CASE StUDY

On

Bronchial
Asthma

INTRODUCTION
I. Definition

Bronchial Asthma
Is a chronic disease of the respiratory system in which the airway
occasionally constricts, becomes inflamed and is lined with excessive
amounts of mucus, often in response to one or more triggers.
Bronchial asthma, an inflammation of the airways is the more correct
name for the common form of asthma. The term 'bronchial' is used to
differentiate it from 'cardiac' asthma, which is a separate condition that
develops when fluid builds up in the lungs as a complication of heart failure.
An acute exacerbation of asthma is referred to as an asthma attack. The
clinical hallmarks of an attack are shortness of breath (dyspnea) and either
wheezing or stridor.
In an asthma attack, the air passages of the lungs, known as bronchi,
overreact to substances that are ordinarily harmless. Cells in the airways
known as mast cells release histamines and leukotrienes, which induce
inflammation. These substances prompt the smooth muscles of the airways
to go into spasm and constrict. Soon, the bronchi become inflamed and
release mucus, which further blocks the passage of air. Narrowing of the air
passages is known as bronchoconstriction. When the airways are reduced in
diameter, more effort is required to move air into and out of the lungs, and
breathing becomes difficult.
Asthma can be classified into 3 types according to causative factors:
Atopic or Extrinsic asthma is due to inhaled allergens

Intrinsic asthma is usually secondary to chronic or recurrent infections

of the bronchi, sinuses, or tonsils and adenoids. There is evidence that
this type develops from a hypersensitivity to the bacteria or, more
commonly, viruses causing the infection. Attacks can be precipitated
by infections, emotional factors, and exposure to nonspecific irritants.
The third type of asthma, mixed, is due to a combination of extrinsic
and intrinsic factors.

II. Causes
Asthma attacks are caused by airway hyperresponsivenessthat is, an overreaction
of the bronchi and bronchioles to various environmental and physiological stimuli,
known as triggers. The most common causes of asthma attacks are extremely small
and lightweight particles transported through the air and inhaled into the lungs.
When they enter the airways, these particles, known as environmental triggers,
cause an inflammatory response in the airway walls, resulting in an asthma attack.

Allergenic air pollution, from nature, typically inhaled, which include waste
from common household pests, such as the house dust mite and cockroach,
grass pollen, mould spores, and pet epithelial cells;

Indoor Allergenic air pollution from Volatile organic compounds, including

perfumes and perfumed products. Examples include soap, dishwashing liquid,
laundry detergent, fabric softener, paper tissues, paper towels, toilet paper,
shampoo, hairspray, hair gel, cosmetics, facial cream, sun cream, deodorant,
cologne, shaving cream, aftershave lotion, air freshener and candles, and
products such as oil-based paint.

Medications, including aspirin, -adrenergic antagonists (beta blockers), and

penicillin.

Use of fossil fuel related allergenic air pollution, such as ozone, smog,
summer smog, nitrogen dioxide, and sulfur dioxide, which is thought to be
one of the major reasons for the high prevalence of asthma in urban areas;

Various industrial compounds and other chemicals, notably sulfites;

chlorinated swimming pools generate chloraminesmonochloramine (NH 2Cl),
dichloramine (NHCl2) and trichloramine (NCl3)in the air around them, which
are known to induce asthma.

Early childhood infections, especially viral respiratory infections. However,

persons of any age can have asthma triggered by colds and other respiratory
infections even though their normal stimuli might be from another category
(e.g. pollen) and absent at the time of infection.

Exercise

Allergenic indoor air pollution from newsprint & other literature such as, junk
mail leaflets & glossy magazines (in some countries).

