What You Should Know About Asthma

Alfrina Hany, S.Kp, MN

Nursing School, Medical Faculty Brawijaya University 2012

Learning Objectives
General
After following this subject the students will be able to apply the nursing care for clients with respiratory disturbances such as Asthma

Spesific
The Students will be able to :

Define, categorize, identify sign & symptoms of clients with Asthma Describe & analyze the pathogenesis of Asthma correctly Take the diagnostic examination for clients with Asthma Apply & manage the best nursing care to clients with Asthma

COPD IS NOT ASTHMA !

Different causes
Different inflammatory cells Different mediators Different inflammatory consequences Different response to treatment

What is Asthma?
A disease that:
Is chronic Produces recurring episodes of breathing problems :
Coughing Wheezing Chest tightness Shortness of breath

Cannot be cured, but can be controlled Leading cause of acute and chronic illness in children Most frequent admitting diagnosis

WHAT IS ASTHMA?
Reversible obstructive airway disease of the lungs bronchial tubes characterized by: Increased airway responsiveness Bronchospasm (constriction of bronchial smooth muscle) Inflammation and edema

Prevalences
Asthma prevalence, morbidity, and mortality are increasing in the U.S. and in other countries as well Affects about 17 to 18 million people in the United States and is becoming more common. Between 1982 and 1992, the number of people with asthma increased by 42%. Asthma is particularly common in blacks living in urban environments (affecting about 7%) and even more so in Hispanic populations living in urban environments (affecting about 11%). The condition also seems to be becoming more serious, requiring more people to be hospitalized. Between 1982 and 1992, the death rate from asthma in the United States increased by 35%.

In a classroom of 30 children, 2 or more children are likely to have asthma

What are the Symptoms of Asthma?

SYMPTOMS: WHEEZE, COUGH, SPUTUM, DYSPNOEA,TIGHTNESS. PERIODICITY: DIURNAL, SEASONAL, PROVOKING FACTORS (COLD, EXERCISE, SMELLS. Coughing at night or after physical activity; cough that lasts more than a week ASSOCIATED: NASAL/SINUS, COLDS, ALLERGIES. Waking at night with asthma symptoms (a key marker of uncontrolled asthma) SMOKING AND OCCUPATION

Whats Happening in the Lungs with Asthma?

The lining of the airways becomes swollen (inflamed) The airways produce a thick mucus The muscles around the airways tighten and make airways narrower

How Airways Narrow

During an asthma attack, the smooth muscle layer goes into spasm, narrowing the airway. The middle layer swells because of inflammation, and more mucus is produced. In some segments of the airway, the mucus forms clumps that nearly or completely block the airway. These clumps are called mucus plugs.

What Makes Asthma Worse?

Allergens
Warm-blooded pets (including dogs, cats, birds, and small rodents) House dust mites Cockroaches Pollens from grass and trees Molds (indoors and outdoors)

Risk Factors
Allergy / Atopy Family history of asthma/allergy Viral respiratory infections Prematurity : Smaller airways at birth; Low birth weight; underdeveloped chest muscles Male gender - pre-adolescence Poverty, Crowded living conditions Obesity exposure to environmental smoke

Triggers
For people with asthma, exposure to certain substances they are sensitive to can trigger an asthma attack or exacerbation These substances are known as triggers

Not all people with asthma have the same triggers that will cause an asthma attack
Triggers can include biologic and chemical substances

What Makes Asthma Worse? (cont.)

Irritants
Cigarette smoke and wood smoke Scented products such as hair spray, cosmetics, and cleaning products Strong odors from fresh paint or cooking Automobile fumes and air pollution Chemicals such as pesticides and lawn treatments

What Makes Asthma Worse? (cont.)

Infections in the upper airways, such as colds (a common trigger for both children and adults) Exercise Strong expressions of feelings (crying, laughing) Changes in weather and temperature

Indoor Air Triggers

Environmental tobacco smoke (ETS) Cockroaches Dust mites Animal dander Mold, mildew Strong scented products (perfumes, scented cleaners)

Outdoor Air Triggers

Ozone - Eastern Wisconsin, Dane County? Particulate matter Sulfur dioxide - Wisconsin Rapids Nitrogen dioxide - vehicle exhaust Outdoor pollens and mold

Additional Triggers
Viral upper respiratory infections Exercise Aggravating conditions gastric reflux, sinusitis, rhinitis Diet Cold air

Is There A Cure For Asthma?

Asthma cannot be cured, but it can be controlled. You should expect nothing less.

