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Asthma
Michael Haines, MPH, RRT-NPS, AE-C
What is Asthma
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Asthma is a disease of inflammation and
bronchial smooth muscle constriction that
causes the trapping of gas and wheezing
 Asthma affects children more than adults due to
anatomical diameter of the airway.
 You are never cured of asthma, you do however
grow and the affects of asthma often lessen as
you grow
 Asthma is completely treatable and manageable
What is Asthma Continued…
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Asthma is one of the most chronic serious
diseases in children and adolescents, affecting
nearly nine million children under the age of 18.
Fifty to 80% of children with asthma develop the
symptoms of asthma before the age of 5.
 Asthma occurs when a stimulus triggers a
reaction in the lung mucosa and nervous system
causing muscle constriction
 This stimulus can occur as a result of a allergen
or an irritant such as smoke
 http://www.youtube.com/watch?v=82gn_rDRpHk
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Who is at risk to develop asthma?
Asthma is commonly divided into two types: allergic
(extrinsic) asthma and non-allergic (intrinsic) asthma
Children whose immune systems are not fully developed
are most at risk for developing the disease. However,
there are no clear markers to predict who will develop
asthma and who won't. Studies have shown that factors
associated with the onset of asthma symptoms in
children include:
Infants and young children who wheeze with viral upper
respiratory infections.
Allergies. The relationship between asthma and allergies
is very strong.
A family history of asthma and/or allergy
Prenatal exposure to tobacco smoke and allergens
 The
most common form of asthma among
children is allergic asthma. In this form,
otherwise harmless allergens, such as
dust mites, cat and dog dander or other
environmental allergens, can trigger an
asthma attack. In addition to allergy
symptoms brought on by exposure to
these allergens-watery eyes, sneezing and
itching-asthmatics can experience severe
airway constriction.
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(Dust mites live primarily in Humid
Environments, they are microscopic)
Allergens
Important treatment= stay away from your allergens!
If you don’t know what you are allergic to get a allergy test
The Role of Heredity in Asthma
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Heredity. To some extent, asthma seems to run in families. People
whose brothers, sisters or parents have asthma are more likely to
develop the illness themselves.
Atopy. A person is said to have atopy (or to be atopic) when he or
she is prone to have allergies. For reasons that are not fully known,
some people seem to inherit a tendency to develop allergies. This is
not to say that a parent can pass on a specific type of allergy to a
child. In other words, it doesn't mean that if your mother is allergic to
bananas, you will be too. But you may develop allergies to
something else, like pollen or mold.
In addition, several factors must be present for asthma symptoms to
develop:
Specific genes must be acquired from parents.
Exposure to allergens or triggers to which you have a genetically
programmed response.
Environmental factors such as quality of air, exposure to irritants,
behavioral factors such as smoking, etc.
Allergy Test
 Skin
test- numerous known substances
are placed on the skin, reactions are noted
and allergens are then determined
Allergy Test
 Besides
the skin allergy test they also due
blood tests
The RAST test measures the levels of the
allergy antibody IgE that
is produced when your
blood is mixed with a
series of allergens in a
laboratory.
What Happens During an Asthma
Episode?
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During normal breathing, the airways to the lungs are
fully open, allowing air to move in and out freely. But
people with asthma have inflamed, super-sensitive
airways. Their triggers cause the following airway
changes, which in turn cause asthma symptoms:
The lining of the airways swell and become more
inflamed
Mucus clogs the airways
Muscles tighten around the airways (bronchospasm)
These changes narrow the airways until breathing
becomes difficult and stressful, like trying to breathe
through a straw stuffed with cotton.
 The
lung is lined with a mucosa layer
which is basically a layer of cells
responsible for lubrication and debris
movement out of the lung
 During an allergic reaction and
subsequent asthma attack, this mucosa
releases histamines from mast cells,
mucus from goblet cells and inflammatory
cells; all of which increase the thickness
and narrowing of the airways.