Emotional stress

III. Risk Factors

Gender
Childhood asthma occurs more frequently in boys than in girls. It's unknown why
this occurs although some experts find a young male's airway size is smaller when
compared to the female's airway, which may contribute to increased risk of
wheezing after a cold or other viral infection. Around age 20, the ratio of asthma
between men and women is the same. At age 40, more females than males
have adult asthma.
Family History of Asthma- Inherited genetic makeup predisposes you to having
asthma.
Frequent respiratory infections- increased production of IgE
Premature birth- immature respiratory system
Infants exposed through maternal smoking- affects development of the fetus
Low socio-economic environment- exposed to irritants
IV. Clinical Manifestations
Dyspnea
Wheezing
Coughing
Shortness of breath
Tachypnea
Tachycardia
Over inflation of the chest (barrel chest)
Cyanosis (severe attacks)
Chest pain
Loss of consciousness
V. Complications
Respiratory failure
Pneumothorax
Lung infection
Chronic obstructive pulmonary disease (COPD)

Atelectasis

VI. Diagnostic Tests

1. Chest X-ray
A chest x ray is a painless, noninvasive test that creates pictures of the
structures inside your chest, such as your heart, lungs, and bones.
A chest x-ray may show mucous buildup and inflammation in the bronchioles
indicating bronchial asthma.
Nursing Responsibilities:
Explain procedure to the client.
Ask if client is pregnant.
Make sure that client isnt wearing any metallic objects.
Instruct client to inspire deeply and hold breath.
2. History Taking and Physical Examination
It is important to obtain the past medical history of the patient whether
he/she had been diagnosed or experiencing clinical manifestations of asthma
before and what triggers it.
Performing physical examination is done to detect or confirm its symptoms.

Nursing Responsibilities:
Establish rapport to patient.
Ask pertinent questions only.
Maintain nurse-patient relationship.
Perform hand washing before and after Physical assessment
Make sure hands and stethoscope are warm before placing to patients skin
Perform physical assessment effectively.
Document only what is important.
3. Lung function tests
- for asthma include numerous procedures to diagnose lung problems. The two most
common pulmonary function tests for asthma are spirometry and methacholine
challenge tests.

Spirometry: This pulmonary function test for asthma is a simple breathing

test that measures how much air you can blow out of your lungs and how quickly. It
is often used to determine the amount of airway obstruction you have. Spirometry
can be done before and after you inhale a short acting medication called
a bronchodilator, such as albuterol. The bronchodilator causes your airways to
expand, allowing for air to pass through freely. This test might also be done at future
doctor visits to check your progress and to help your doctor determine if and how to
adjust your treatment plan.

Methacholine challenge test: This lung function test for asthma is more
commonly used in adults than in children. It might be performed if your symptoms
and screening spirometry do not clearly or convincingly establish a diagnosis of
asthma. Methacholine is an agent that, when inhaled, causes the airways to spasm
(contract involuntarily) and narrow if asthma is present. During this test, you inhale
increasing amounts of methacholine aerosol mist before and after spirometry. The
methacholine test is considered positive, meaning asthma is present, if the lung
function drops by at least 20%. A bronchodilator is always given at the end of the
test to reverse the effects of the methacholine.
Using a spirometer, an instrument that measures the air taken into and exhaled
from the lungs, the doctor will determine several values:

Vital capacity (VC), the maximum volume of air that can be inhaled or
exhaled.

Peak expiratory flow rate (PEFR), commonly called the peak flow rate, the
maximum flow rate that can be generated during a forced exhalation.
Forced expiratory volume (FEV1), the maximum volume of air expired in one
second.

If the airways are obstructed, these measurements will fall.

Nursing Responsibilities:
Explain Procedure
Instruct patient not to have a heavy meal before the test
Instruct patient not to smoke 4-6 hours before the test
Demonstrate the proper breathing technique
4. Nitric Oxide
An exhaled nitric oxide test is one of several tests that can be used to check
for asthma. It involves breathing into a mouthpiece attached to a machine
that measures the level of nitric oxide gas in your breath. Nitric oxide is
produced by the body normally, but high levels in your breath can mean that
your airways are inflamed a sign of asthma.
More than 25 parts per billion in children and 35 parts per billion in adults
may signal airway inflammation caused by asthma.
Nursing Responsibilities:
Explain procedure
Instruct patient not to take alcohol 4-6 hours before the test

5. Sputum eosinophils
This test looks for certain white blood cells (eosinophils) in the mixture of
saliva and mucus (sputum) you discharge during coughing. Eosinophils are
present when symptoms develop and become visible when stained with a
rose-colored dye (eosin).
Nursing Responsibilities:
Instruct patient to clear nose and throat and rinse mouth to decrease
contamination of the sputum.
Instruct patient to cough out the sputum not spit.
Make sure specimen is in a sterile container and deliver it to the lab within
two hours.
Judging the Severity of Asthma
1.