Classification
Asma bronkial tipe non atopi (intrinsik) Asma bronkial tipe atopi (Ekstrinsik). Asma bronkial campuran (Mixed)

Tipe non atopi (intrinsik)

Keluhan tidak ada hubungannya dengan paparan (exposure) terhadap alergen sifat-sifatnya adalah: - timbul setelah dewasa - keluarga tidak ada yang menderita asma - penyakit infeksi - pekerjaan atau beban fisik - perubahan cuaca atau lingkungan peka

Tipe atopi (Ekstrinsik).

Keluhan ada hubungannya dengan paparan terhadap alergen lingkungan yang spesifik. Kepekaan ini biasanya dapat ditimbulkan dengan uji kulit atau provokasi bronkial. timbul sejak kanak-kanak, pada famili ada yang menderita asma

Di Inggris jelas penyebabnya House Dust Mite, di USA tepungsari bunga rumput.

Asma bronkial campuran (Mixed)

Pada golongan ini, keluhan diperberat baik oleh faktorfaktor intrinsik maupun ekstrinsik.

Stepwise approach ( children)

classificati on Minor symptoms
exacerbati on/ nocturnal PEF between attacks

mild Intermitte nt < 1/week

Mild persistent 1-3 /week

Moderate persistent 4-5/week

Severe persistent Continuou s

< 1/month 1 /month

2-3/month > 4 /month 60-80% < 60%

>80%

>80%

Step 1

Step 2

Step 3

Step 4

Stepwise approach ( adult)

classificati on Minor symptoms
exacerbati on/ nocturnal PEF between attacks

mild Intermitte nt < 2 /week

<2 /month >80%

Mild persistent 2-3 /week

2-3 /month >80%

Moderate persistent 4-5 /week

4-5 /month 60-80%

Severe persistent Continuou s

>5 /month < 60%

Step 1

Step 2

Step 3

Step 4

PATHOPHYSIOLOGY
There are 2 primary components to asthma:
inflammation bronchospasm and obstruction

Pathophysiology
1. Bronchospasm The smooth muscles that wrap around the windpipe (bronchi) tighten, reducing the size of the airway.
normal

Asthma attack

Pathophysiology
2. Inflammation
The mucosal lining of the windpipe becomes inflamed and swells, thereby reducing the size of the airway even further. 3. Mucus Increased mucus production takes up more space; now the airway is very constricted.

Alergen atau Antigen yang telah terikat oleh IgE yang menancap pada permukaan sel mast atau basofil

Lepasnya macam-macam mediator dari sel mast atau basofil

Kontraksi otot polos

Spasme otot polos, sekresi kelenjar bronkus meningkat Penyempitan/obstruksi proksimal dari bronkus kecil

pada tahap inspirasi dan ekspirasi

Edema mukosa bronkus

MODERN VIEW OF ASTHMA

Allergen
Macrophage Th2 cell Eosinophil Mucus plug Epithelial shedding Nerve activation Mast cell Neutrophil

Subepithelia fibrosis Plasma leak Oedema

Sensory nerve activation

Mucus Vasodilatation hypersecretion New vessels hyperplasia

Cholinergic reflex Bronchoconstriction Hypertrophy/hyperplasia

Pathogenetic process of inflammation

Increasing number of smooth muscles fibres Increasing number of mucous glands Ongoing of Release of inflammatory fibrogenetic cells factors Elastolysis

Sever bronchospasms during exacerbation

Increase of mucous secretion during exacerbation

Inflammation

Deposition of collagen in basal and epithelial membranes

Decrease of elasticity of the wall

Normal Airway Looking at the Main Carina

Airway During Asthma Exacerbation

Edema mukosa bronkus

Keluarnya sekrit ke dalam lumen bronkus

Sesak napas

Tekanan partial oksigen di alveoli menurun

Oksigen pada peredaran darah menurun

Hipoksemia

CO2 mengalami retensi pada alveoli hipokapneaRR Hipoventilasi

Kadar CO2 dalam darah meningkatrangsang pusat napas Hiperventilasi

Gagal napas

Ventilation: Perfusion Its never perfect

EXAMINATION
FEVER WHEEZES AND HYPERINFLATION TACHYCARDIA (>100 BPM) PULSUS PARADOXUS (>10 MMHG) PEAK FLOW (<100L/MIN OR <40% PREDICTED) CYANOSIS, SYNCOPE, HYPOTENSION, SILENT CHEST HYPOXEMIA (<8.5 KPA) HYPERCAPNIA EVEN MILD

Diagnostic Tests
CXR INFILTRATES SEVERE BLOOD EOSINOPHILIA POSITIVE SEROLOGY OR SKINPRICK ORGANISM IN SPUTUM COMPLICATIONS - APICAL FIBROSIS, BRONCHIECTASIS Pulmonary function tests reveal a decreased forced expiratory volume, increased residual volume from air trapping and decreased vital capacity (max amount of air exhaled) Skin tests to identify allergens

Asthma Patient: Mucous Plug, Pneumothorax and Chest Tube

CASE SCENARIO
Tuginem 14 years old come to the clinic c/o shortness of breath for one day duration. He is a known asthmatic patient for more than 8 years, he visited A/E frequently. His school performance is below average, with frequent absence from school due to his illness.