 At the same time the muscle around the
lung tightens
Following an Asthma attack; the patient will have
congestion and increased sputum production for several
days
Causes
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Substances that cause allergies (allergens) such as dust
mites, pollens, molds, pet dander, and even cockroach droppings. In
many people with asthma, the same substances that cause allergy
symptoms can also trigger an asthma episode. These allergens may
be things that you inhale, such as pollen or dust, or things that you
eat, such as shellfish. It is best to avoid or limit your exposure to
known allergens in order to prevent asthma symptoms.
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Irritants in the air, including smoke from cigarettes, wood fires,
or charcoal grills. Also, strong fumes or odors like household sprays,
paint, gasoline, perfumes, and scented soaps. Although people are
not actually allergic to these particles, they can aggravate inflamed,
sensitive airways. Today most people are aware that smoking can
lead to cancer and heart disease. Smoking is also a risk factor for
asthma in children, and a common trigger of asthma symptoms for
all ages
Causes
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Respiratory infections such as colds, flu, sore throats, and
sinus infections. These are the number one asthma trigger in
children
GERD: Gastric espohgeal reflux disease, stomach acid can be
aspirated and inflam the airway
Exercise and other activities that make you breathe harder.
Exercise—especially in cold air—is a frequent asthma trigger. A
form of asthma called exercise-induced asthma is triggered by
physical activity. Symptoms of this kind of asthma may not appear
until after several minutes of sustained exercise. (When symptoms
appear sooner than this, it usually means that the person needs to
adjust his or her treatment.) The kind of physical activities that can
bring on asthma symptoms include not only exercise, but also
laughing, crying, holding one's breath, and hyperventilating (rapid,
shallow breathing). The symptoms of exercise-induced asthma
usually go away within a few hours
More Causes…
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Weather such as dry wind, cold air, or sudden changes
in weather can sometimes bring on an asthma episode.
Expressing strong emotions like anger, fear or
excitement. When you experience strong emotions, your
breathing changes -- even if you don’t have asthma.
When a person with asthma laughs, yells, or cries hard,
natural airway changes may cause wheezing or other
asthma symptoms.
Some medications like aspirin can also be related
to episodes in adults who are sensitive to aspirin.
Irritants in the environment can also bring on an asthma
episode. These irritants may include paint fumes, smog,
aerosol sprays and even perfume.
Why Does My Asthma Act Up at Night?
 For reasons we don't fully understand,
uncontrolled asthma -- with its underlying
inflammation -- often acts up at night. It
probably has to do with natural body
rhythms and changes in your body’s
hormones, as well as the fact that some
symptoms appear hours after you come in
contact with a trigger.
 Also during sleep you release less
norepinephrine (adrenaline) which acts as
your bodies natural bronchodilator
Symptoms
Symptoms
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Coughing. Coughing from asthma is often worse at
night or early in the morning, making it hard to sleep.
 Wheezing. Wheezing is a whistling or squeaky sound
when you breathe.
 Chest tightness. This can feel like something is
squeezing or sitting on your chest.
 Shortness of breath. Some people say they can't catch
their breath, or they feel breathless or out of breath. You
may feel like you can't get enough air in or out of your
lungs.
 Tachypnea and tachycardia
 Desaturation
*In children the only symptom may be a persistent cough,
that occurs more the morning
Status Asthmaticus
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As severe asthma attack not responsive to bronchodilators
Typically requires intubation and mechanical ventilation due to
respiratory failure
Typically, patients present a few days after the onset of a viral
respiratory illness, following exposure to a potent allergen or irritant,
or after exercise in a cold environment. Frequently, patients have
underused or have been underprescribed anti-inflammatory therapy.
Illicit drug use may play a role in poor adherence to antiinflammatory therapy. Patients report chest tightness, rapidly
progressive shortness of breath, dry cough, and wheezing and may
have increased their beta-agonist intake (either inhaled or
nebulized) to as often as every few minutes.
Vitals signs and Lab tests used to
diagnose:
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Periods of coughing, wheezing, shortness of
breath, or chest tightness that come on suddenly
or occur often or seem to happen during certain
times of year or season
Colds that seem to "go to the chest" or take
more than 10 days to get over
Medicines you may have used to help your
breathing
Your family history of asthma and allergies
What things seem to cause asthma symptoms or
make them worse.
