Asthma

Asthma
Definition
 Reactive airway disease
 Chronic inflammatory lung disease
Inflammation causes varying degrees of
obstruction in the airways
 Asthma is reversible in early stages
 Triggers of Asthma

 Allergens
 Exercise
 Respiratory Infections
 Nose and Sinus problems
 Drugs and Food Additives
 GERD
 Emotional Stress
Early and Late Phases of Responses of
Asthma

Fig. 28-1
 Asthma
Pathophysiology

 Bronchospasm
 Airway inflammation
 Asthma
Pathophysiology
Early-Phase Response
 Peaks 30-60 minutes post exposure, subsides 30-

90 minutes later
 Characterized primarily by bronchospasm

 Increased mucous secretion, edema formation,

and increased amounts of tenacious sputum

 Patient experiences wheezing, cough, chest

tightness, and dyspnea

 Asthma
Pathophysiology
Late-Phase Response
 Characterized primarily by inflammation
 Histamine and other mediators set up a self-
sustaining cycle increasing airway reactivity
causing hyperresponsiveness to allergens and
other stimuli
 Increased airway resistance leads to air trapping
in alveoli and hyperinflation of the lungs
 If airway inflammation is not treated or does not
resolve, may lead to irreversible lung damage
Factors Causing Airway Obstruction in
Asthma

Fig. 28-3
 Summary of Pathophysiologic
Features
 Reduction in airway diameter
 Increase in airway resistance r/t
 Mucosal inflammation
 Constriction of smooth muscle
 Excess mucus production
 Asthma
Clinical Manifestations
 Unpredictable and variable

 Recurrent episodes of wheezing,

breathlessness, cough, and tight chest
 Asthma
Clinical Manifestations
 Expiration may be prolonged from a
inspiration-expiration ratio of 1:2 to 1:3 or
1:4

 Between attacks may be asymptomatic

with normal or near-normal lung function
 Asthma
Clinical Manifestations
 Wheezing is an unreliable sign to gauge
severity of attack
 Severe attacks can have no audible
wheezing due to reduction in airflow
 “Silent chest” is ominous sign of
impending respiratory failure
 Asthma
Clinical Manifestations

Difficulty with air movement can create a

feeling of suffocation
 Patient may feel increasingly anxious
 Mobilizing secretions may become difficult
 Asthma
Clinical Manifestations
Examination of the patient during an acute
attack usually reveals signs of hypoxemia
 Restlessness
 Increased anxiety
 Inappropriate behavior
 Increased pulse and blood pressure
 Pulsus paradoxus (drop in systolic BP during
inspiratory cycle >10)
 Asthma
Complications
Status asthmaticus
 Severe, life-threatening attack refractory

to usual treatment where patient poses

risk for respiratory failure
 Asthma
Diagnostic Studies

 Detailed history and physical exam

 Pulmonary function tests
 Peak flow monitoring
 Chest x-ray
 ABGs
 Asthma
Diagnostic Studies

 Oximetry
 Allergy testing
 Blood levels of eosinophils
 Sputum culture and sensitivity
 Asthma
Collaborative Care
 Education
 Start at time of diagnosis
 Integrated into every step of clinical care
 Self-management
 Tailored to needs of patient
 Emphasis on evaluating outcome in terms of
patient’s perceptions of improvement
 Asthma
Collaborative Care
Acute Asthma Episode
 O2 therapy should be started and monitored
with pulse oximetry or ABGs in severe cases
 Inhaled -adrenergic agonists by metered
dose using a spacer or nebulizer
 Corticosteroids indicated if initial response is
insufficient
 Asthma
Collaborative Care
Acute Asthma Episode
Therapy should continue until patient
• is breathing comfortably

• wheezing has disappeared

• pulmonary function study results are

near baseline values

 Asthma
Collaborative Care
Status asthmaticus
 Most therapeutic measures are the same as for
acute
 Increased frequency & dose of
bronchodilators
 Continuous -adrenergic agonist nebulizer
therapy may be given
 Asthma
Collaborative Care
Status asthmaticus
 IV corticosteroids
 Continuous monitoring
 Supplemental O2 to achieve values of 90%
 IV fluids are given due to insensible loss of
fluids
 Mechanical ventilation is required if there is
no response to treatment
 Asthma
Drug Therapy
 Long-term control medications
 Achieve and maintain control of persistent
asthma
 Quick-relief medications
 Treat symptoms of exacerbations
 Asthma
Drug Therapy
 Bronchodilators
  -adrenergic agonists
(e.g., albuterol, salbutamol[Ventolin])
 Acts in minutes, lasts 4 to 8 hours

 Short-term relief of bronchoconstriction

 Treatment of choice in acute exacerbations

 Asthma
Drug Therapy
 Bronchodilators
 Useful in preventing bronchospasm
precipitated by exercise and other stimuli
 Overuse may cause rebound bronchospasm