HOW YOU WILL PROCEED?

How Is Asthma Controlled?

Follow an individualized asthma management plan Avoid or control exposure to things that make asthma worse Use medication appropriately
Long-term-control medicine Quick-relief medicine

How Is Asthma Controlled? (cont.)

Monitor response to treatment
Symptoms Peak flow

Get regular follow-up care

Therapeutic Management
1999 Canadian Asthma Guidelines Control of the disease Control the environment Asthma education, favoring selfmanagement Inhaled short acting bronchodilator as 1st line Additional therapy (long-acting B2 agonists, leukotriene-receptor antagonists)

Asthma Medications
Long-term Controllers Quick-Relief
Provides quick relief of an acute asthma episode by opening up the bronchioles Used as needed for symptoms and before exercise

Used to control and prevent asthma symptoms Must be taken daily

Long Term Controller Medications

Control and prevent asthma symptoms Make airways less sensitive to triggers and prevent inflammation that leads to an acute asthma episode Taken on a daily basis

Quick Relief Medications

Provide relief of an acute asthma episode
Short acting inhaled bronchodilators - albuterol, pirbuterol (Maxair) Oral prednisone burst, when albuterol alone is not effective

Tata Laksana Medikamentosa

Obat asma dapat dibagi dalam 2 kelompok besar, yaitu obat pereda (reliever) dan obat pengendali (controller) : Reliever, sering disebut obat serangan, digunakan untuk meredakan serangan atau gejala asma jika sedang timbul. Bila serangan sudah teratasi dan sudah tidak ada gejala lagi, maka obat ini tidak digunakan lagi. beta agonis (inhaler/spray) kerja pendek (short acting 2-agonist, SABA); bronkodilator: golongan xantin kerja cepat (teofilin) Controller, sering disebut obat pencegah, digunakan untuk mengatasi masalah dasar asma, yaitu inflamasi respiratorik kronik (peradangan saluran napas menahun). Dengan demikian pemakaian obat ini terus-menerus dalam jangka waktu relatif lama, tergantung derajat penyakit asma, dan responnya terhadap pengobatan/penanggulangan. Controller diberikan pada Asma Episodik Sering dan Asma Persisten. budesonid ; Anticholinergic Drugs: ipratropium, block acetylcholine ; Corticosteroids

Delivery of asthma medication

Delivery System Nebulizer Inhaler alone Inhaler/aerochamber Recommended age All ages (with O2) 10 years and up All ages (yellow 4 months to 5 years blue 4 years up) 5 years and older 5 years and up

Turbuhaler Diskus

Nebulizer
Wash hands and prepare medication and diluent as ordered and empty into nebulizer Do chest assessment, put mask on child and set 02 to 5-7 LPM Treatment usually takes 10-15 minutes Do post assessment and rinse the nebulizer with water, allow to air dry

HOW TO DIAGNOSE BRONCHIAL ASTHMA ?

Consultation skill Relevant History -Symptom -history of allergic disease -Family history -Environmental history -Exclusion of other medical condition

NURSING CARE
What Should People with Asthma Be Able To Do?

Be active without having asthma symptoms; this includes participating in exercise and sports Sleep through the night without having asthma symptoms Prevent asthma episodes (attacks) Have the best possible lung function (e.g., good peak flow number) Avoid side effects from asthma medicines

Prevention-environmental control
Irritants, smoke and allergens Goal is to decrease the frequency and severity of attacks by recognizing and controlling triggers Allergy testing If dust mites are the source of allergywash sheets Qweekly, cover mattresses and pillows with impermeable covers and remove carpets from the childs room

Prevention- exercise
Exercise induced asthma is triggered by rapid breathing Warm air by breathing through nose or covering mouth and nose with scarf Using inhaled bronchodilator before exercise Using techniques to decrease hyperventilation (ie. muscle relaxation and diaphragmatic breathing)

Prevention- infection
Viral infections are the most frequent trigger Avoid exposure Influenza vaccine

Prevention- emotions
Asthma is not caused by psychosocial problems Laughing, crying or shouting can act as a mechanical trigger to bronchoconstriction Anxiety can cause hyperventilation

Health Teaching
Consult a physician When there is no relief 15-20 minutes after inhaler Inhaler is needed earlier than 4 hours Inhaler is required 46 times a day after 2-3 days Help client live with disease

