Asthma

Pathophysiology
Chronic inflammatory disorder of airways o Early phase = bronchospasm when allergen activates IgE exposure causes bronchial smooth muscle constriction, mucus secretion, vascular leakage, mucosal edema obstruction of large and small airways air trapping respiratory acidosis & hypoxemia o Reduction in airway diameter if not treated can lead to permanent lung damage Status Asthmaticus = severe prolonged asthma attack, unresponsive to therapy o DANGER: death by respiratory acidosis Triggers: o Exaggerated IgE response to allergens (pollen, dust, smoke, animal dander, automobile exhaust) o Infection of bronchi, sinuses, tonsils/adenoids hypersensitivity to bacteria or virus causing infection o Exercise o Genetics

Assessment
Wheezing and dyspnea type respirations Chest tightness, Tachycardia, cyanosis (lips and nails), cough Skin pale & moist w/ perspiration Restlessness, anxiety, inappropriate behaviour with increased dyspnea Prevalence: night & early AM Early attack: cough is dry progresses to thickened, tenacious, white, gelatinous mucus Severity determined by frequency and duration of symptoms, presence of persistent airflow limitation and the medication required to control

Diagnostics
History and physical examination ABG: respiratory acidosis, decreased pH, increased CO2, decreased O2 Peak expiratory flow monitoring (PEFR)usually decreased (abnormal) Cultures to see what type of infection Allergy assessment to help identify the trigger Chest X-ray

Serum lytes especially potassium because high doses of beta2-agonists hypokalemia

Nursing Care/Priorities
Sitting upright and leaning forward to use all accessory muscles of respiration Monitor respiratory and oxygenation status to determine need for intervention Teach correct performance of lung function tests to ensure accurate data Administer medications (eg: bronchodilators/corticosteroids) to improve respiratory function Asucultate lung sounds post treatments to note improvement Regulate fluid intake to optimize fluid balance and liquefy secretions to facilitate removal Status Asthmaticus (EMERGENCY) o Inhaled beta2-adrenergic agents & anticholinergic agents o Oxygen (NP/mask) o ABG o IV fluids, magnesium, corticosteroids (po or iv) o Intubation and assisted ventilation (if indicated) o Heliox therapy/IV ketamine (if indicated)

Discharge/Patient Teaching
Teach client how to use prescribed inhalers Evaluate the clients ability to self0administer medications to assess correct technique Instruct client on the purpose action, dosage and duration of each medications Include family to ensure the client will receive appropriate help as needed Provide asthma education to help client to understand conditions and avoid triggers Establish written asthma action plan with the client to manage exacerbations; make sure client knows how to use it in case of emergencies

Associated Pharmacology (Meds)

Bronchodilators (Beta2-adrenergic) o salbutamol/ventolin stimulated beta2-receptors on airway smooth muscle causing relaxation producing bronchodilation Side effect: tremor, tachy, hypokalemia Onset 1-3 min; duration: 2-4 hours o Salmeterol (BID not used for acute exacerbation) Onset: 10-20min; Duration: 8-12hrs Anticholinergics o Ipratropium bromide (Atrovent) blocks acetylcholine action bronchodilation Side: dry mouth, bad taste, nausea Onset: 5-25min; Duration: 4-8 hours

Caution in people with narrow angle glaucoma, prostatic hyperplasia or bladder neck obstruction o Ipratropium and salbutamol (combivent) o Tiotropium bromide (Spiriva) Side: constipation, urinary retention Onset: 30min; Duration 24hours Anti-inflammatory agents o Steroidal anti-inflammatory agents Hydrocortisone (IV) /Methylprednisone (PO, IV)/ Prednisone / dexamethasone(PO) potent anti-inflammatory and immunosuppressive effects ; decreases edema in bronchial airways and mucus secretions Side: weight gain, mood changes, skin changes (acne, bruising, striae), cushingoid appearance; LT changes: adrenal suppression, immune suppression, osteoporosis, hyperglycemia, obesity, peptic ulcers Onset: 2-4 hours Beclomethasone acts locally Side: oral candidiasis infection Rinse mouth post use Budesonide (pulmicort) Rinse mouth post use