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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

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  • 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


  • Bronchospasm

  • Airway inflammation


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


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

AsthmaClinical Manifestations

  • Unpredictable and variable

  • Recurrent episodes of wheezing, breathlessness, cough, and tight chest

AsthmaClinical 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

AsthmaClinical 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

AsthmaClinical Manifestations

Difficulty with air movement can create a feeling of suffocation

  • Patient may feel increasingly anxious

  • Mobilizing secretions may become difficult

AsthmaClinical 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)


Status asthmaticus

  • Severe, life-threatening attack refractory to usual treatment where patient poses risk for respiratory failure

AsthmaDiagnostic Studies

  • Detailed history and physical exam

  • Pulmonary function tests

  • Peak flow monitoring

  • Chest x-ray

  • ABGs

AsthmaDiagnostic Studies

  • Oximetry

  • Allergy testing

  • Blood levels of eosinophils

  • Sputum culture and sensitivity

AsthmaCollaborative 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

AsthmaCollaborative 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

AsthmaCollaborative Care

Acute Asthma Episode

Therapy should continue until patient

  • is breathing comfortably

  • wheezing has disappeared

  • pulmonary function study results are near baseline values

AsthmaCollaborative 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

AsthmaCollaborative 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

AsthmaDrug Therapy

  • Long-term control medications

    • Achieve and maintain control of persistent asthma

  • Quick-relief medications

    • Treat symptoms of exacerbations

AsthmaDrug 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

AsthmaDrug 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

AsthmaDrug 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

AsthmaDrug 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

AsthmaDrug 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

AsthmaDrug 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

AsthmaDrug Therapy

  • Leukotriene modifiers (e.g. Singulair)

    • Leukotriene – potent bronchco-constrictors and may cause airway edema and inflammation

    • Have broncho-dilator and anti-inflammatory effects

AsthmaPatient Teaching Related to DrugTherapy

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

AsthmaPatient Teaching Related to DrugTherapy

  • 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 ManagementNursing Diagnoses

  • Ineffective airway clearance

  • Anxiety

  • Ineffective therapeutic regimen management

Nursing ManagementPlanning

  • 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 ManagementHealth 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 ManagementHealth Promotion

  • Prompt diagnosis and treatment of upper respiratory infections and sinusitis may prevent exacerbation

  • Fluid intake of 2 to 3L every day

Nursing ManagementHealth Promotion

  • Adequate nutrition

  • Adequate sleep

  • Take -adrenergic agonist 10 to 20 minutes prior to exercising

Nursing ManagementNursing Implementation

Acute Intervention

  • Monitor respiratory and cardiovascular systems

    • Lung sounds

    • Respiratory rate

    • Pulse

    • BP

Nursing ManagementNursing Implementation

  • ABGs

  • Pulse oximetry

  • FEV and PEFR

  • Work of breathing

  • Response to therapy

  • Nursing ManagementNursing Implementation

    • Nursing Interventions

      • Administer O2

      • Bronchodilators

      • Chest physiotherapy

      • Medications (as ordered)

      • Ongoing patient monitoring

    Nursing ManagementNursing 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 ManagementNursing Implementation

    • The patient must learn about medications and develop self-management strategies

    • Patient and health care professional must monitor responsiveness to medication

    • Patient must understand importance of continuing medication when symptoms are not present

    Nursing ManagementNursing Implementation

    • Important patient teaching:

      • Seek medical attention for bronchospasm or when severe side effects occur

      • Maintain good nutrition

      • Exercise within limits of tolerance

    Nursing ManagementNursing 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 ManagementNursing Implementation

    • Counseling may be indicated to resolve problems

    • Relaxation therapies may help relax respiratory muscles and decrease respiratory rate

    Nursing ManagementNursing Implementation

    Peak Flow Results

    • Greenzone

      • Usually 80-100% of personal best

      • Remain on medications

    Nursing ManagementNursing Implementation

    Peak Flow Results

    • Yellow zone

      • Usually 50-80% of personal best

      • Indicates caution

      • Something is triggering asthma

    Nursing ManagementNursing Implementation

    Peak Flow Results

    • Red zone

      • 50% or less of personal best

      • Indicates serious problem

      • Definitive action must be taken with health care provider

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