Crisis Plan for Asthma

Begin this plan when I have: These Symptoms: Taking these medications: _______________ _____________________ _______________ _____________________ Call my doctor: Name: _______________ Phone number: _________________ If I cannot reach my doctor immediately: Take ______________________________________________________ If I have severe symptoms or I am getting worse very quickly: Go to the emergency room if within ten minutes distance: Location of emergency room ________________________ Contact and emergency transport system____________________________________________ Phone number _____________________________ Name of system ________________________ Planning for Travel

Key Elements of Asthma Therapy

Suggested Reading
Brunner & Suddarth (2002). Buku Ajar Keperawatan Medikal Bedah. Volume I. EGC : Jakarta Black & Jacobs (1997). Medical Surgical Nursing : Clinical Management for Continuity Care. 5th edition. Philadelphia : WB Saunders Company Price & Wilson (1995). Patofisiologi : Konsep Klinis Proses Penyakit. Edisi IV. Volume II. Jakarta : EGC Soeparman & Waspadji (1995). Ilmu Penyakit Dalam. Jilid II. Jakarta : Balai Penerbit FKUI Kapita Selekta Kedokteran Tuberculosis by Frederick Southwick (University of Florida), 2003 Permasalahan TB kini, masa datang & penanggulangaannya oleh Pokja TB Balitbangkes Jakarta

Additional Resources
Allergy & Asthma Network/Mothers of Asthmatics, Inc. -http://www.aanma.org American Academy of Allergy, Asthma, and Immunology -- http://www.aaaai.org

American Academy of Pediatrics -- http://www.aap.org

American College of Allergy, Asthma, and Immunology -http://www.allergy.mcg.edu

American Association of Respiratory Care -http://www.aarc.org

Additional Resources
American Lung Association -- http://www.lungusa.org Asthma & Allergy Foundation of America -http://www.aafa.org/home National Asthma Education and Prevention Program -http://www.nhlbi.nih.gov US Environmental Protection Agency -http://www.epa.gov/iaq Centers for Disease Control and Prevention -http://www.cdc.gov/nceh/airpollution/asthma Asthma and Schools -http://www.asthmaandschools.org

INTERNET SITE
Guidelines NHLBI/ WHO report http://www.ginasthma.com Cochrane Site: http://www.cochrane.org/ Clinical Evidence: http://www.clinicalevidence.org

Types of Long Term Controller Medications

Brand names are listed as examples only, and are not inclusive.
Inhaled corticosteroids - Flovent, Pulmicort, QVAR, Azmacort, Aerobid, Pulmicort Respules (only nebulized form), Vanceril , Beclovent . Preferred therapy for persistent asthma.

Long acting bronchodilators Serevent, Foradil.

Types of Long Term Controller Medications (cont.)

Brand names listed as examples only, and are not inclusive.
Combination inhaled corticosteroids/long-acting brochodilator - Advair Leukotriene modifiers - Singulair, Accolate. A pill, not an inhaler, not a steroid Inhaled nonsteroid anti-inflammatory medications Intal, Tilade Oral steroids

Using a Peak Flow Meter

A peak flow meter is a useful tool for objectively measuring the severity of asthma The value obtained is called a peak expiratory flow rate (PEFR) The PEFR shows the degree of airway obstruction or narrowing

Determining a Personal Best Value

Each person has a normal PEFR based on height and gender. This is a predicted value. Many physicians prefer to use the persons personal best value The personal best represents the highest rate obtained over a specific period of time.

Correct Technique for Using a Peak Flow Meter

Place indicator at the base of the numbered scale Stand up Take a deep breath Place the meter in the mouth and close lips around the mouthpiece Blow out as hard and fast as possible Write down the achieved value Repeat the process two more times Record the highest of the 3 numbers achieved

Using a Metered Dose Inhaler(MDI)

MDIs deliver asthma medication directly to the lungs. To use:
Remove the cap and hold inhaler upright Shake the inhaler Keep the head and neck in a neutral position and breathe out Position the inhaler in one of the following ways:
Open mouth and hold inhaler 1-2 inches away Use holding chamber (recommended for young children) Put in the mouth

Using a MDI (cont)

Press down on inhaler to release medication as you start to breathe in Breathe in slowly (3 to 5 seconds) Hold breath for 10 seconds to allow medicine to reach deeply into lungs Repeat puffs as directed

Rules of 2
When do you need more than a rescue bronchodilator?
Do you take your quick relief inhaler more than 2 times per week? Do you awaken at night with asthma more than 2 times per month? Do you refill your quick relief inhaler more than 2 times per year?

If the answer to these questions is yes, a long term controller anti-inflammatory medication may be needed.