Mild intermittent asthma. Symptoms occur less than twice a week, rare
exacerbation or asthma attacks and infrequent nighttime asthma symptoms. (There
are also specific findings on lung function tests.)

2.

Mild persistent asthma. Symptoms occur more than twice a week, but less
than once a day, and asthma attacks that affect activity. These people do have
nighttime symptoms of asthma more than twice a month. (There are also specific
findings on lung function tests.)

3.

Moderate persistent asthma. Symptoms occur daily, with nighttime

symptoms more than once a week. These people tend to have asthma attacks that
affect their activity that may last several days. In addition, these patients require
daily use of their quick acting asthma medication to control symptoms. (There are
also specific findings on lung function tests.)

4.

Severe persistent asthma. Continual symptoms occur day and night, limited
activity and frequent asthma attacks. (There are also specific findings on lung
function tests).
VII. Treatment
Medical Management
There are two general process of asthma medication: quick relief medication for
immediate treatment of asthma symptoms and exacerbations and long acting
medication to achieve and maintain control and persistent asthma. Because
of underlying pathology of asthma is inflammation, control of persistent asthma is
accomplish primarily with the regular use of anti-inflammatory medications.
Quick relief medication
Bronchodilators (Short acting beta adrenergic agonists and Anti-cholinergic)
-are the medications of choice for relief of acute symptoms and prevention of
exercise-induced asthma. They have the rapid onset of action.
You take them when you are coughing, wheezing, having trouble breathing, or
having an asthma attack. They are also called "rescue" drugs.
Long-acting control Medication
1. Corticosteroid
-are the most potent and effective anti inflammatory currently available. They are
broadly effective in alleviating symptoms, improving air way functions, and
decreasing peak flow variability. These medications are contraindicated in acute
asthma exacerbation.
2. Long acting beta-adrenergic agonist is use with anti-inflammatory medications to
control asthma symptoms, particularly those that occur during the night these
agents are also effective in the prevention of exercise-induced asthma.
3. Leukotriene Receptor Antagonists
-Direct antagonist of mediators responsible for airway inflammation in asthma.
- Used for prophylaxis of EIA and long-term treatment of asthma as alternative to
low doses of inhaled corticosteroids.
4. Mast Cell Stabilizers
- Prevent the release of mediators from mast cells that cause airway inflammation
and bronchospasm.
5. Combination Beta-Agonist/ Corticosteroid
- Advair is a unique inhaled combination medication used frequently in the
treatment of asthma.
- It consists of a long-acting beta-agonist (salmeterol) and inhaled corticosteroid
(fluticasone).
6. 5-Lipoxygenase Inhibitors
- Inhibit the formation of leukotrienes. Leukotrienes activate receptors that may be
responsible for events leading to the pathophysiology of asthma, including airway
edema, smooth muscle constriction, and altered cellular activity associated with
inflammatory reactions.
Nursing Responsibilities:
Check doctors order
Confirm right client
Assess or ask if patient has any allergies to certain kinds of drugs
Check if the patient manifests contraindications of the drug
Calculate the right dosage of drug
Explain the action of the drug
Administer drug to the right route
Observe patient if patient shows any allergies
Instruct client to report any discomforts
NURSING MANAGEMENT:

1. Assess respiratory status by closely evaluating breathing patterns and monitoring

vital signs
2. Administer prescribed medications, such as bronchodilators, anti-inflammatories,
and antibiotics
3. Promote adequate oxygenation and a normal breathing pattern
4. Explain the possible use of hyposensitization therapy
5. Help the child cope with poor self-esteem by encouraging him to ventilate
feelings and concerns. Listen actively as the child speaks, focus on the childs
strengths, and help him to identify the positive and negative aspects of his
situation.
6. Discuss the need for periodic PFTs to evaluate and guide therapy and to monitor
the course of the illness.
7. Provide child and family teaching. Assist the child and family to name signs and
symptoms of an acute attack and appropriate treatment measures
8. Refer the family to appropriate community agencies for assistance.

