R.

NURJANAH, MN

Define term of asthma Describe etiology and pathophysiology of asthma Identify clinical manifestations of asthma Identify the collaborative care of treating asthma Describe the nursing care of patient with asthma Describe the condition of patient with status asmaticus

inflammatory disease of airway that is characterized by episodes of reversible airway obstruction sudden onset and intermittent attack varies from every individual severity can vary from shortness of breath to death

it is particularly at night or early in the morning the episodes are associated with widespread airflow obstruction of asthma reverse either spontaneously or treatment.

Asthma is a disease in which inflammation of the airways causes airflow into and out of the lungs to be restricted. When an asthma attack occurs, mucus production is increased, muscles of the bronchial tree become tight, and the lining of the air passages swells, reducing airflow producing the characteristic wheezing sound.

Allergens
Cover 40% of all cases of asthma Mainly in young adult and children Consist of :

Seasonal form: related to tree or weed

pollen Non-seasonal (tear round-perennial) form: related to dust mites, molds, animals, feathers and cockroaches

Exercise

Mostly after vigorous exercise: joggings, aerobics, walking briskly, and climbing stairs Called as exercise-induced asthma (EIA)

Air pollutants

Various air pollutants: cigarette or wood smoke, vehicle exhaust, sulfur dioxide and nitrogen dioxide

Respiratory infections

Due to viral infections: influenza and rhinovirus (major pathogen)

Nose and sinus problems

Allergic rhinitis Nasal polyps Sinus due to bacterial

Drugs and food additives Psychologic factors

Asthma can be classified as either intrinsic or extrinsic

Intrinsic asthma trigger or stimulus such as cold air, emotional upset, environmental stimuli (such as air pollution) bronchial irritant produces symptom in people who are predisposed to bronchospasm. Extrinsic asthma trigger from allergens (animal dander, dust), tobacco smoke and irritant gases (e.g. sulfur dioxide and nitrogen dioxide).
Pharmacology trigger aspirin and other NSAIDs and beta-blockers.

Infants Children Teenagers Pregnant Women

With exposure to a trigger, a cascade of cellular responses result in:

Increased mucus production Mucosal swelling Bronchial muscle contraction

Stimulus

Chemical mediator release

Bronchospams

Inflamatory cell activation

Epithelial damage

Edema

Increase mucus production

Increase airway resistance, obstruction & airflow limitation

Acute Asthma Attack

There is chronic inflammation in the bronchi (air passages) This makes their walls swell up so that they become narrower and muscles around the air passages become irritated The inflammation can also make mucus glands produce excessive sputum which further blocks up air passages which are already narrowed. If the inflammation is not controlled with treatment, as well as causing acute attacks, it can lead to permanent narrowing and scarring of the air passages so that eventually asthma drugs won't relieve the symptoms any more. This process is known as airway remodelling

Early phase response: 30 60 minutes

Allergen or irritant activates mast cells Inflammatory mediators are released

histamine, bradykinin, leukotrienes, prostaglandins, plateletactivating-factor, chemotactic factors, cytokines

Intense inflammation occurs

Bronchial smooth muscle constricts

Increased vasodilation and permeability Epithelial damage

Bronchospasm
Increased mucus secretion Edema

Late phase response: 5 6 hours

Characterized by inflammation

Eosinophils and neutrophils infiltrate Mediators are released mast cells release histamine and additional mediators Self-perpetuating cycle Lymphocytes and monocytes invade as well Future attacks may be worse because of increased airway reactivity that results from late phase response
Individual becomes hyperresponsive to specific

allergens and non-specific irritants such as cold air and dust

Specific triggers can be difficult to identify and less

stimulation is required to produce a reaction

Coughing
Wheezing

Chest tightness
Shortness of breath

Expiratory & inspiratory wheezing Dry or moist non-productive cough Dyspnea Anxious &Agitated Prolonged expiratory phase Increased respiratory & heart rate Decreased PEFR Prolonged expiratory phase [1:3 or 1:4]

Hypoxia Confusion Increased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathing Use of accessory muscles Diaphoresis & pallor Cyanotic nail beds Flaring nostrils

Mild intermittent

Mild persistent Moderate persistent Severe persistent

The presence of one of the features of severity is sufficient to place a patient in that category. Global Initiative for Asthma (GINA) WHO/NHLBI, 2002

CLASSIFY SEVERITY
Clinical Features Before Treatment Nighttime PEF Symptoms Symptoms Continuous <60% predicted Frequent Limited physical Variability >30% activity Daily
Use b2-agonist daily Attacks affect activity

