Asthma

Presenter:
Nazia Kulsoom

Facilitator: Ma’am Salma

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Objectives
By the end of this presentation, learners will be able to;
• Review A & P of lower respiratory tract.
• Define and explain asthma.
• Describe the types of asthma briefly.
• Elaborate the causes, pathophysiology of asthma.
• Identify the clinical manifestations and diagnostic procedures for
asthma.
• Discuss the medical, surgical and nursing management of asthma.

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 Case study
5-year-old male, presented to OPD with wheezing, shortness of breath,
and chest tightness. Symptoms exacerbated by exposure to
environmental triggers like dust and pollen. Past history includes
recurrent episodes of coughing and nocturnal awakenings due to
breathlessness. He was diagnosed with asthma during childhood and has
no history of using inhalers.

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Diagnostic Test: Spirometry
Chest Xray
PEF
Methacholine test
Medications:
Inhale corticosteroids: Fluticasone ,Budesonide
Bronchodialators:Salbutamol, Formoterol
LRA: Montelukast
Oral corticosteroids: Prednisone

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 A & P of lower respiratory tract

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 Asthma
Asthma is a chronic inflammatory disorder of the airways that causes
airway hyperresponsiveness, mucosal edema and mucus production.

• Asthma is characterized by chronic airway

inflammation and increased airway hyper
Responsiveness leading to the symptoms
Of wheezing,cough,chest tightness and
dyspnea

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• Asthma is a disorder of bronchial airways characterized by period of
reversible bronchospasm.
• Unlike other obstructive lung diseases, asthma is largely reversible ,
either spontaneously or with treatment.
• Patients with asthma may experience symptoms free periods alternating
with acute exacerbation, which last from minutes to hours or days.

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Asthma attack
• When person breathe normally, muscles around his airways are relaxed,
letting air move easily and quietly. During an asthma attack, three things
can happen:
• Bronchospasm: The muscles around the airways constrict (tighten). When
they tighten, it makes the airways narrow. Air cannot flow freely through
constricted airways.
• Inflammation: The lining of airways becomes swollen. Swollen airways
don’t let as much air in or out of lungs.
• Mucus production: During the attack, the body creates more mucus. This
thick mucus clogs airways.

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 Etiology and risk factors
• Family history
• Allergy(strongest predisposing factor)
• Airway irritants(air pollutants,cold,heat,weather changes,smoke,strong
odors,ocuupational exposure)
• Viral respiratory tract infections(common cold)
• Gastroesophageal reflux
• Exercise
• Certain medications{aspirin,NSAID(ibuprofen) ,beta adrenergic blockers}
• Foods(shellfish ,nuts)

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 Non allergic
asthma
Allergic
Nocturnal asthma
asthma
Asthma
types

Exercise Occupational
induced asthma
asthma Cough
variant
asthma

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I)Allergic asthma:
• When the symptoms are induced by a hyperimmune response to the
the inhalation of specific allergen.
Type I(immediate)hypersensitivity reaction is the basis of the IgE.

II)Non allergic asthma:

• This type of asthma is triggered by the presence of irritants in the air that are
not related to allergies.
• The irritants stimulate parasympathetic nerve fibers in the airways causing
• Bronchoconstriction and inflammation.

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IV)Cough variant asthma(CVA)
• This does not have the classic symptoms of asthma such as wheezing
and shortness of breath. Instead it is characterized by one symptom ,a
persistent cough.
• CVA is one of the most common causes of chronic cough. More
importantly, 30 to 40% of adult patients with CVA, unless adequately
treated, may progress to classic asthma.

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V)Exercise induced asthma
• Exercise-induced bronchoconstriction (EIB)
• Affects the person during exercise or physical activity.
• EIB occurs in 40% to 90% of people with asthma and up to 20% of those
without asthma.

VI)Nocturnal asthma
• Characterized by symptoms that worsen during the night
• The patient can also experience symptoms during day time
• The mechanisms of nocturnal asthma are intimately related to circadian
rhythms, which influence inflammatory cells and mediators, hormone
levels and cholinergic tone.
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VI)Occupational asthma:
• It occurs when person breathe in chemical fumes, gases, dust or other
substances on the job.
• When that happens, it causes an allergic or immunological response.

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Pathophysiology
Contributing Factors
Causal factors • Respiratory infection
Predisposing factors • Exposure to indoor and
• Atopy • Air pollution
outdoor exposure • Active/passive smoking
• Female gender
• Occupational sensitizer

Inflammation

Symptoms
Hyperresponsiveness Airway • Wheezing
of airway limitations • Cough
• Dyspnea
• Chest tightness
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Clinical manifestations
An exacerbation may be begin abruptly but most frequently is preceded
by increasing symptoms over the previous few days.
• Cough(with mucus or without mucus)
• Generalized wheezing(Ist on expiration then possibly during inspiration
as well)
• Generalized chest tightness and dyspnea.
The above three are the most common symptoms of asthma. Sometimes
cough may the only symptom.
• Expiration requires effort and may be prolonged

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 As the exacerbation progress,
• Diaphoresis
• Tachycardia
• Widened pulse pressure
• Hypoxemia
• Central cyanosis(a late sign of poor oxygenation) may also occur.