VIII. Prevention
Patient with recurrent asthma should undergo test to identify the substance that
participate the symptoms. Patients are instructed to avoid the causative agents
whenever possible. Knowledge is the key to quality asthma care.

PATIENTS PROFILE

Name:

Mrs. A.C

Age:

75 y/o

Gender:

Female

Date of Birth:
Status:
Address:
Nationality:

October 2, 1937
Widow
Balzain West. Tuguegarao City
Filipino

Religion:

Jehovas Witness

Date of Admission:

November 12, 2012

Time of Admission:

6:05 AM

Chief Complaint:
Attending Physician:
Admitting Diagnosis:
Exacerbation

Cough and dyspnea

Dr. Zingapan
Bronchial Asthma in Acute

Date of discharge:

November 14, 2012

Time of discharge:

8:00 am

Source of information:

Chart, patient, S.O.

NURSING HISTORY

Past History
According to the patient, she never had any of the vaccines when she was a
child because vaccines were not yet widely offered in the country that time. She
experienced having mumps, chicken pox, and measles. She also added that she was
often bitten by a dog, maraming beses na, siguro mga apat o lima. When further
asked if what were the interventions done, she said that hinuhugasan ko lang ng
maigi gamit yung sabong panlaba, pagkatapos pinapahiran ko ng bawang. When
asked if she had any allergies on food and medication, none of these were mentioned
but she verbalized that she experiences allergic symptoms when exposed to dust.
She said that when she encounters sickness like headache and toothache, she just
took a rest but if she cant tolerate it anymore she takes OTC drugs. She added that
whenever she experiences having cough her mother would let her drink her excreted
urine in the morning. When further asked if how could this help her, she just
answered by believing that it would relieved her cough. She added that she had a
history of occasional smoking in her teenage years. She also acknowledged that she
was 47 years old when she was diagnosed of having hypertension and 55 years old
when first diagnosed of having asthma. She added that she copes with it by using her
puff and nebulizer (Symbicort, Ventolin respectively).

History of Present Illness

According to the patient, 4 days prior to hospitalization, she experienced
having cough and difficulty of breathing (dyspnea), and she managed it by using her

puff and nebulizer (Symbicort, Ventolin respectively). On the day prior to admission,
the patient again experienced difficulty of breathing (dyspnea) which prompted her
to seek immediate medical attention. She was then told that she will be needing
confinement as said by the attending physician, Dr. Zinggapan at PGH. She then had
an admitting diagnosis of Bronchial Asthma in Acute Exacerbation. The physician
ordered for the administration of oxygen via nasal cannula to aid the patient in
respiration and nebulization every 4 hours with CPT (Chestphysio Therapy) during
and after nebulization to loosen and expel secretions. The physician prescribed
cefuroxime 750mg, hydrocortisone 100mg and requested the patient to undergo
Diagnostic Tests such as CBC (Complete Blood Count) with APC , Na,K, and Chest XRay.

Family History
FATHER
(
(
(
(
(
(

MOTHER

) Cancer
/) Asthma
) TB
) DM
) Heart Disease
) Hypertension

( ) Cancer
( ) Asthma
( ) TB
( ) DM
( ) Heart Disease
(/) Hypertension

Social History
According to the patient, she stays at home most of the time. Their family
attends mass on Sundays to worship. According to her, she has a good relationship
with her family. And also manages to have a good relationship with her neighbors.
Because of her age and condition (that is having bronchial asthma), her family let her
do simple chores like folding clothes and sometimes washing the dishes . The patient
finished her Elementary Education but wasnt able to continue her H.S and College
education due to financial constraints.

