Asthma

Presented By Group 2a
Objectives
By the end of the presentation, colleagues should be able to describe the
following
• Definition of asthma

• Classification of asthma

• Etiology of asthma

• Pathophysiology of asthma

• Clinical manifestation of asthma

• Assessments for clients with asthma

• Treatment of asthma
Asthma
• This is a chronic inflammatory disorder of the airways in which inflammation
causes varying degrees of obstruction in the airways, causing recurrent episodes
of wheezing, breathlessness, chest tightness, and cough particularly at night and
early in the morning and is associated with hypersensitiveness to a variety of
certain stimuli.
• The hypersensitiveness of the airways is variable, producing spontaneous
fluctuation in the severity of obstruction.
• The mechanisms that causes asthma remains unknown up to date.
• With proper medical seeking behavior, medical treatment, and adherence to
prescribed therapy, asthma fatality can be reduced.
Triggers Of Asthma
Allergens
In other asthmatic people, an exaggerated response of immunoglobulin E to certain allergies like
dust, pollen, mites, grasses, roaches, molds, and latex may occur, triggering asthma attacks.
Exercises
In this case, asthma is induced after the exercises, not during the exercises.
Airway obstruction may occur due to changes in the airway mucosa caused by hyperventilation
during exercise, with either cooling or rewarming the of air and capillary leakage in the airway
wall.
Air pollution
Caused by pollutants such as cigarrete or wood smoke or vehicle exhaust,
The pollutants are associated with an accelerated decrease in lung function in asthmatic client,
increases the severity and even these may cause client to be less responsive to treatment .
Triggers Of Asthma cont’d…
Occupation factors
Agricultural workers, bakers, hospital workers, plastic manufacturers, and
beauticians are at high risk of occupation asthma due to years of exposure to airway
irritants.
Irritants cause the change in the responsiveness of the airways, thus leading to
asthma
Respiratory tract infections
Viral or bacterial acute respiratory infection may increase the airway narrowing and
airway hyper responsiveness
Viral induced alterations such as alteration in epithelial cells, edema of airway
walls, and exposure of airway nerve ending may promote to altered airway function.
Triggers Of Asthma cont’d…
Nose and sinus problems
Problems like allergic rhinitis, and chronic sinusitis cause the inflammation of
mucous membranes leading to asthma.
Drugs and food additives
Sensitivity to specific drugs may occur in some people, especially those with nasal
polyps and sinusitis.
Drugs and food additives that contains salicylic acid such as aspirin, NSAIDS.
Oral β-adrenergic blockers such as metoprolol can cause bronchospasms
Angiotensin-converting enzyme inhibitors may also induce cough in known
asthmatic patients.
Triggers Of Asthma cont’d…
Psychological triggers
Asthma is not a psych disease, however many people with asthma report with
asthma report that symptoms worsens with stress.
Extreme emotion expressions are also associated with hyperventilation which may
also narrow the airways.
Gastroesophageal reflux disease
The reflex triggers bronchoconstriction and cause aspiration, which in turn worsen
the asthma symptoms.
Asthma medications (βeta-2 agonist) are may worsen these refluxes because they
may relax the lower esophageal sphincter , thus allowing the contents to reflux into
the esophagus and possibly aspirated into the lungs.
CLASSIFICATION OF ASTHMA
Intermittent
• Its symptoms occur twice or less in a week. Client is free between
episodes
• Do not interfere with daily activities
• Night time symptoms occur less than 2 times in a month
Mild
• Symptoms occur more than 2 days in a week but not every day
• Attacks interfere with daily activities
• Night time symptoms occur 3-4 times in a month
CLASSIFICATION OF ASTHMA
Moderate
• Symptoms occur daily
• Inhaled short acting medication is used everyday
• Symptoms interfere with daily activities
• Night time symptoms occur more than once in a week
Severe
• Symptoms occur through out each day
• Severity limits daily activities
• Night time symptoms occur often, sometimes every day
Risk Factors
 Having a blood relative with asthma such as parent or siblings

 Having another allergic condition such as dermatitis which causes red, itchy skin

 Hay fever which causes a runny nose, congestion and itchy ayes

 Overweight

 Smoking/exposure to second hand smoke

 Exposure to exhaust fumes/other forms of pollution

 Exposure to occupational triggers such as chemicals used in farming

 People with weak immune system on exposure to irritants e.g. children

 Prolonged use of drugs like aspirin

Pathophysiology
 Asthma is a complex condition where interaction of genetics, and environment
occurs involving many inflammatory cells which release a wide range of
mediators.
 These mediators acts on the cells of the airways leading to smooth muscle
contraction, mucus hypersecretion, plasma leakage, edema, activation of
cholinergic reflexes and sensory nerves.
 The primary physiologic process in asthma is persistent but variable
inflammation of the airways. The airflow is limited because the inflammation
results in bronchoconstriction, airway hyper responsiveness (hyper reactivity)and
the edema of the airway.
Pathophysiology cont’d…
• Exposure to allergens or irritants initiate the inflammatory cascade where
inflammatory cells, mast cells, macrophages, eosinophils, neutrophils, T and
B lymphocytes, and epithelial cells of the airways are involved.
• During the beginning of the inflammatory process mast cells beneath the
basement membrane of the bronchial wall degranulate and releases the
multiple inflammatory mediators. IgE antibodies are linked to mast cells,
and the allergen cross links the IgE, leading to the release of inflammatory
mediators (leukotrienes, histamines, cytokines, prostaglandins and nitric
oxide.
Pathophysiology cont’d…