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Diagnosis
• History(medical, family and environmental)
• Physical examination
• Peak expiratory flow rate
• Spirometry( decrease FEV1/FVC ratio)
(PFR and spirometry are used to measure lung function)
• Methacholine challenge(this is done
if spirometry give normal report)

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Conti…
• Blood and sputum test(disclose eosinophilia,
elevated IgE count).
• ABG,s and Pulse oximetry reveals hypoxemia.
• X ray of chest(normally normal)

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Medical management
Immediate intervention may be necessary because
continuing and progressive dyspnea leads to increased anxiety,
aggravating the situation.
• Oxygen therapy
• Pharmacological therapy
Two classes of medications
1. Quick relief medications(immediate treatment of asthma symptoms and
exacerbations)
2. Long acting medications(To achieve and maintain control of persistent
asthma)
Also there are antiallergic medications
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 Drugs used in asthma

Anti inflammatory
Bronchodilators
agents

B2 agonist Muscarinic antagonists

Antibodies
SABA LABA Leukotrienes modifiers

Methylxanthines
Corticosteroids
Lipoxygenase R blockers
inhibitors
ICS Oral
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1. Quick relief medications
I. Short acting Beta 2-adrenergic agonist(SABA)
• Medications of choice for relief of acute symptoms and prevention of
exercise induced asthma
E.g :albuterol,pirbuterol,levalbuterol.
II. Anticholinergics
• Used in patients who do not tolerate SABA
Drugs: Ipratropium, Tiotropium
III. Oral corticosteroids
• These medications may be taken usually for a limited time(to treat
severe asthma attacks).

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Examples: Prednisone, systemic Methylprednisolone

2. Long acting control medications:

• Taken regularly to control chronic symptoms and prevent asthma attacks
• The most important type of treatment for most people with asthma
I. Inhaled corticosteroids
• Most effective and commonly used long-term control
• Examples: Fluticasone ,Budesonide, Mometasone ,Beclomethasone,
Ciclesonide.
II. Leukotriene modifiers
Zafirlukast , Zileuton, Montelukast

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III. Long-acting beta agonists (LABAs)
Examples. Salmeterol ,Formoterol

IV. Long-acting muscarinic antagonists (LAMAs)

Examples. Tiotropium (Spiriva Respimat)

V)Methylxanthines
Examples:Theophyline
VI)Combination inhalers:
• Some inhaled asthma medication combinations contain both a
corticosteroid and a bronchodilator(LABA)
Examples: Budesonide and formoterol (Symbicort), fluticasone furoate and
vilanterol(Dulera)
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VII.Leukotrines modifiers
a) Leukotrienes receptor agonist(montekulast,zafirulukast)
b) 5-lipoxygenase inhibitor(zileuton)

VIII) Biologic Therapies(Refractory Asthma):

Examples: omalizumab(Anti IgE antibody)
Misc IL-4, IL-5, IL-13 Specific Monoclonal antibodies
Antibiotics:
• Evidenced from clinical trials suggests that antibiotic theraphy,wether given
routinely or when suspicion of bacterial infection is low, is not beneficial for
asthma exacerbation
• Antibiotics may be appropriate in the treatment of acute asthma exacerbation
in patients with comorbid conditions(fever and purulent sputum, evidence of
pneumonia ,suspected bacterial sinusitis)
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How to Use a Metered dose inhalers (puffers)

•Shake the inhaler before use. The health-care

•Breathe out fully. provider should
•Hold the inhaler in the right position. evaluate inhaler
•Breathe in deeply as you puff the medicine technique at each visit.
into your mouth, then hold your breath for as
long as possible (and for at least 5 seconds).
•Make sure you shake the inhaler in between
puffs.
Surgical management:
Bronchial thermoplasty
This treatment is used for severe asthma that doesn't improve with
inhaled corticosteroids or other long-term asthma medications. It
isn't widely available nor right for everyone.
During bronchial thermoplasty,
• Doctor heats the insides of the airways in the lungs with an
electrode.
• The heat reduces the smooth muscle inside the airways.
• This limits the ability of the airways to tighten, making breathing
easier and possibly reducing asthma attacks.
Lung transplant
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Prevention of asthma

• Follow the asthma action plan.

• Get vaccinated for influenza and pneumonia.
• Identify and avoid asthma triggers
• Identify and treat attacks early.
• Take medication as prescribed
Nursing Diagnosis:
• Impaired gas exchange related to decreased ventilation
• Disturbed sleep pattern related to dyspnea
• Activity intolerance related to inadequate oxygenation
• Anxiety related to acute breathing difficulties and fear of suffocation
• Ineffective airway clearance related to excessive secretions/coughing

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Nursing interventions:
• Give prescribed medications and inhalers.
• Place the patient in high fowler position.
• Encourage pursed lips and diaphragmatic breathing.
• Administer prescribed humidified oxygen.
• Adjust oxygen according to patient vital sign’s and ABGs.
• Assist with intubation and mechanical ventilation, if appropriate.
• If patient is intubated, suction as needed.
• Keep room temperature comfortable.

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Conti….
• Monitor patient’s
o Vital signs
o I/O
o Response to treatments
o Breath sounds
o Adverse effects of drugs
o Breath sounds
o Pulse oximetry
o PFT result
o Anxiety
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References
• Brunner & Suddart’s Textbook of Medical Surgical Nursing, Volume
1,14 ed,2020-2021;pp 654-664.
• https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-
causes/syc-20369653
• https://my.clevelandclinic.org/health/diseases/6424-asthma
• https://www.nhlbi.nih.gov/health/asthma

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