OB History
The patient had her menarche at the age of 13 and usually consumes 2-3
pads per day and it typically last for 4 days. She had her coitarche as soon as she got
married at the age of 20. She then had an OB score of G5P5 (4105). She had her
menopause at the age of 50.

Gordons 11 functional health pattern

FUNCTIONAL
PATTERN

BEFORE HOSPITALIZATION

Patient AC perceives herself as a

healthy individual who is able to
do her chores and can take care of
her family. She defines health as
Health
the absence of pain and disease
Perception/Health
and can do whatever she wishes
Management
to. Whenever she feels something
pattern

DURING HOSPITALIZATION
She considers herself
unhealthy due to her
underlying condition. For her,
she is a bit useless because
she cant do her daily routine of
doing the chores, she easily
gets tired. One more reason

is wrong with her health such as

headache, common colds, fever,
cough, and stomach ache. She
manages it by taking OTC drugs
like Paracetamol, Alaxan, Enervon
C, and Mefenamic Acid.
Importante ang kalusugan kaya
dapat nating pangalagaan as
verbalized by the patient.

Nutritional Metabolic
Pattern

Elimination
Pattern

Activity Exercise
Pattern

Sleep - Rest
Pattern

Cognitive
Perceptual
Pattern

Client AC eats three times a day

without any difficulty and takes
her snack on the afternoon. She
loves to eat vegetables and fish.
She claims that she doesnt have
any food allergies. The patient
drinks an average of 6- 8 glasses
of water a day. She weighs 47 kg
& has a height of 56. Her BMI
17.08 is.
Patient AC defecates twice a day,
with a brownish color. She voids 45 times in a day. Urine is yellow in
color and aromatic in smell, no
pain felt when voiding and
defecating.
In the morning, she eats her
breakfast at around 6; after her
meal, she does her household
chores such as watering the plants
around their house and considers
this as her exercise. At noon, after
lunch, her leisure activities include
watching television programs.
The patient claims that she usually
sleeps 8-9 hours a day with no
difficulties in falling and staying
asleep. He usually goes to bed
around 9pm and wakes up at
around 6:00am. She enjoys
watching T.V. while resting. She
usually takes 25 to 30- minutes
sleep in the afternoon.
She can speak and understand
Tagalog, English, Ytawes and
Ybanag. She has visual and
hearing impairment as evidenced

why she considers herself

unhealthy is that she needs to
take her medicines to regain
her strength.
Hindi ko na masyadong
nagagawa yung mga dati kong
gawain dahil madali na akong
mapagod. Mas kailangang
pangalagaan ang kalusugan ko
lalo na ngayong tumatanda na,
mas madaling dapuan ng sakit
Diet as tolerated prescribed by
physician. Hindi ako
masyadong nakakakain. Wala
akong gana. Wala din naman
akong malasahan sa mga
kinakain ko. She drinks
approximately 5-6 glasses of
water a day. She weighs 46 kg
and BMI of 16.31.
Patient AT defecates twice a
day, brownish in color, soft in
consistency; she voids 2-4
times a day, yellowish in color,
without pain.

Patient AC ambulates inside the

room assisted by her mother,
she also does ROM exercises
like arm flexion & extension. To
ease boredom, she talks with
other clients.

Patient AC sleeps at 10pm or

11 pm and wakes up early at
6am. Her sleep is usually being
interrupted by routines like VS
taking and medication
administration and the noise of
other patients.

The patient doesn`t have any

difficulty in expressing herself.
She is oriented to time and
place. She can speak dialects

SelfPerception
Self-Concept
Pattern

Role
Relationship
Pattern

Sexuality
Reproductive
Pattern

Coping
Stress
Tolerance
Pattern

Value Belief
Pattern

by use of eyeglasses and asking of

repetitions of questions though
she can understand, respond and
follow instructions.

understood by others (Tagalog,

English, Ytawes and Ybanag).
There is no problem in visual
and hearing, there is presence
of decreased sense of taste.

