Asthma

-exerise induced
-exposure to cold air
-cigarette, air pollution, etc
-occupational
-exposure to diverse agents... they arrive at work ok in the morning but
then later on they develop difficulty breathing.
-Infection
-Nose and Sinus Problems
-nasal Polyps, Sinusitis, Rhinitis
-Drugs
-Aspirin, NSAIDS
-may trigger allergic reaction and bronchial spasms
-wheezing develops 2 hours later
-B-Adrenergic
-may cause bronchoconstriction
-Food
-allegries (Seafoods, Peanuts, Foods with Coloring, High Calcium)
-GERD
-high levels of reflux acid could be asspirated into lungs, causing bron
choconstriction.
-Emotional Stress
-psychologic factors,
-anxiety, ager, fear, etc leads to hyperventilation etc....
Pathophy
-chronic inflammation from exposure to allergens and irritants
-airway hyperresponsiveness leads to bronchospasms
inflammatory response
-vascular congestion, edema, thick mucus, bronchial spasms, thickening of airway
wall
***thickening takes a long time to heal and continues thickening due to
attack piles up
Late response
-occurs4-10 hours after initial
-if not treated damage it leads to damage in lungs and lead to Status Asthmaticu
s
Manifestations
-unpredictable and variable
-some have wheezing some not
-Cough Variant Asthma
-only manifestation is chronic Cough
-upon further assessment there is no post nasal drip, reflux, tb
-bronchospasm not severe enough to cause bronchoconstriction
-tigthening of chest
-Breathlessness
**last minutes to hours some are releived without meds....
Inspiration:Expiration ratio 1:2, 1:3, or 1:4
****Wheezing is unreliable
-severe attacks have no audible wheezing
-usually begins in expiration
Patient's with Acute attacks manifests:
hypoxemia

-restlessness, inc anxiety, inappropriate behavior

-inc pulse and BP
-Pulsus Paradoxus - drop in systolic BP during inspiration of more than
10mmHg
Classification
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Complications
Severe Acute Asthma
-tachypnea, tachycardia, PEFR is 40% at best, Usually seen in ED or hospitalized
Life-threthening Asthma
-too dyspneic to speak, sweating profusely, drowsy, required for hospital care a
nd often admitteed to ICU
***if the pt has hx of intubation or hooking up to a mechvent du
e to asthma, and is re-admitted, even years later on from last admission, please
treat the case (even if mild) as severe case of asthma
Diagnostics
-History
-Pulmonary Functon Tests
-Spirometry :
to check which is Asthma and COPD, give inhaler and the one relieved is
asthma
-Peak Flow Monitoring
-Chest X-Ray
-used to check for trigger particularly infection
-ABG's
-Culture & Sensitivity
-Oximetry
Allergy Testing
Collab Care
Education
-start at daiagnosis
-integrate through care
-teach about use of inhalers, etc
Self-Managementt
-should be tailored to the needs of the pt
-culturally sensitive
-teach them to take care of themselves
Desireable Therapeutic Outcome (GINA Goals)
-control and eliminate sypmtoms
-Attain normal lung function
-restore normal activities
-reduce or eliminate excacerbation and lessen side effects of medication
s
Drug Therapy
-vaccination
-Salbutamol
-Steroids (anti-inflamm) used for inflammatory induced asthma
-anti-leukotrienes (cuts prostaglandin chain)