• Some of the inflammatory mediators causes vasodilation and

increased capillary permeability in the blood vessels and some
causes airways to be infiltrated by eosinophils, lymphocytes
and neutrophils.
• The whole process results into vascular congestion, edema,
production of thick tenacious mucus, bronchial muscle spasms,
thickening of the airways, and increased bronchial hyper
responsiveness.
Pathophysiology cont’d…
 Thisleads to implication of
the continuing inflammatory
response.
 Theinflammatory response
occurs in two phases
namely:-
a) Early asthmatic response
b) Late asthmatic response
Early Inflammatory asthmatic Response
• Early asthmatic response:- this occurs 90 minutes after exposure to the triggers of
asthma. Inflammatory mediators are released from bronchial mast cells to begin
local inflammatory process. Examples of mediators includes histamines,
leukotrienes, bradykinin, and serotonin.

• As a result, there is bronchoconstriction and increased capillary permeability,

leading to edema and increased mucus production, further narrowing airways.

• Labored breathing is manifested due to airway resistance, obstruction and airflow

limitation.
Late Asthmatic Inflammatory Response

 It begins 3-10 hrs. upon exposure to the triggers and may last several hours,
hence prolonging attack
 In this phase cellular components are activated (neutrophils and macrophages)
which damages the airway epithelium, produces mucosa edema, impairs airway
clearance, as a result bronchoconstriction is manifested.
Clinical manifestations
Asthma is manifested in three main
manifestations. These are:-
• Airway blockage due to tightened
muscles around the airway, making it
harder for air to pass
• Inflammation that causes swollen red
bronchial tube, thus predisposing to
lung damage.
• Airway irritability due to sensitive
airways that tend to overreact and
narrow when they come into contact
with slight triggers
These manifestations may lead to the following signs and
symptoms:-
• Cough, especially at night, or in the morning
• Shortness of breath
• Tightness, pain, or pressure in the chest
• Trouble sleeping due to breathing problems
• Wheezing when exhaling
• Post tussive vomiting (vomiting after coughing)
The above manifestations may be accelerated by physical
exercises, allergies, occupation e.t.c.
Assessment of an asthmatic client
Subjective Data Objective Data
Complaints of cough, difficulty and shortness of Respiratory status
breath, fatigue, apprehension Oxygen saturation
History of asthma allergies and known exposure Ability to converse without passing for a breath
to triggers Dyspnea, nasal flaring
Current medication, effectiveness and last date Chest expansion, use of accessory muscles, lung
of usage by the client sounds through out the chest
Family history of asthma Sputum production
History of coughing/wheezing after exercises Presence and effectiveness of cough
History of wheezing/coughing episodes in a Vital signs (respiration, PR, RR)
particular period Level of consciousness and mental status
Diagnosis of Asthma
Spirometry

The patient blows air into a spirometer, an instrument used to measure how fast one can breathe and
amount of air that one can hold.

If the spirometer records measurements below the normal for certain age group, it may indicate that
asthma has narrowed the airways

Exhaled nitric oxide test

One breath in a tube connected to a machine that measures the amount of nitric oxide gas in a breath.

Nitric oxide is normally produced by the body but high levels may indicate that airways are inflamed,
a sign of asthma
Diagnosis of Asthma

Imaging test

Chest x-ray to identify structural abnormalities/disease e.g. infection that can cause
or aggravate breathing problems.

Challenge test

Asthma is triggered by inhaling substance that may accelerate asthma symptoms

e.g. metacholine, or physical exercises.

Lung tests in children under 5 yrs.

Drug therapy
Anti-inflammatory drugs
Corticosteroids
These are medications that can reduce bronchial hyper
responsiveness, inhibit migration of inflammatory cells
and block the late phase response.
More effective than any other long term drug
First line therapy for people with persistent asthma
Examples are fluticasone and budesodine.
Therapeutic effect is manifested in 24 hrs
Can be administered without systemic side effects
unless there is high dose
Leukotriene modifiers
These are leukotriene receptor blockers e.g.
accolate, montelukast and leukotriene synthesis
inhibitors e.g. zileuton.
They interfere with the synthesis or block the
action of leukotrienes, inflammatory mediators
produced from arachidonic acid metabolism which
are responsible for bronchoconstriction, edema and
inflammation of airways
They have both anti-inflammatory and
bronchodilation effect.
They are used as prophylactic and maintenance
therapy
Drug therapy cont’d…
Bronchodilators Methylxanthines
β2-adrenergic agonists Sustained-release methyl xanthine (theophylline)
They may either be short acting or long acting preparations are not a first-line controller medication.
Examples includes albuterol and pirbuterol They are used only as an alternative therapy in mild
They are also know as rescue medication due to
persistent asthma.
their effectiveness in relieving bronchospasm as Methyl xanthine is a bronchodilator with mild anti-
their onset action is within minutes and their inflammatory effects, but the exact mechanism of
effectiveness is within 4-6hrs.
action is unknown.
These drugs act by stimulating β-adrenergic
receptors in the bronchioles leading to
bronchodilation
They also help in muco-ciliary clearance
Management of mild-persistent asthma
• No daily medication needed
• Environment free from allergens can reduce the attacks
• If exacerbations occur, short acting bronchodilators are used, salbutamol 2 puffs via spacer
device repeated initially then every 8 hrs.
• Keep under observation for at least 24 hrs.
• If required once every day preventive therapy, inhaled steriod, eg. Beclamenthazone 2 puffs
(200mg) twice a day via a spacer increasing to 4 puffs twice a day as required.
• Alternatively if the above are not available, give
• Salbutamol 2-4mg 3-4 times daily
• Aminophylline 100mg b.i.d daily
• Prednisolone 5mg p.o. daily.
 Moderate asthma

