Introduction
High morbidity due to:
1. Underdiagnosis and inappropriate therapy
2. Limited access to health care
3. Inaccurate assessment of control
4. Delays in seeking medical help
5. Inappropriate medical therapy
6. Non-adherence to prescribed therapy
Risk factors for asthma
Include family history, allergy (strongest factor).
Chronic exposure to airway irritants or allergens
(example: grass, dust, or animals).
Common triggers for asthma symptoms and
exacerbations include airway irritants (eg, toxin,
cold, heat, strong odors, smoke, perfumes).
Exercise, rhinosinusitis with postnasal drip.
Viral respiratory tract infections.
Pathophysiology of Asthma
Primary response is chronic inflammation
from exposure to allergens or irritants.
Reversible and airway inflammation may
leads to obstruction and narrowing of airways
Basic characteristics of asthma
Swelling of membranes
Contraction of bronchial smooth muscle/bronchospasm
Increase mucus production
Pathophysiology of Asthma
PATHOPHYSIOLOGY
Early-Phase Response
Increased mucous secretion, edema formation, and
increased amounts of firm sputum
Client experiences wheezing, cough, chest tightness, and
dyspnea
Late-Phase Response
Characterized by airway inflammation
Increased airway resistance leads to air catch in alveoli and
hyperinflation of the lungs
If airway inflammation is not controlled, may lead to irreversible
lung damage
Clinical Manifestations
• Most common symptoms of asthma are:
Cough (with or without mucus production)
Dyspnea
Wheezing (first on expiration, then possibly during inspiration as
well).
Asthma attacks occur at night or in the early morning.
Chest tightness and dyspnea occur.
Expiration requires effort and becomes prolonged.
As exacerbation progresses, central cyanosis secondary to
severe hypoxia may occur.
Additional symptoms, such as diaphoresis, tachycardia, and a
widened pulse pressure, may occur
Clinical Manifestations
• Exercise-induced asthma: maximal symptoms during
exercise, absence of nocturnal symptoms, and
sometimes only a description of a “choking” sensation
during exercise.
• A severe, continuous reaction, status asthmaticus, may
occur. It is life-threatening.
• Bronchospasm, edema, and mucus in
bronchioles narrow the airways
• Severe attacks may have no audible wheezing
usually begins upon exhalation
Assessment and Diagnostic Findings
• Family, environment, and occupational history is
essential.
• Pulmonary function tests
• Chest x-ray
• Oximetry
• Allergy testing
• Sputum culture and sensitivity
Triggers of Asthma
Allergens: 40% of cases due to allergy
common in young adult and children
Exercise: Characterized by bronchospasm, SOB,
coughing, and wheezing
Respiratory Infections: Most common precipitating
factor of an asthma exacerbation
Nose and Sinus Problems: Nasal problems include
allergic rhinitis and nasal polyps
Triggers of Asthma
Drugs and Food Additives
Sensitivity to aspirin and NSAIDs
Wheezing develops in about two hours
Gastroesophageal Reflux Disease
Aspiration of stomach acid causes
bronchoconstriction
Clients with hiatal hernia and prior ulcer or reflux
history may have GERD as an asthma trigger
Classification of Asthma
Mild intermittent: symptoms no more
frequent than twice weekly
Mild persistent: symptoms more frequent
than twice weekly, but less than once a day
Moderate persistent: daily symptoms
Severe persistent: continuous symptoms,
limited physical activity
Complications
Status asthmaticus
Pneumothorax
Atelectasis
Pneumonia
Respiratory Failure
Collaborative Care
Education
Start at time of diagnosis
Integrated into every step of clinical care
Self-management
Tailored to needs of client
Emphasis on evaluating outcome in terms of client’s
perceptions of improvement
Prevention : allergic test to identify the substances
cause the symptoms and avoid it as possible
Medications Used for Asthma
Two general classes of asthma medications:
1. long-acting medication: to achieve and maintain
control of persistent asthma
2. Quick-relief medication: for immediate treatment of
asthma symptoms and exacerbations
These medication have systematic side effects when
they used for long term
Medications
LONG-ACTING MEDICATION
Corticosteroids are the most powerful and effective
anti-inflammatory medications currently available
- Effective in elevating symptoms, improving airway
function
Initially, the inhaled form is used
Used to manage severe and persistent asthma
Corticosteroids (inhalers, systemic)
Long acting beta2-adrenergic agonists
Leukotriene modifiers or inhibitors (singulair)
Medications
- Cromolyn sodium [intal] and nedocromil
[Tilade] are mild to moderate anti-
inflammatory agent used in children
Long acting beta2 adrenergic agonists are
used with anti-inflammatory medication to
control asthma symptoms mainly those
occur at night
Not indicated for immediate relief of
symptoms
Medications
QUICK- RELIEF MEDICATIONS
Drug of choice for relieving acute symptoms and
preventing exercise induced asthma
Beta -adrenergic agonists (e.g.
