1. Asthma

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

3. Triggers of Asthma Allergens Exercise Respiratory Infections
Nose and Sinus problems
Drugs and Food Additives
GERD
Emotional Stress

4. Early and Late Phases of Responses of Asthma
Fig. 28-1

5. Asthma Pathophysiology
Bronchospasm
Airway inflammation

6. Asthma Pathophysiology
Early-Phase Response
Peaks minutes post exposure, subsides 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

7. 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

8. Factors Causing Airway Obstruction in Asthma
Fig. 28-3

9. Summary of Pathophysiologic Features
Reduction in airway diameter
Increase in airway resistance r/t
Mucosal inflammation
Constriction of smooth muscle
Excess mucus production

10. Asthma Clinical Manifestations
Unpredictable and variable
Recurrent episodes of wheezing, breathlessness, cough, and tight chest

11. 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

12. 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

13. Asthma Clinical Manifestations
Difficulty with air movement can create a feeling of suffocation
Patient may feel increasingly anxious
Mobilizing secretions may become difficult

14. 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)

15. Asthma Complications Status asthmaticus
Severe, life-threatening attack refractory to usual treatment where patient poses risk for respiratory failure

16. Asthma Diagnostic Studies
Detailed history and physical exam
Pulmonary function tests
Peak flow monitoring
Chest x-ray
ABGs

17. Asthma Diagnostic Studies
Oximetry
Allergy testing
Blood levels of eosinophils
Sputum culture and sensitivity

18. 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

19. 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

20. 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

21. 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

22. 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

23. Asthma Drug Therapy Long-term control medications
Achieve and maintain control of persistent asthma
Quick-relief medications
Treat symptoms of exacerbations

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Nursing Management Nursing Diagnoses
Ineffective airway clearance
Anxiety
Ineffective therapeutic regimen management

34. 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

35. 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

36. 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

37. Nursing Management Health Promotion
Adequate nutrition
Adequate sleep
Take -adrenergic agonist 10 to 20 minutes prior to exercising

38. Nursing Management Nursing Implementation
Acute Intervention
Monitor respiratory and cardiovascular systems
Lung sounds
Respiratory rate
Pulse BP

39. Nursing Management Nursing Implementation
ABGs
Pulse oximetry
FEV and PEFR
Work of breathing
Response to therapy

40. Nursing Management Nursing Implementation
Nursing Interventions
Administer O2
Bronchodilators
Chest physiotherapy
Medications (as ordered)
Ongoing patient monitoring

41. 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

42. Nursing Management Nursing 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

43. 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

44. 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

45. Nursing Management Nursing Implementation
Counseling may be indicated to resolve problems
Relaxation therapies may help relax respiratory muscles and decrease respiratory rate

46. Nursing Management Nursing Implementation
Peak Flow Results
Green zone
Usually % of personal best
Remain on medications

47. Nursing Management Nursing Implementation
Peak Flow Results
Yellow zone
Usually 50-80% of personal best
Indicates caution
Something is triggering asthma

48. 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