Client AT describes herself as

loving and caring, humble and
God fearing person. She has a
positive outlook about life. She
said that she is concerned about
her family.

Despite having a health

problem, she still believed that
everything will be alright. She
is more concerned right now
about her recovery.

Patient AC is a friendly and active

person she loves to socialize with
her neighbors. She has a great
bond with her familyshares
stories with them, spends most of
free time with them. There is no
conflict in their family that they
cannot resolve.

Her admission caused changes

in her role. She is cooperative
and participative with the
health care regimen. Her
concern is that, she cant take
care of her family while shes in
the hospital; instead, they are
the ones taking care of her.
Nakakahiya kasi dumagdag pa
akong aalagaan nila

Patient AC had her menarche

when she was 14 years old with
duration of 3-5 days using 2 pads
a day (soaked). She had her
menopausal period when she was
50 years of age.
Whenever she had a problem, she
tells it to her family & friends. She
said that by merely voicing out to
them, she feels comfortable and is
at ease. Handles life stresses
through prayers and believes that
everything will go well in the end.
AC is a Jehovahs witness and she
goes to church every week with
her family. She claims that she
has a strong devotion and faith to
Jehovah and that nothing is
impossible as long as she
believes.

The patient still expresses her

feminity by using appropriate
clothes to her gender and through
her actions.

Hospitalization is the most

stressful experience for her.
She finds relief and comfort
through the support of her
family and friends, and prayers.

She stated that she knows that

God will always be at her side.
AC always prays for her
recovery and asks God to
protect her family and to help
her endure her suffering.

ANATOMY AND PHYSIOLOGY

RESPIRATORY SYSTEM

Respiration is the process of taking in oxygen, producing energy with it, and
excreting gaseous waste products.

Basic functions of the respiratory system

Supplies body with oxygen

Disposes of carbon dioxide

Four processes involved in respiration

Pulmonary ventilation - exchange of gases between lungs and

atmosphere

External respiration( Pulmonary) - exchange of gases between

alveoli and pulmonary capillaries

Transport of respiratory gases - processes of gas exchange and

various metabolic functions taking place in the lungs, generally at the
alveolar level.

Internal respiration (Tissue) - exchange of gases between systemic

capillaries and tissue cells

Parts of the Upper Respiratory Tract

Nose & nasal cavity: The function of this part of the system is to warm,
filter and moisten the incoming air.

Pharynx: Here the throat divides into the trachea (wind pipe) and esophagus
(food pipe). There is also a small flap of cartilage called the epiglottis which
prevents food from entering the trachea.

Larynx: This is also known as the voice box as it is where sound is

generated. It also helps protect the trachea by producing a strong cough
reflex if any solid objects pass the epiglottis.

Parts of the Lower Respiratory Tract

Trachea: Also known as the windpipe this is the tube which carries air from
the throat into the lungs. The inner membrane of the trachea is covered in

tiny hairs called cilia, which catch particles of dust which we can then remove
through coughing. The trachea is surrounded by 15-20 C-shaped rings of
cartilage at the front and side which help protect the trachea and keep it
open. They are not complete circles due to the position of the esophagus
immediately behind the trachea and the need for the trachea to partially
collapse to allow the expansion of the esophagus when swallowing large
pieces of food.

Bronchi: The left bronchi is narrower, longer and more horizontal than the
right. Irregular rings of cartilage surround the bronchi, whose walls also
consist of smooth muscle. Once inside the lung the bronchi split several
ways, forming tertiary bronchi.

Bronchioles: Tertiary bronchi continue to divide and become bronchioles,

very narrow tubes, less than 1 millimeter in diameter. There is no cartilage
within the bronchioles and they lead to alveolar sacs.

Alveoli: Individual hollow cavities contained within alveolar sacs (or ducts).
Alveoli have very thin walls which permit the exchange of gases Oxygen and
Carbon Dioxide. They are surrounded by a network of capillaries, into which
the inspired gases pass. There are approximately 3 million alveoli within an
average adult lung.

