ASTHMA OVERVIEW- DR.VISHWA MEDICAL COACHING

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Asthma

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Asthma Definition

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

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Triggers of Asthma

• Allergens
• Exercise
• Respiratory Infections
• Nose and Sinus problems
• Drugs and Food Additives
• GERD
• Emotional Stress

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

• Bronchospasm
• Airway inflammation

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AsthmaPathophysiology

• 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

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AsthmaPathophysiology

• 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

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Factors Causing Airway Obstruction in Asthma
Fig. 28-3
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Summary of Pathophysiologic Features

• Reduction in airway diameter
• Increase in airway resistance r/t
• Mucosal inflammation
• Constriction of smooth muscle
• Excess mucus production

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AsthmaClinical Manifestations

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

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AsthmaClinical Manifestations

• Expiration may be prolonged from a
  inspiration-expiration ratio of 12 to 13 or 14
• Between attacks may be asymptomatic with normal
  or near-normal lung function

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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

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AsthmaClinical Manifestations

• Difficulty with air movement can create a
  feeling of suffocation
• Patient may feel increasingly anxious
• Mobilizing secretions may become difficult

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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 gt10)

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AsthmaComplications

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

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AsthmaDiagnostic Studies

• Detailed history and physical exam
• Pulmonary function tests
• Peak flow monitoring
• Chest x-ray
• ABGs

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AsthmaDiagnostic Studies

• Oximetry
• Allergy testing
• Blood levels of eosinophils
• Sputum culture and sensitivity

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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
  patients perceptions of improvement

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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

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AsthmaCollaborative Care

• Acute Asthma Episode
• Therapy should continue until patient
• is breathing comfortably
• wheezing has disappeared
• pulmonary function study results are near
  baseline values

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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

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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

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Asthma Drug Therapy

• Long-term control medications
• Achieve and maintain control of persistent asthma
• Quick-relief medications
• Treat symptoms of exacerbations

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AsthmaDrug Therapy

• Bronchodilators
• ?-adrenergic agonists
• (e.g., albuterol, salbutamolVentolin)
• Acts in minutes, lasts 4 to 8 hours
• Short-term relief of bronchoconstriction
• Treatment of choice in acute exacerbations

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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

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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

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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

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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

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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

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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

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AsthmaPatient 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

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AsthmaPatient 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

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Nursing ManagementNursing Diagnoses

• Ineffective airway clearance
• Anxiety
• Ineffective therapeutic regimen management

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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

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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

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Nursing ManagementHealth Promotion

• Prompt diagnosis and treatment of upper
  respiratory infections and sinusitis may prevent
  exacerbation
• Fluid intake of 2 to 3L every day

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Nursing ManagementHealth Promotion

• Adequate nutrition
• Adequate sleep
• Take ?-adrenergic agonist 10 to 20 minutes prior
  to exercising

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Nursing ManagementNursing Implementation

• Acute Intervention
• Monitor respiratory and cardiovascular systems
• Lung sounds
• Respiratory rate
• Pulse
• BP

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Nursing ManagementNursing Implementation

• ABGs
• Pulse oximetry
• FEV and PEFR
• Work of breathing
• Response to therapy

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Nursing ManagementNursing Implementation

• Nursing Interventions
• Administer O2
• Bronchodilators
• Chest physiotherapy
• Medications (as ordered)
• