Asthma: Jessica Stoefen, MN, RN, CCRN

Asthma
Jessica Stoefen, MN, RN, CCRN
Copyright © 2017, Elsevier Inc. All Rights Reserved.

Asthma
Definition
• Heterogenous disease characterized by a
combination of clinical manifestations along
with reversible expiratory airflow limitation
or bronchial hyperresponsiveness

Significance
• Affects about 18.8 million Americans
• Women are 62% more likely to have
asthma than men
• Prevalence 38% higher among African
Americans than whites
• Female African Americans highest mortality
rate compared with other ethnic groups
• Older adults may be undiagnosed
Risk Factors and Triggers
• Related to patient (e.g., genetic factors)

• Related to environment (e.g., pollen)
• Male gender is a risk factor in children
(but not adults)
• Obesity
• Genetics-inherited component is complex
• Immune response–hygiene hypothesis
Triggers of Asthma
Allergens
• May be seasonal or year-round
depending on exposure to allergen
• Cockroaches
• Furry animals
• Fungi
• Pollen Lewis et al. Table 28-1
• Molds
Triggers of Asthma
Exercise
• Exercise-induced asthma (EIA) or
exercise-induced bronchospasm (EIB) is
induced or exacerbated during physical
exertion
• Occurs after vigorous exercise
• Pronounced with exposure to cold air

Triggers of Asthma
Air Pollutants
• Can trigger asthma attacks
• Cigarette or wood smoke
• Vehicle exhaust
• Concentrated pollution

Triggers of Asthma
Occupational Factors
• Most common form of occupational lung
disease
• Exposure to diverse agents
• May take months or years of exposure
• Arrive at work well, but experience a gradual
decline

Triggers of Asthma
Respiratory Infections
• Major precipitating factor of an acute
asthma attack
• ↑ Inflammation and hyperresponsiveness of
tracheobronchial system

Triggers of Asthma
Nose and Sinus Problems
• Allergic rhinitis and nasal polyps
• Large polyps need to be removed
• Sinus problems are usually related to
inflammation of the mucous membranes
• http://www.whiar.org

Triggers of Asthma
Drugs and Food Additives
• Asthma triad: Nasal polyps, asthma, and
sensitivity to aspirin and NSAIDs
• Wheezing develops in about 2 hours.
• Sensitivity to salicylates
• Found in many foods, beverages, and flavorings
• β-Adrenergic blockers
• ACE inhibitors
Triggers of Asthma
Drugs and Food Additives
• Food allergies may cause asthma
symptoms
• Rare in adults
• Oral food challenges

Triggers of Asthma
Gastroesophageal Reflux Disease
• GERD more common in persons with
asthma
• Reflux may trigger bronchoconstriction as
well as cause aspiration
• Asthma medications may worsen GERD
symptoms

Triggers of Asthma
Emotional Stress
• Psychologic factors can worsen the
disease process
• Extreme emotional expressions
• Attacks can trigger panic and anxiety

Early Phase Response of Asthma Triggered
by Allergen

Factors Causing Obstruction

Know your Pathophysiology!
• Late-phase response
• If airway inflammation is not treated or does
not resolve, it may lead to irreversible lung
damage
• Structural changes in the bronchial wall
known as remodeling

Asthma attack
• Unpredictable and variable

• Recurrent episodes of wheezing,
breathlessness, cough, and tight chest
• May be abrupt or gradual
• Lasts minutes to hours

Asthma Attack
• Expiration may be prolonged.

• Inspiration-expiration ratio of 1:2 to 1:3 or
1:4
• Bronchospasm, edema, and mucus in
bronchioles narrow the airways
• Air takes longer to move out

Asthma Attack
• Most common manifestations

• Cough
• Shortness of breath (dyspnea)
• Wheezing
• Chest tightness
• Variable airflow obstruction

Cough variant asthma
• Cough is only symptom

• Bronchospasm is not severe enough to
cause airflow obstruction

Classification of Asthma
• Intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

Complications
• Severe and life-threatening exacerbations

• Respiratory rate >30/min
• Dyspnea at rest, feeling of suffocation
• Pulse >120/min
• PEFR is 40% at best
• Usually seen in ED or hospitalized

Complications
• Life-threatening asthma
• Too dyspneic to speak
• Perspiring profusely
• Drowsy/confused
• PEFR <25%
• Require hospital care and often admitted to
ICU
Diagnostic Studies
• Detailed history and physical exam

• Spirometry
• Peak expiratory flow rate (PEFR)
• Chest x-ray

Diagnostic Studies
• Oximetry
• Allergy testing
• Blood levels of eosinophils

Interprofessional Care
• The current guidelines focus on

• Assessing the severity of the disease at
diagnosis and initial treatment and then
• Monitoring periodically to control the
disease

(Modified from
Expert Panel Report
3: Guidelines for the
Diagnosis and
Management of
Asthma. Bethesda,
Md, 2007, National
Asthma Education
and Prevention
Program, National
Copyright © 2017, Elsevier Inc. All Rights Reserved. Heart, Lung, and
Blood Institute)
• Intermittent and persistent asthma

• Avoid triggers of acute attacks
• Pre-medicate before exercising
• Short-term (rescue or reliever) medication
• Long-term or controller medication

• Acute asthma exacerbations

• Respiratory distress
• Treatment depends upon severity and
response to therapy
• Classified as mild, moderate, severe, or life-
threatening
• Management focuses on correcting hypoxemia
and improving ventilation
• Assessment during acute exacerbation

• Respiratory and heart rate
• Use of accessory muscles
• Percussion and auscultation of lungs
• PEFR to monitor airflow obstruction
• ABGs
• Pulse oximetry
• Acute asthma exacerbations

• O2 given via nasal cannula or mask to
achieve a PaO2 of at least 60 mm Hg or O2
saturation greater than 90%
• Continuous oxygen monitoring with pulse
oximetry
• Bronchodilator treatment
• Short-acting β2-adrenergic agonists (SABAs)
• Severe and life-threatening

exacerbations
• Most therapeutic measures are the same as
for acute episode
• Inhaled ipratropium is used in conjunction with
SABA


• “Silent chest”
• Severely diminished breath sounds
• Absence of wheeze after patient has been
wheezing
• Patient is obviously struggling
• Life-threatening situation


• Requires ED and possible ICU
• IV magnesium sulfate
• 100% oxygen
• Hourly or continuous nebulized SABA
• IV corticosteroids

Test your learning!
A patient is admitted to the emergency

department with a severe exacerbation of asthma.
Which finding is of most concern to the nurse?
a. Unable to speak and sweating profusely
b. PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg
c. Presence of inspiratory and expiratory wheezing
d. Peak expiratory flow rate at 60% of personal best

Drug Therapy
• Long-term control medications

• Achieve and maintain control of persistent
asthma
• Quick-relief medications
• Treat symptoms of exacerbations

Drug Therapy
• Three types of antiinflammatory drugs

• Corticosteroids
• Leukotriene modifiers
• Monoclonal antibody to IgE

Drug Therapy
• Corticosteroids (e.g., beclomethasone,

budesonide)
• Suppress inflammatory response
• Inhaled form is used in long-term control
• Systemic form to control exacerbations and
manage persistent asthma

Drug Therapy
• Corticosteroids
• Reduce bronchial hyperresponsiveness
• Decrease mucous production
• Are taken on a fixed schedule

Drug Therapy
• Corticosteroids
• Oropharyngeal candidiasis, hoarseness, and
a dry cough are local side effects of inhaled
drug
• Can be reduced using a spacer or by gargling
after each use

Spacer

Drug Therapy
• Leukotriene modifiers or inhibitors (e.g.,

zafirlukast, montelukast, zileuton)
• Block action of leukotrienes—potent
bronchoconstrictors

Drug Therapy
• Leukotriene modifiers or inhibitors

• Have both bronchodilator and
antiinflammatory effects
• Not indicated for acute attacks
• Used for prophylactic and maintenance
therapy

Drug Therapy
• Three types of bronchodilators

• β2-Adrenergic agonists
• Methylxanthines
• Anticholinergics

Drug Therapy
• β-Adrenergic agonists (SABAs)

• Examples: albuterol, pirbuterol
• Effective for relieving acute bronchospasm
• Onset of action in minutes and duration of 4
to 8 hours

Drug Therapy
• β-Adrenergic agonists
• Prevent release of inflammatory mediators
from mast cells
• Not for long-term use

Drug Therapy
• Long-acting β2-Adrenergic Agonist Drugs

• Salmeterol (Serevent) and formoterol
(Foradil)
• Added to daily ICSs
• Decrease the need for SABAs
• Never used as monotherapy
• Combination ICS and LABA available
Drug Therapy
• Methylxanthines (e.g., theophylline)

• Less effective long-term bronchodilator
• Alleviates early phase of attacks but has
little effect on bronchial
hyperresponsiveness
• Narrow margin of safety

Drug Therapy
• Anticholinergic drugs
• Block action of acetylcholine
• Promote bronchodilation
• Short-acting drugs used for severe acute
asthma exacerbation

Patient Teaching Related to
Drug Therapy
• Correct administration of drugs is a major
factor in success
• Inhalation of drugs is preferable to avoid
systemic side effects
• MDIs, DPIs, and nebulizers are devices used
to inhale medications

Patient Teaching Related to
Drug Therapy
• Correct administration of drugs
• Using an MDI with a spacer is easier and
improves inhalation of the drug
• DPI (dry powder inhaler) requires less
manual dexterity and coordination

Example of DPI

Nonprescription Combination Drugs
• Should be avoided in general

• Epinephrine can also increase heart rate and
blood pressure
• Ephedrine stimulates CNS and
cardiovascular system

Nursing Management
Nursing Assessment
• Health history
• Especially of precipitating factors and
medications
• ABGs
• Lung function tests
• Asthma Control Test (ACT)

Nursing Management
Nursing Assessment
• Physical examination
• Use of accessory muscles
• Diaphoresis
• Cyanosis
• Lung sounds

Nursing Management
Nursing Diagnoses
• Ineffective airway clearance
• Anxiety
• Deficient knowledge

Nursing Management
Planning
• Overall Goals
• Have minimal symptoms
• Maintain acceptable activity levels
• Maintain >80% of personal best PEFR
• Few or no adverse effects of therapy
• No acute exacerbations of asthma
• Adequate knowledge to participate in and
carry out plan of care
Nursing Management
Health Promotion
• Teach patient to identify and avoid
known triggers
• Use dust covers
• Use scarves or masks for cold air
• Avoid aspirin and NSAIDs

Nursing Management
Health Promotion
• Prompt diagnosis and treatment of upper
respiratory infections and sinusitis may
prevent asthma exacerbation
• Fluid intake of 2 to 3 L every day
• Good nutrition
• Adequate rest

Nursing Management
Nursing Implementation
• Acute Intervention
• Monitor respiratory and cardiovascular
systems
• Lung sounds
• Respiratory rate, pulse and BP
• Pulse oximetry, peak expiratory flow rates, and
ABGs

Nursing Management
• An important goal of nursing is to ↓
patient’s anxiety and sense of panic
• Stay with patient
• Position comfortably
• Use “talking down”

Nursing Management
• Ambulatory Care
• Teach about medications and self-
management strategies
• Patient and HCP must monitor
responsiveness to medication
• Patient must understand importance of
continuing medication when symptoms are
not present
Nursing Management
• Important patient teaching
• Seek medical attention for bronchospasm or
when severe side effects occur
• Maintain good nutrition
• Exercise within limits of tolerance
• Uninterrupted sleep is important

Nursing Management
• Important patient teaching
• Written asthma action plan
• Measure peak flow at least daily
• Patients with asthma frequently do not
perceive changes in their breathing

Peak Flow Results
Green Zone Yellow Zone Red Zone
50% to 80% of personal best 50% or less of personal best

80% to 100% of personal best
Indicates serious problem

Indicates caution
Definitive action must be
Remain on medications Something is triggering
taken with health care
asthma
provider

Nursing Management
• Involve patient’s caregiver or family
• Where patient's inhalers, oral medications,
and emergency phone numbers are located.
How to decrease the patient's anxiety if an
asthma attack occurs
• Remind patient about doing daily PEFR
Table 28-15
Nursing Management
Nursing Outcomes
• Nursing Outcomes
• Describe the disease process and treatment regimen
• Demonstrate correct administration of inhaled drugs
• Express confidence in ability for long-term management of
asthma
• Maintain clear airway with removal of excessive secretions
• Experience normal breath sounds and respiratory rate
• Report decreased anxiety with increased control of
respirations

Gerontologic Considerations: Asthma
• Older adults diagnosed with asthma

• More complicated health issues than
younger patients
• Costly medications
• Nonadherence to medical regimen
• Difficulty accessing the health care system

Cultural Considerations: Asthma
• African Americans and Hispanics have

higher rates of poorly controlled asthma
and deaths
• Disparities in socioeconomic status and
access to proper health care
• Cultural beliefs about management of
asthma

Asthma: Jessica Stoefen, MN, RN, CCRN

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Asthma

Jessica Stoefen, MN, RN, CCRN

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Related to patient (e.g., genetic factors)

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Unpredictable and variable

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Expiration may be prolonged.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Most common manifestations

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Cough is only symptom

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Severe and life-threatening exacerbations

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Detailed history and physical exam

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• The current guidelines focus on

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Intermittent and persistent asthma

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Acute asthma exacerbations

• Assessment during acute exacerbation

• Acute asthma exacerbations

• Severe and life-threatening

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Severe and life-threatening exacerbations

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Severe and life-threatening exacerbations

Copyright © 2017, Elsevier Inc. All Rights Reserved.

A patient is admitted to the emergency

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Long-term control medications

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Three types of antiinflammatory drugs

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Corticosteroids (e.g., beclomethasone,

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Leukotriene modifiers or inhibitors (e.g.,

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Leukotriene modifiers or inhibitors

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• Three types of bronchodilators

Copyright © 2017, Elsevier Inc. All Rights Reserved.

• β-Adrenergic agonists (SABAs)

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.