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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
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Allergens
Exercise
Respiratory Infections
Nose and Sinus problems
Drugs and Food Additives
GERD
Emotional Stress
Early and Late Phases of Responses of Asthma
Asthma
Pathophysiology
 Bronchospasm
 Airway inflammation
Asthma
Pathophysiology
Early-Phase Response
 Peaks 30-60 minutes post exposure, subsides 30-90 minutes later
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Characterized primarily by bronchospasm
 Increased mucous secretion, edema formation, and increased amounts of
tenacious sputum
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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
Summary of Pathophysiologic Features
 Reduction in airway diameter
 Increase in airway resistance r/t
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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
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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
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Restlessness
Increased anxiety
Inappropriate behavior
Increased pulse and blood pressure
Pulsus paradoxus (drop in systolic BP during inspiratory cycle >10)
Asthma
 Mild intermittent
 Mild persistent
Classification
 Moderate persistent
 Severe persistent
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
 Education
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Collaborative Care
Start at time of diagnosis
Integrated into every step of clinical care
 Self-management
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Tailored to needs of patient
Emphasis on evaluating outcome in terms of patient’s perceptions of
improvement
Asthma
Collaborative Care
Mild Intermittent and Mild Persistent Asthma
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Avoid triggers of acute attacks
Premedicate before exercising
 Inhaled -adrenergic agonists
 Cromolyn or nedocromil
Asthma
Collaborative Care
Moderate Persistent
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Requires regular or maintenance use of inhaled antiinflammatory
medications
 Corticosteroids
 cromolyn (Intal)
 nedocromil (Tilade)
Asthma
Collaborative Care
Severe Persistent Asthma
 Corticosteroids
or oral -adrenergic agonists
 theophylline
 Inhaled
Asthma
Collaborative Care
Acute Asthma Episode
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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
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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
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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
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Achieve and maintain control of persistent asthma
 Quick-relief medications
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Treat symptoms of exacerbations
Asthma
 Bronchodilators
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Drug Therapy
-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
 Bronchodilators
Drug Therapy
 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
 Bronchodilators
Drug Therapy
 Longer-acting,
used 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
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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
Antiinflammatory drugs
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Mast cell stabilizers (e.g., cromolyn, nedocromil)
 Inhibit late-phase response
 Long-term administration can prevent and reduce bronchial
hyperreactivity
 Effective
in exercise-induced asthma when used 10 to 20 minutes
before exercise
Asthma
Patient Teaching Related to Drug Therapy
Correct administration of drugs is a major factor in determining
success in asthma management
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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
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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
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Teach patient to identify and avoid known triggers
 Use
dust covers
 Use of scarves or masks for cold air
 Avoid aspirin or NSAIDs
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Desensitization can decrease sensitivity to allergens
Nursing Management
Health Promotion
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Prompt diagnosis and treatment of upper respiratory infections
and sinusitis may prevent exacerbation
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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
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Nursing Management
Nursing Implementation
Acute Intervention
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Monitor respiratory and cardiovascular systems
 Lung sounds
 Respiratory rate
 Pulse
 BP
Nursing Management
Nursing Implementation
 ABGs
 Pulse
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oximetry
 FEV and PEFR
 Work of breathing
Response to therapy
Nursing Management
Nursing Implementation
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Nursing Interventions
 Administer
O2
 Bronchodilators
 Chest physiotherapy
 Medications (as ordered)
 Ongoing patient monitoring
Nursing Management
Nursing Implementation
An important goal of nursing is to decrease the patient’s sense of
p a n ic
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Stay with patient
Encourage slow breathing using pursed lips for prolonged expiration
Position comfortably
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
Nursing Management
Nursing Implementation
 Important patient teaching:
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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.):
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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
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Usually 80-100% of personal best
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Remain on medications
Nursing Management
Nursing Implementation
Peak Flow Results
 Yellow zone
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Usually 50-80% of personal best
Indicates caution
Something is triggering asthma
Nursing Management
Nursing Implementation
Peak Flow Results
 Red zone
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50% or less of personal best
Indicates serious problem
Definitive action must be taken with health care provider