STEP 4 Severe Persistent STEP 3 Moderate Persistent

>1 time week

>60%-<80% predicted Variability >30% >80% predicted Variability 2030%

STEP 2 Mild Persistent

STEP 1 Intermittent

>1 time a week but <1 time a day < 1 time a week Asymptomatic and normal PEF between attacks

>2 times a month

<2 times a month

>80% predicted Variability <20%

There are 4 main components management in asthma:

Assess severity of the asthma and monitor the response to treatment using objective test of lung function e.g. spirometry and peak flow meter. Medication to reverse and prevent airway inflammation that contributes to the airway narrowing. Preventive measures to avoid or eliminate factors that induce or trigger asthma. Patient educations.

Pulmonary Function Tests

FEV1 decreased
Increase of 12% - 15% after bronchodilator indicative of asthma

PEFR decreased

Symptomatic patient

eosinophils > 5% of total WBC

Increased serum IgE Chest x-ray shows hyperinflation

ABGs

Early: respiratory alkalosis, PaO2 normal or near-normal

severe: respiratory acidosis, increased PaCO2,

Peak flow meter monitoring:

Measures the highest airflow during a forced expiration. Daily peak flow monitoring is recommended for all patients with moderate or severe asthma because it helps measure asthma severity.

FBC WBC increase of eosinophil. ABG show hypoxemia decrease PaO2 and mild respiratory alkalosis with increase pH and low PaCO2 due to tachypnea. Examination of the sputum present many of eosinophil and others white blood cells.

Mild intermittent

Avoid triggers

Premedicate before exercising May not need daily medication

Mild persistent asthma

Avoid triggers

Premedicate before exercising Low-dose inhaled corticosteroids

Moderate persistent asthma

Low-medium dose inhaled corticosteroids

Long-acting beta2-agonists Can increase doses or use theophylline or leukotriene-modifier [singulair, accolate, zyflo]

Severe persistent asthma

High-dose inhaled corticosteroids

Long-acting inhaled beta2-agonists Corticosteroids if needed

Acute episode

FEV1, PEFR, pulse oximetry compared to baseline

O2 therapy Beta2-adrenergic agonist

via MDI w/spacer or nebulizer Q20 minutes 4 hours prn

Corticosteroids if initial response insufficient

Severity of attack determines po or IV If poor response, consider IV aminophylline

To prevent airway obstruction and to treat it when an acute episode occurs. Bronchodilator To control their symptom. Inhalation of nebulizer.

Primary bronchodilator include: beta-adrenergic agonists or sympathomimetics, methylxanthines and anticholinergic agents.

Beta-adrenergic stimulate receptors on smooth muscle of the respiratory tract bronchodilatation and smooth muscle relax. Onset rapid effects within minutes but duration is short, lasting 4 6 hours (e.g. Ventolin). Administered by MDI.

Theophyline is the primary methylxanthine relaxes bronchial smooth muscle and also inhibit the release of chemical mediators of the inflammatory response.
Anticholinergic prevent bronchoconstriction by blocking input from the parasympathetic nervous system via vagal pathways (e.g. Atrovent).

b2-adrenergic agonists

Rapid onset: quick relief of bronchoconstriction

Treatment of choice for acute attacks If used too much causes tremors, anxiety, tachycardia, palpitations, nausea Too-frequent use indicates poor control of asthma Short-acting
Albuterol[proventil]; metaproterenol [alupent]; bitolterol

[tornalate]; pirbuterol [maxair]

Long-acting
Useful for nocturnal asthma

Not useful for quick relief during an acute attack Salmeterol [serevent]

Methylxanthines Less effective than beta-adrenergics Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma Does not relieve hyperresponsiveness Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures Theophylline, aminophylline

Anticholinergics Inhibit parasympathetic effects on respiratory system Increased mucus Smooth muscle contraction Useful for pts w/adverse reactions to beta-adrenergics or in combination w/betaadrenergics Ipratropium [atrovent] Ipratropium + albuterol [Combivent]

Both corticosteroid and NSAIDs are used to suppress airway inflammation and reduce asthma symptom.
For severe attack, oral or parenteral corticosteroid may be used to alleviate symptom.