2
Ventolin)
Anticholinergics (e.g. Atrovent)
Antibiotic if there is respiratory infection
Nursing Management
The immediate nursing care of patients with asthma
depends on the severity of symptoms.
The patient and family are often frightened and anxious
because of the patient’s dyspnea. Therefore, a calm
approach is an important aspect of care.
Assess the patient’s respiratory status by monitoring the
severity of symptoms, breath sounds, peak flow, pulse
oximetry, and vital signs.
Obtain a history of allergic reactions to medications
before administering medications.
Nursing Management
Identify medications the patient is currently taking.
Administer medications as prescribed and monitor
the patient’s responses to those medications.
Administer fluids if the patient is dehydrated.
Assist with intubation procedure, if required
Promoting Home- and Community-Based
Care
Teaching Patients Self-Care
• Teach patient and family about asthma (chronic
inflammatory), purpose and action of medications,
triggers to avoid and how to do so, and proper inhalation
technique.
• Instruct patient and family about peak-flow monitoring.
• Teach patient how to implement an action plan and how
and when to seek assistance.
• Obtain current educational materials for the patient
based on the patient’s diagnosis, causative factors,
educational level, and cultural background.
Continuing Care
Emphasize adherence to prescribed therapy,
preventive measures, and need for follow-up
appointments.
Refer for nearest medical center as indicated.
Assess for allergens (with recurrent
exacerbations).
Remind patients and families about the
importance of health promotion strategies and
recommended health screening.
Status Asthmaticus
Status asthmaticus is severe and persistent asthma that
does not respond to conventional therapy; attacks can occur
with little or no warning and can progress rapidly to
asphyxiation.
Contribute to these episodes:
- Infection.
- Anxiety
- Nebulizer abuse.
- Dehydration.
- Nonspecific irritants.
Status Asthmaticus
An acute episode may be precipitated by
hypersensitivity to aspirin.
Two predominant pathologic problems
occur:
1. Decrease in bronchial diameter
2. Ventilation–perfusion abnormality.
Pathophysiology
Increased airway resistance from edema
Mucous plugging
Bronchospasm with thick secretions leading to asphyxia
(a lack of oxygen or excess of carbon dioxide in the body
that results in unconsciousness and often death and is
usually caused by interruption of breathing or inadequate
oxygen supply)
This leads to hypoxemia
Reduced PaO2 = respiratory alkalosis
Initially reduced PaCO2 and increased PH
Lastly PaCO2 increased and PH decreased =Respiratory
Acidosis
Clinical Manifestations
Same as those in severe asthma.
Difficult breathing
Prolong exhalation
Distended neck vein
Wheezing
No correlation between severity of attack and number
of wheezes; with greater obstruction, wheezing may
disappear, possibly signaling impending respiratory
failure.
Assessment and Diagnostic Findings
Primarily pulmonary function studies
ABG analysis
Respiratory alkalosis most common finding
Medical Management
•Initial treatment:
Beta2-adrenergic agonists, corticosteroids, supplemental
oxygen and IV fluids to hydrate patient.
Sedatives are contraindicated.
High-flow supplemental oxygen .
Magnesium sulfate, a calcium antagonist, may be administered
to induce smooth muscle relaxation.
Hospitalization if no response to repeated treatments or if blood
gas levels deteriorate or pulmonary function scores are low.
Mechanical ventilation if patient is in respiratory failure or if
condition does not respond to treatment.
Nursing Management
The focus to assess the airway and patient’s response to treatment.
The nurse should be prepared for the next intervention if the patient
does not respond to treatment.
Constantly monitor the patient for the first 12 to 24 hours.
Blood pressure and cardiac rhythm should be monitored continuously.
Assess the patient’s for signs of dehydration
Fluid intake is essential to combat dehydration, to loosen secretions,
and to facilitate expectoration.
Nursing Management
Administer IV fluids as prescribed, up to 3 to 4 L/day, unless
contraindicated.
Ensure patient’s room is quiet and free of respiratory
irritants (eg, flowers, tobacco smoke, perfumes, or odors of
cleaning agents).
Patient Teaching/ self care
Topics
The nature of asthma as a chronic inflammatory
disease
Definition of inflammation and bronchoconstriction
Purpose and action for each medication
Identification of triggers and how to avoid them
Proper inhalation techniques
How to perform peak flow monitoring
How to implement an action plan
When and how to seek assistance
Using a Peak Flow Meter
Peak Flow Meter
Peak flow meters measure the highest volume of air flow
during a forced expiration
Volume is measured in color-coded zones:
green zone signifies 80% to 100% of personal best
The
Yellow, 60% to 80%
Red, less than 60%.
If peak flow falls below the red zone, the patient should
take the appropriate actions prescribed by his or her health
care provider.
PEAK FLOW METER
Measure highest volume of airway during a
forced expiration
Volume is measured in colored code zone:
Green: indicate 80%-100% of person best
Yellow: 60%-80%
Red: less than 60%
If the peak flow falls under the red zone medical
consultation is needed.