Diaphragm: The diaphragm is a broad band of muscle which sits underneath

the lungs, attaching to the lower ribs, sternum and lumbar spine and forming
the base of the thoracic cavity.

Breath Sounds

Breath sounds can be classified into two categories, either NORMAL or

ABNORMAL (adventitious). Breath sounds originate in the large
airways where air velocity and turbulence induce vibrations in the
airway walls.

Normal Breath Sounds

Bronchial Sounds
Bronchial breath sounds consist of a full inspiratory and expiratory phase with the
inspiratory phase usually being louder. They are normally heard over the

trachea and larynx.

Bronchovesicular Sounds
Bronchovesicular breath sounds consist of a full inspiratory phase with a
shortened and softer expiratory phase. Sounds intermediate between bronchial
and vesicular breath sounds; it is normally heard between the 1st and 2nd
intercostal spaces anteriorly and posteriorly between scapulae.
Vesicular Sounds
Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a
short, almost silent expiratory phase. They are heard over the periphery of the
lung field.
Abnormal Breath Sounds

Crackles
Crackles are discontinuous, explosive, "popping" sounds that originate within the
airways. They are heard when an obstructed airway suddenly opens and the
pressures on either side of the obstruction suddenly equilibrates resulting in
transient, distinct vibrations in the airway wall. The dynamic airway obstruction
can be caused by either accumulation of secretions within the airway lumen or
by airway collapse caused by pressure from inflammation or edema in
surrounding pulmonary tissue.
Wheezes
Wheezes are continuous musical tones that are most commonly heard at end
inspiration or early expiration. They result as a collapsed airway lumen
gradually opens during inspiration or gradually closes during expiration.
Wheezes may be monophonic (a single pitch and tonal quality heard over an
isolated area) polyphonic (multiple pitches and tones heard over a variable
area of the lung).
Rhonchi

Ronchi (Low pitched wheezes) are continuous, both inspiratory and

expiratory, low pitched adventitious lung sounds that are similar to
wheezes. They often have a snoring, gurgling or rattle-like quality.
Stridor
Stridor are intense continuous monophonic wheezes heard loudest over
extrathoracic airways. They tend to be accentuated during inspiration when
extrathoracic airways collapse due to lower internal lumen pressure.
Stertor
A heavy snoring inspiratory sound occurring in coma or deep sleep,
sometimes due to obstruction of the larynx or upper airways.

IMMUNE SYSTEM

The immune system protects the body from possibly harmful

substances by recognizing and responding to antigens.
Antigens are substances (usually proteins) on the surface of cells,
viruses, fungi, or bacteria. Nonliving substances such as toxins,
chemicals, drugs, and foreign particles (such as a splinter) can also be
antigens.
The immune system recognizes and destroys substances that contain
antigens.

Immune Response
The immune response is how your body recognizes and defends itself against
bacteria, viruses, and substances that appear foreign and harmful.
Innate Immunity
Innate, or nonspecific, immunity is the defense system with which you were born. It
protects you against all antigens. Innate immunity involves barriers that keep
harmful materials from entering your body. These barriers form the first line of
defense in the immune response.

Cough reflex

Enzymes in tears and skin oils

Mucus, which traps bacteria and small particles

Skin

Stomach acid

Acquired Immunity

Acquired immunity is immunity that develops with exposure to various

antigens. Your immune system builds a defense against that specific antigen.

Passive Immunity

Passive immunity is due to antibodies that are produced in a body other than
your own. Infants have passive immunity because they are born with
antibodies that are transferred through the placenta from their mother. These
antibodies disappear between ages 6 and 12 months.
Immune System Cells and their Primary Functions
Phagocytosis and inflammation;
usually the first cell to leave the
blood and enter infected tissues.
Monocyte
Leaves the blood and enters the
tissues to become a macrophage.
Macrophage
Most effective phagocyte; important
in later stages of infection and tissue
repair; located throughout the body
Neutrophil

Basophil

Mast cell

Eosinophil

Natural killer cell

to intercept foreign substances.