Corticosteroids
Not useful for acute attack Beclomethasone: vanceril, beclovent, qvar

Leukotriene modifiers

Interfere with synthesis or block action of leukotrienes

Cromolyn & nedocromil

Inhibits immediate response from exercise and allergens

Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade

Have both bronchodilation and anti-inflammatory properties Not recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo

Correct use of medications Signs & symptoms of an attack

Dyspnea, anxiety, tight chest, wheezing, cough

Relaxation techniques When to call for help, seek treatment Environmental control Cough & postural drainage techniques

Teaching about:

Name of medications, its frequency, dose and optimal use. Effects of the medications and how the patients can evaluate for this effect. Potential adverse effects of the medications and their management including effects that signal the need to notify the physician.

Potential interactions of this medications with others medications or with foods including the necessity of avoiding over the counter medications.
In tolerance is known to occur with medications, how the patients can identify tolerance and what to do about it.

If patients or family member is smoker teach about the effects of tobacco smoke on asthma. Help patients to find ways to avoid these triggers, warning signs of an impending attack and strategy for preventing and treating an attack.

Adequate rest, rest good nutrition and stress management. Demonstrate the use of inhalation therapy (nebulizer, puffer - MDI). Teach and encourage patient to do breathing technique (pursed-lip), coughing and diaphragmatic exercise.

Discuss environmental control:

Avoid people with respiratory infections. Avoids substances and situations known to precipitate bronchospasm, such as allergens, irritants, strong odors, gases, and smoke. Wear mask if cold weather. Stay inside when pollution is high.

Promote optimal health practices, including nutrition, rest and exercise:

Encourage regular exercise. Increase fluid intake to keep secretion thin. Use relaxation technique

Avoid allergens and environmental triggers such as controlling dust, removing carpets, covering mattresses and pillow to reduce dust mite populations. May need to remove pets, eliminating tobacco smoke. Avoid cold weather wear mask that retains humidity and warm air.

Review clients record; ask about coughing, dyspnea, chest tightness, wheezing and increased mucous production.
Observe patient and assess the rate, depth and character of respirations (can be assess by using peak flow meter). Auscultate the chest for breath sound or wheezing.

Assess for triggers of asthma.

After acute episode subsides, attempt to determine clients degree of adherence with medication/ management.

Observe inhalation technique.

Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus

Anxiety r/t difficulty breathing, fear of suffocation Ineffective therapeutic regimen management r/t lack of information about asthma

Is severe, prolonged asthma that does not respond to treatment (within 24 hours), or without aggressive therapy status asthmaticus can lead to respiratory failure with hypoxemia, hypercapnia and acidosis.

Patient required mechanical ventilation. Acute asthma can also cause dehydration, respiratory infection, atelectasis, pneumothorax and cor pulmonale.

Infection Inhalation of air pollutants and allergens Noncompliance in taking medications Aspiration of gastric acid

Tachypnea. Use of accessory muscle of respiratory. Anxiety, irritability, fatigue, headache, impaired mental functioning. Diaphoresis. Tachycardia , elevated B/P.

Monitor respiratory rate and SPO2, ABG, B/P and ECG. Administer repeated aerosol treatment such as beta2-agonist bronchodilator (ventolin) and anticholinergic (atrovent). IV therapy e.g. Aminophyllin, corticosteroid and fluid (treat dehydration).

Initiate mechanical ventilation if necessary. Assist with mobilization of obstructing bronchial mucus; perform chest physiotherapy, administer expectorant and mucolytic drugs and remove secretions by suctioning. Provide continues O2.

Provide adequate hydration. Obtain chest x-ray. Stay with the patient if patients anxiety and fear make comfort. Constantly monitors the patient for the first 12 24 hours until under control. Assess patients skin turgor to identify sign of dehydration.

Fluid intake to prevent dehydration and to loosen secretion. Avoid respiratory irritants including flowers, tobacco smoke, perfumes or odors of cleaning agents.

Asthma involves chronic inflammation, swelling, and narrowing of the airways. The bronchial narrowing is usually totally reversible with treatments. Asthma is now the most common chronic childhood illness affecting one in every 15 children. Asthma involves only the bronchial tubes and usually does not affect the air sacs or the lung tissue. The narrowing that occurs in asthma is caused by three major factors: inflammation, bronchospasm, and hyperreactivity. Allergy can play a role in some, but not all, asthma patients.

Many factors can precipitate asthma attacks and they are classified as either allergens or irritants. Symptoms of asthma include shortness of breath, wheezing, cough, and chest tightness. Asthma is usually diagnosed based on the presence of wheezing and confirmed with breathing tests. Chest X-rays are often normal in asthma patients. Avoiding precipitating factors is important in the management of asthma. Medications can be used to reverse or prevent bronchospasm in patients with asthma.

Any questions ?