Early and Late
Asthmatic Response
 Late
response is usually more severe and
longer lasting.
Spirometry
The test measures how much air and how fast you can
blow air out of your lungs after taking a deep breath. The
results will be lower than normal if your airways are
inflamed and narrowed, as in asthma, or if the muscles
around your airways have tightened up. Sometimes
bronchial provocation is used to trigger an attack and
then bronchodilators are given to test for reversibility
(Asthma is the only reversible COPD and is considered
very treatable). A substance such as methacholine,
which causes narrowing of the airways in asthma, is
inhaled. The effect is measured by spirometry. Children
under age 5 usually cannot use a spirometer
successfully. If spirometry cannot be used, the doctor
may decide to try medication for a while to see if the
child's symptoms get better.
Spirometry
Diagnosis
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Diagnosis of Asthma is made with clinical symptoms
and assessment; allergy awareness; PFT’s that show
reverability of >10% post bronchodilator and the ruling
out of other possible problems. To rule out asthma the
doctor would order:
A chest X-ray (asthmatics usually have normal CXR;
use to find foreign bodies)
Tests to see if you have gastroesophageal reflux
disease (GERD)
EKG: Rule out cardiac problems that may lead to SOB
and cardiac wheezing
ABG not necessarily useful
Once Diagnosed…
Based on symptoms, the four levels of asthma severity classification
are:
 Mild Intermittent (comes and goes)--when your asthma is not well
controlled, you have asthma symptoms twice a week or less, and
you are bothered by symptoms at night twice a month or less.
 Mild persistent asthma--when your asthma is not well controlled,
you have asthma symptoms more than twice a week, but no more
than once in a single day. You are bothered by symptoms at night
more than twice a month. You may have asthma attacks that affect
your activity.
 Moderate persistent asthma--when your asthma is not well
controlled, you have asthma symptoms every day, and you are
bothered by nighttime symptoms more than once a week. Asthma
attacks may affect your activity.
 Severe persistent asthma--when your asthma is not well controlled,
you have symptoms throughout the day on most days, and you are
bothered by nighttime symptoms often. In severe asthma, your
physical activity is likely to be limited.
Treatment
Treatment and ManagementAvoiding things that bring on your asthma symptoms or make symptoms
worse. Doing so can reduce the amount of medicine you need to
control your asthma. Allergy medicine and allergy shots in some
cases may help your asthma.
Using asthma medicines.
 Medications for asthma. There are two main types of medicines for
asthma:
1. Quick Relief medicines give rapid, short-term treatment and are
taken when you have worsening asthma symptoms that can lead to
asthma episodes or attacks. You will feel the effects of these
medicines within minutes.
2. Long-term Control medicines are taken every day, usually over long
periods of time, to control chronic symptoms and to prevent asthma
episodes or attacks. You will feel the full effects of these medicines
after taking them for a few weeks. People with persistent asthma need
long-term control medicines.
Treatment Cont…
 Quick
Acting Drugs are called Beta 2
Adrenergic Bronchodilators. They include
such drugs as Albuterol and Xopenex
 They react within minutes and generally
last between 4-8 hours
MDI
or
Nebulizer
Treatments Cont…
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Fast Acting Bronchodilators work to quickly relax
bronchial smooth muscle.
 Long Acting Drugs work to maintain open lungs
but are not to be given during an acute attack.
 Steroids are long acting drugs; common ones
include Advair, Azmacort and Pulmicort
Advair
Azmacort
Treatments Continued…
 Other
treatments include drugs that
prevent mast cells from releasing
histamines; such as Singular and other
allergen targeted drugs (given before
attack occurs)
 Avoiding Allergens
 Mast Cell inhibitors such as Intal or Foradil
 Allergy Shots given annually
Pharmacotherapy
Corticosteroids
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Most effective mediation in treatment of asthma
• Reduces symptoms and mortality
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Use of inhaled steroids for long-term treatment preferred
• Use spacer and rinse mouth to eliminate or minimize
side effects
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Long-term use of oral steroids should be restricted to
patients with asthma refractory to other treatment.
