Asthma DISEASE DEFINITION TYPES Asthma

Asthma is a chronic lung condition. It is characterized by the variable airflow obstruction that is the result of airway hyper responsiveness and airway inflammation. Asthma is classified by severity using these features: y frequency, severity, and duration of symptoms y degree of airflow obstruction (spirometry measure) or peak expiratory flow (PEF) y frequency of nighttime symptoms and the degree that the asthma interferes with daily activities. Severity can change over time, and even milder cases can become severe in an uncontrolled attack. Long-term therapy depends on whether the patient's asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent. For all patients, quick relief can be obtained by using a short-acting bronchodilator (2 to 4 puffs of short-acting inhaled beta2-adrenergic agonists as needed for symptoms). However, the use of a short-acting bronchodilator more than twice a week in patients with intermittent asthma or daily or increasing use in patients with persistent asthma may indicate the need to initiate or increase long-term control therapy. Sensitivity to specific external allergens is the leading cause. Incidence is highest with chronic exposure to the allergens. Internal, nonallergenic factors, such as genetic factors and stress, may also lead to asthma. Allergic asthma (atopic asthma) y Food additives containing sulfites and any other sensitizing substance y Perennial allergens, such as house dust, mold, and animal dander y Kapok or feather pillows y Seasonal allergens, such as pollen from grass, trees, or weeds Non-allergic asthma (nonatopic asthma) y Emotional stress y Genetic factors Bronchoconstriction y Cold air y Drugs, such as aspirin, beta-adrenergic blockers, and nonsteroidal antiinflammatory drugs y Exercise y Hereditary predisposition y Psychological stress y Sensitivity to allergens or irritants such as pollutants y Tartrazine y Viral infections Mild intermittent asthma The signs and symptoms of mild intermittent asthma include: y daytime symptoms no more than twice a week y nighttime symptoms no more than twice a month y lung function testing (either PEF or forced expiratory volume in 1 second) is 80% of predicted value or higher y PEF varies no more than 20%. Mild persistent asthma The signs and symptoms of mild persistent asthma include: y daytime symptoms 3 to 6 days a week

EPIDEMIOLOGY / RISK FACTORS

ALTERATION

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y nighttime symptoms 3 to 4 times a month y lung function testing is 800/0 of predicted value or higher y PEF varies between 20% and 30%. Moderate persistent asthma The signs and symptoms of moderate persistent asthma include: y daily daytime symptoms y at least weekly nighttime symptoms y lung function testing is 60% to 80% of predicted value y PEF varies more than 30%. Severe persistent asthma The signs and symptoms of severe persistent asthma include: y continual daytime symptoms y frequent nighttime symptoms y lung function testing is 60% of predicted value or lower y PEF varies more than 30%. Pathophysiology  Tracheal and bronchial linings overreact to various stimuli, causing episodic smooth-muscle spasms and swelling that severely constrict the airways.  Mucosal edema and thickened secretions further block the airways.  Immunoglobulin (Ig) E antibodies, attached to histamine-containing mast cells and receptors on cell membranes, initiate allergic asthma attacks.  When exposed to an antigen such as pollen, the IgE antibody combines with the antigen. On subsequent exposure to the antigen, mast cells degranulate and release mediators.  The mediators cause the bronchoconstriction and edema of an asthma attack.  During an asthma attack, expiratory airflow decreases, trapping gas in the airways and causing alveolar hyperinflation.  Atelectasis may develop in some lung regions.  The increased airway resistance causes labored breathing. y Wheeze y Breathlessness y Chest tightness y Cough y Dyspnea y Hyperinfaltion y Prolongued expiration y Difficulty speaking in complete sentences y Signs of hypoxemia (restlessness, increased anxiety, increased pulse rate & BP, increased respiratory rate, use of accessory muscles) y Status asthmaticus y Respiratory failure y Pneumonia y Atelectasis y Air-leak syndrome (such as pneumothorax) y Syndrome of inappropriate secretion of antidiuretic hormone y Death y Respiratory and lung assement (breath sounds) y Monitor for signs of respiratory distress (watch for use of accessory muscles & nasal flaring y Vital signs & pulse oximetry

CLINICAL MANIFESTATIONS

COMPLICATIONS

ASSESSMENTS

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TREATMENTS

y y y General y y y

Intake and output Response to treatment Level of anxiety & fatigue Identification and avoidance of precipitating factors Desensitization to specific antigens Establishment and maintenance of a patent airway

Medications y Generally, two categories of asthma medications quick relief for immediate symptom relief and long-acting medications to control the underlying inflammation y Quick relief bronchodilators, such as albuterol sulfate inhaler, as needed y Quick relief anticholingerics, such as ipratropium bromide, for relief of bronchospasm y Corticosteroids, such as systemic methylprednisolone, prednisolone, and prednisone, to prevent exacerbation progression during moderate or severe excerbations y Corticosteroids for persistent asthma, such as an inhaled corticosteroid of fluticasone (Flovent), beclomethasone (QVAR), budesonide inhaled (Pulmicort Turbuhaler), or mometasone inhaled (Asmanex) y Long-acting beta-agonist or combination drug, such as salmeterol inhaled (Serevent), formoterol inhaled (Foradil), fluticasone and salmeterol inhaled (Advair), or budesonide and formoterol inhaled (Symbicort) y Leukotriene antagonists (antileukotrienes) such as montelukast (Singulair) y Anticholinergic bronchodilators such as tiotropium inhaled (Spiriva) y Monoclonal antibody such as omalizumab (Xolair) y Anti-inflammatory, such as nedocromil sodium (Tilade), inhaled before exercise to reduce bronchospasm y Low-flow oxygen y Antibiotics

NURSING DIAGNOSES

INTERVENTIONS

y y y y y y y y y y y y y y y y

Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Fear Anxiety Give prescribed inhalers and asthma medications. Place the patient in high Fowler's position. Encourage pursed-lip and diaphragmatic breathing. Administer prescribed humidified oxygen. Adjust oxygen according to the patient's vital signs and ABG values. Assist with intubation and mechanical ventilation, if appropriate. Perform postural drainage and chest percussion, if tolerated. Suction an intubated patient as needed. Treat the patient's dehydration with I.V. or oral fluids as tolerated. Keep the room temperature comfortable. Use an air conditioner or a fan in hot, humid weather.