 Too frequent use indicates poor asthma

control and may mask severity

 Asthma
Drug Therapy
 Bronchodilators (longer acting)
8 – 12 or 24 hr; useful for nocturnal asthma
 Avoid contact with tongue to decrease side
effects
 Can be used in combination therapy with
inhaled corticosteroid
 Asthma
Drug Therapy
Antiinflammatory drugs
 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

 Asthma
Drug Therapy
Antiinflammatory drugs
 Corticosteroids

 Do not block immediate response to

allergens, irritants, or exercise
 Do block late-phase response to subsequent
bronchial hyperresponsiveness
 Inhibit release of mediators from
macrophages and eosinophils
 Asthma
Drug Therapy
Anti-inflammatory drugs
 Mast cell stabilizers (e.g., cromolyn, nedocromil)
 Inhibit release of histamine

 Inhibit late-phase response

 Long-term administration can prevent and reduce

bronchial hyper-reactivity
 Effective in exercise-induced asthma when used 10

to 20 minutes before exercise

 Asthma
Drug Therapy
 Leukotriene modifiers (e.g. Singulair)
 Leukotriene – potent bronchco-constrictors
and may cause airway edema and
inflammation
 Have broncho-dilator and anti-inflammatory
effects
 Asthma
Patient Teaching Related to Drug
Therapy
Correct administration of drugs is a major
factor in determining success in asthma
management
 Some persons may have difficulty using an MDI
and therefore should use a spacer or nebulizer
 DPI (dry powder inhaler) requires less manual
dexterity and coordination
 Asthma
Patient Teaching Related to Drug
Therapy

 Inhalers should be cleaned by removing dust

cap and rinsing with warm water
 -adrenergic agonists should be taken first if
taking in conjunction with corticosteroids
 Nursing Management
Nursing Diagnoses
 Ineffective airway clearance

 Anxiety

 Ineffective therapeutic regimen

management
 Nursing Management
Planning
 Normal or near-normal pulmonary function
 Normal activity levels
 No recurrent exacerbations of asthma or
decreased incidence of asthma attacks
 Adequate knowledge to participate in and
carry out management
 Nursing Management
Health Promotion
 Teach patient to identify and avoid
known triggers
 Use dust covers
 Use of scarves or masks for cold air

 Avoid aspirin or NSAIDs

 Desensitization can decrease sensitivity

to allergens
 Nursing Management
Health Promotion
 Prompt diagnosis and treatment of upper
respiratory infections and sinusitis may
prevent exacerbation

 Fluid intake of 2 to 3L every day

 Nursing Management
Health Promotion
 Adequate nutrition
 Adequate sleep

 Take -adrenergic agonist 10 to 20

minutes prior to exercising

 Nursing Management
Nursing Implementation
Acute Intervention
 Monitor respiratory and cardiovascular systems
 Lung sounds

 Respiratory rate

 Pulse

 BP
 Nursing Management
Nursing Implementation

 ABGs

 Pulseoximetry
 FEV and PEFR

 Work of breathing

 Response to therapy
 Nursing Management
Nursing Implementation

 Nursing Interventions
 Administer O2
 Bronchodilators

 Chestphysiotherapy
 Medications (as ordered)

 Ongoing patient monitoring

 Nursing Management
Nursing Implementation

An important goal of nursing is to decrease

the patient’s sense of panic
 Stay with patient
 Encourage slow breathing using pursed lips for
prolonged expiration
 Position comfortably
 Nursing Management
Nursing Implementation
 Thepatient must learn about medications
and develop self-management strategies

 Patient
and health care professional must
monitor responsiveness to medication

 Patientmust understand importance of

continuing medication when symptoms are
not present
 Nursing Management
Nursing Implementation
 Important patient teaching:
 Seek medical attention for bronchospasm or
when severe side effects occur
 Maintain good nutrition
 Exercise within limits of tolerance
 Nursing Management
Nursing Implementation

 Important patient teaching (cont.):

 Patient must learn to measure their peak flow
at least daily
 Asthmatics frequently do not perceive changes
in their breathing
 Nursing Management
Nursing Implementation

 Counseling may be indicated to resolve

problems
 Relaxation therapies may help relax
respiratory muscles and decrease
respiratory rate
 Nursing Management
Nursing Implementation

Peak Flow Results

 Green zone
 Usually 80-100% of personal best
 Remain on medications
 Nursing Management
Nursing Implementation

Peak Flow Results

 Yellow zone
 Usually 50-80% of personal best
 Indicates caution
 Something is triggering asthma
 Nursing Management
Nursing Implementation

Peak Flow Results

 Red zone
 50% or less of personal best
 Indicates serious problem
 Definitive action must be taken with health care
provider