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Short-term oral steroid use during exacerbation reduces
severity, duration, and mortality.
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derived items © 2009 by
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of Elsevier Inc.
33
Pharmacotherapy (cont.)
Cromolyn (NSAID)
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Protective against allergens, cold air, exercise
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Administered prophylactically, CANNOT be used during an
acute asthma attack
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Of limited use in adults
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Drug of choice for atopic children with asthma
Nedocromil (NSAID)
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Similar to cromolyn, it is 4–10 times more potent in
preventing acute allergic bronchospasm.
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
34
Pharmacotherapy (cont.)
Leukotriene inhibitors
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Leukotrienes mediate inflammation and bronchospasm.
Modestly effective to control mild to moderate asthma
Inhaled steroids remain the antiinflammatory drug of
choice for the treatment of asthma.
Methyxanthines (use is controversial)
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Oral or IV use if admitted for acute asthma attack
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
35
Pharmacotherapy (cont.)
2-Adrenergic agonists
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Most rapid and effective bronchodilator
Drug of choice for exercise-induced asthma
and emergency relief of bronchospasm
• Should be used PRN
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Improves symptoms not underlying
inflammation
• Regular use may worsen asthma control and
increase risk of death.
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
36
Pharmacotherapy (cont.)
Anticholinergics
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Can be used as adjunct to first-line
bronchodilators if there is an inadequate
response
Has an additive affect to 2-agonists
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
37
Asthma and Environmental
Control
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Recognized relationship between asthma and allergy
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75–85% asthma patients react to inhaled allergens
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Environmental control is aimed at reducing exposure to allergens.
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Avoid outdoor allergens by remaining inside, windows closed,
AC on
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Indoor allergens are combated by
• Air purifiers and no pets
• Dust mites: airtight covers on bed and pillow, no carpets in
bedroom, chemical agents to kill mites
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
38
Special Considerations in
Asthma Management (cont.)
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Nocturnal asthma
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Present in two-thirds of poorly controlled asthmatics
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May be due to diurnal decrease in airway tone or gastric reflux
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Treatment should include:
• Steroid treatment targeted to relieve night symptoms
• Sustained release theophylline
• New long-acting 2-agonists
• Antacids for reflux
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
39
Special Considerations in
Asthma Management (cont.)
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Aspirin sensitivity
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5% of adult asthmatics will have severe, life-threatening asthma
attacks after taking NSAIDs.
All asthmatics should avoid; suggest Tylenol use.
Asthma during pregnancy
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A third of asthmatics have worse control at this time.
Much higher fetal risk associated with uncontrolled asthma than
that of asthma medications
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Theophyllines, 2-agonists, and steroids can be used without
significant risk of fetal abnormalities.
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derived items © 2009 by
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of Elsevier Inc.
40
Special Considerations in
Asthma Management (cont.)
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Sinusitis may cause asthma exacerbation.
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CT of sinuses will diagnosis problem.
Treat: 2–3 weeks antibiotics, nasal decongestants, and nasal
inhaled steroids
Surgery
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Asthmatics at higher risk for respiratory complications
• Arrest during induction
• Hypoxemia with/without hypercarbia
• Impaired cough, atelectasis, pneumonia
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Optimize lung function preoperatively.
Use steroids during procedure.
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derived items © 2009 by
Mosby, Inc., an affiliate
of Elsevier Inc.
41
Using a Peak Flow
A
Peak Flow device is a assessment tool
used to measure the effectiveness of fast
acting bronchodilators.
 Given during the attack, before and after
treatments
 It is a handheld device that the patient
exhales forcibly on; as the airway opens
and improves, the value increases
Peak Flow Continued…
 http://www.youtube.com/watch?v=CZHO_
JCTjXo
Conclusion
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Asthma is a disease of inflammation and
bronchial muscle constriction
Caused by sensitive lungs that swell when
introduced to an allergen or irritant
Symptoms include cough, wheezing, chest
congestion and tightness and SOB
Diagnose with PFT, symptoms and allergy test
Treat with Bronchodilators, Steroids, Allergen
Medications and avoidance of allergies.