• Preferred treatment, low-medium dose inhaled corticosteroids and long

acting inhaled corticosteroids and long acting inhaled β-agonists,
hydrocortisone both as maintenance and as a relief therapy
Severe asthma

• Consider other cases of acute severe breathlessness with careful examinations

• Set up iv line and rehydrate with N/S 0.9%
• Administer salbutamol nebulizer repeated initially as required then every 6 hrs
/salbutamol 4 puffs inhaled via space device and hydrocortisone 200 mg IV as
a single daily dose in the morning for anther 5 days
• Give appropriate antibiotictherapy
• amoxicillin 500 mg t.d.s x 5/7 or DCN 200 mg in the first day followed
by 100 mg o.d x 4/7
Severe asthma cont’d…
In the case of emergency!
Repeat the salbutamol dose vi nebulizer every 15-30 mls until improved and
reassess the client after one hour if he has improved
Give aminophylline 250 mg slowly over 10 minutes with caution of aminophylline
toxicity
If no response
Administer aminophylline 250-500 mg IV in 1L OF 5% dextrose/ 0.9% normal
saline
Magnesium sulphate 1.2-2g IV over 20 mins
Adrenaline 0.5-1.o ml of 1:1000 slowly nebulized or IM.
Reassess continuously until patient settles
Complications Of Asthma
Status asthmaticus
• It is the extreme form of an asthma exacerbation that can result in hypoxemia, hypercarbia, and
secondary respiratory failure. 
• All patients with bronchial asthma are at risk of developing an acute episode with a progressive
severity that does not respond to standard treatments of bronchodilators (inhalers)
and corticosteroid
• If not recognized and managed appropriately, asthmatics promote to the risk of acute
ventilatory failure and even death.
• Usually it is caused by viral illnesses, ingestion of aspirin or other NSAIDS, coming in contact
with asthma triggers, abrupt discontinuation of drug therapy
• Symptoms include chest tightness, rapidly progressive dyspnea(shortness of breath),
dry cough, use of accessory respiratory muscles, fast and/or labored breathing, and
extreme wheezing.
Status asthmaticus cont’d…
On examination,
The respiratory rate may be elevated (more than 25 breaths per minute),
The heart rate may be rapid (110 beats per minute or faster)
There is reduced oxygen saturation levels (but above 92%) are often encountered.
Examination of the lungs with a stethoscope may reveal reduced air entry and/or
widespread wheeze.
The peak expiratory flow can be measured at the bedside; in acute severe asthma,
the flow is less than 50% of a person's normal or predicted flow.
Status asthaticus cont’d…
Very severe acute asthma (termed "near-fatal" as there is an immediate risk to life)
is characterized by the following:-
• Peak flow of less than 33% predicted
• Oxygen saturations below 92% or cyanosis (blue discoloration, usually of the
lips)
• Absence of audible breath sounds over the chest ("silent chest" : wheezing is not
heard because there is not enough air movement to generate it)
• Reduced respiratory effort and visible exhaustion or drowsiness.
• Irregularities in the heartbeat and abnormal lowering of the blood pressure.
 Management of status asthmaticus
• Higher doses of inhaled bronchodilators, such as albuterol or
levalbuterol to open up your airways
• Oral, injected, or inhaled corticosteroids to reduce
inflammation
• Ipratropium bromide, another type of bronchodilator different
than albuterol
• An epinephrine shot
• Temporary ventilation support
COMPLICATIONS CONT’D…
Pneumonia
Respiratory failure
Atelelostasis
PREVENTION OF ASTHMA
People can not prevent form getting asthma but the can prevent the frequency
and reduce the severity of asthma attacks by following the following
recommendations:-
• Identify and avoid asthma triggers
• Learn to identify and avoid personal asthma triggers
• Monitor breathing periodically by using peak air flow meter while at home.
• Treat attacks early to prevent severe attacks
• Take asthma medications as directed even when the asthma seems to be
getting better.
References
Dersarkissian, C., (2022), Status Asthmaticus, Retrieved From
https://www.wemd.com/asthma/guide/statusasthmaticus