-Anti-muscarinic
-methylxanthines (theophyline)
***Control could be achieved 3-6 months or longer
-it is controlled if patient has no exacerbation when you slowly remove
medications one by one
Mild Intermittent and Persistent Asthma
-avoid triggers
-premedicate before exercise
Acute Asthma Episode
-is tachypneic but the ABG shows a normal CO2 levels
-tachypneic ABG is normal (it means pt is starting to retain CO2) begin
to be more aggresive in tx of patient
Severe Exacerbations
-expect inc in frequency and dose of bronchodilators
-IV corticosteroids q4-6 hours
-continous monitoring
-if pt manifiest changes in sensorium assist in prepping intubation
-IV fluid rate is increase (due to inc in your insensible water loss)
-Supplemental O2 peer nasal cannula 90%
MED GUIDE
BLUE - Reliever (Salbutamol)
RED - control asthma (leukotriene)
Drug Therapy
Corticosteroids (beclomethasone, etc)
-suppresses growth and causing stunting in children be careful
-if inhaled ask to gargle to pv thrush
-can cause candidiasis, dry cough, pain in swallowing (Thrush)
Leukotrien modifiers or inhibitors
-bronchodilator and anti-inflam
-don't use during an acute attack, it is long acting it doesn't kick in as quick
ly as salbutamol
Anti-IgE (Xolair)
-pv IgE from attaching to muscles and inhibits the release of histamines from ma
st cells, w/c pv the asthma attack
B2-Adrenergic agonists (salbutamol)
-for acute attacks, actions is in seconds or mins
-can cause palpitations (because it is non-selective and once B2 receptors are s
aturated B1 is then hit leading to inc PR)
-pv release of inflammatory mediators from mast cells
-causes hypokalemia
-not for long-term use
-if no longer releiveing the bronchoconstriction use steroids
Anticholinergics (ipatropium)
-causes dry mouth
-can cause glaucoma and hpn
-males: urinary retention due to prostatic hypertrophy
Methylxanthines (theophylline)
-has a role in early phas eof asthma attacks
-narrow margin of safety (inc in small amounts of theophylline can cause toxicit
y)

***teach about proper inhaler use with or without Spacer

***Avoid buying OTC drugs like epinephrine, epidrine, etc since it can cause bro
nchospams and inc BP due to drug interactions
tx
-fluid inc due to insensible h2o loss
-treat infections
-nebulize
-meds
-inhalers
-relax the patients to alleviate the anxiety
-peak flow monitoring
-determine if pt is in Green (80-100%
meaning anytime it can exacerbate it could go
indicates serious problems, avoid aspiration
e taken: bring inhaler for necessary puffs on

of personal best), Yellow (50-80%

to red or green), Red (50% or less
problems, definitive action must b
the way to hospital)

home care
-know cause
-food products (preservatives, caffeiene, etc)
-maintain good nutrition
Status Asthmaticus
-no response to conventional tx
-causes same as acute asthma
-management is same as other forms of asthma but more aggresive since it may lea
d to respiratory distress and failure
TRAUMA
Blunt Trauma
-hypoxemia, hypovolemia, cardiac failure
s/sx-airway obstruction, hemothorax, tension pneumothorax
tx: correct underlying cause
-hemo and pneumothorax use chest tube
-fracture in ribs use straps as binders
Flail Chest
-complication blunt trauma
-due to multiple adjacent ribs at two or more sites
-paradoxical moement in flail segment during expiration
-pressure inside is positive leads to redced alveolar ventialtion and compliance
leading to hypoxemia, acidosis hypotension
TX;surgery to correct fracture, etc
Pulmonary Contusion
-due to chest trauma
-abnormal accumulation of fuid in the ICS and intra-alveolar spaces causing leak
s
-TX control pain, o2, hydration, etc
Occupational Lung Diseases
-associated with exposure to Silica, Asbestos and Coal
-important lenght of time from exposure to onset of sypmtoms (development is fre
quently after 10yrs)
-Pathophy mainly Fibrosis
-Manifestation: poor compliance, hypoxemia, risk to dv cor pulmonale

Respiratory Modalities
O2 Theraphy
-nasal cannula ((upto 40%)
-face mask(60%)
-venturi mask
-tent
compli
-toxicity
-fire
-hypoxemia
-reduced respi drive
Incentive Spirometry
-sitting or fowler's position
-method of deep breathing
-to pv atelectasis
Mech Vent
-positive or negative pressure
-indications: pleural effusion, ARDS, severe pneumonia, has a depressed respi dr
ive, drug overdose, CO poisoning, heart failure, cor pulmonale, etc
TYPES:
-Pressure Cycled
-Time Cycled
-Volume Cycled
**there are many modes just read up ^_^
MONITORING:
Monitor as to type, mode, settings, sensitivity, water in tubing, humidification
, alarms, complications
**usually this can be seen in the Chart....
**more sensitive Mech Vents are more "toxic"
**in case of alarms, don't put in silent mode immediately, check the cause of th
e alarm and if it is a problem please do something about it.... Don't ignore it
... look for the cause...
Complications:
-body trauma
-ventilator associated pneumonia
-pulmonary embolism
-bipedal edema
-dehydration leading to renal failure
__________________________END_____________________________________
*** please read your book and notes as well....