Motile cell that leaves the blood,
enters tissues, and releases
chemicals that promote
inflammation.
Nonmotile cell in connective tissues
that promotes inflammation through
the release of chemicals.
Enters tissues from the blood and
release chemicals that inhibit
inflammation.
Lyses tumor and virus- infected cells.

Chemical Mediators

Histamine an amine released from mast cells, basophils and platelets;

causes vasodilation and increases vascular permeability.

Kinins polypeptides derived from plasma proteins; causes vasodialtion,

increase vascular permeability, stimulate pain receptors and attract
neutrophils.

Interferons are proteins produced by most cells, thet interfere with virus
production and infection.

Complement a group of plasma proteins that stimulate the release of

histamine, activate kinins, lyse cells and promote phagocytosis.

Prostaglandins a group of lipids, some of which cause smooth muscle

relaxation and vasodilation. It stimulates pain receptors.

Leukotrienes a group of lipids, produced primarily by mast cells and

basophils, that cause prolonged smooth muscle contraction (especially in the
lung bronchioles).

Blood Components
The immune system includes certain types of white blood cells. It also includes
chemicals and proteins in the blood, such as antibodies, complement proteins, and
interferon.

B lymphocytes become cells that produce antibodies. Antibodies

attach to a specific antigen and make it easier for the immune cells to
destroy the antigen.

T lymphocytes attack antigens directly and help control the immune

response. They also release chemicals, known as cytokines, which control the
entire immune response

Antibody

any of a large variety of proteins normally present in the body or

produced in response to an antigen which it neutralizes, thus producing
an immune response.

Classes of Antibodies and Their Functions

Antibody
IgG

Total Serum Antibody

(%)
80-85

IgM

5-10

IgA

15

IgE

0.002

IgD

0.2

Description
It can cross the placenta
and provide immune
protection to the fetus and
newborns.
It is responsible for
transfusion reactions in
the ABO blood system.
Secreted into saliva, into
tears, and onto mucous
membranes to provide
protection on body
surfaces; found in
colostrums and milk to
provide immune
protection to newborns.
Binds to mast cells and
basophils and stimulates
the inflammatory
response.
Functions as antigen
binding receptor on B
cells.

PATHOPHYSIOLOGY OF BRONCHIAL ASTHMA

Predisposing Factors

Precipitating Factors

-age

-exposure to allergens and

pollutants
-gender

-obesity

-race

-viral respiratory infections

-history of allergies

-Beta blockers medications

-family history
-Psychological stress
-weather

-Hygiene
-Antibiotic use
-Socioeconomic factor
-GERD
-Exercise
-Emotional expression
Stimulation of B lymphocytes
Production of IgE
Attachment of IgE to mast cells and basophils

A
Release of chemical mediators

Inflammation

cAMP
Imbalanced stimulation of beta and alpha

adrenergic receptors
mucous production

Capillary dilation

bronchospasm

Edema of the airway

of Beta receptors

stimulation of alpha receptor

Bronchoconstriction

bronchodilation

DOB/SOB and chest tightness

Cough

Wheezing

Hyperventilation

nasal flaring Pursed lip breathing

Loss of Carbon Dioxide

Increased respiratory work demand

Labored breaths/ Use of accessory muscle

Tachycardia

Uneven Lung aeration

Elevated Blood pH

Tachypnea

Incomplete emptying of alveoli

Respiratory Alkalosis

hypoventilation
Compensating mechanism failed
Respiratory failure

Fatigue

hypoventilation poor fluid and food intake

Hyperinflation of alveoli
D

Impaired gas exchange

CO2 retention anorexia

B
B

Hypoxemia

breakdown of fats

E
C

Respiratory Acidosis Hypercapnea Hypoxemia Barrel chest

Hypoxia
Cellular Ischemia
Tissue necrosis
Vital Organ Failure death
Death

increased fatigue

Hyperventilation
Lactic Acid production

Production of fats

Ketone formation
Metabolic acidosis

metabolic acidosis
Hypoventilation Headache Mental dullness Kussmauls breathing Hyperkalemia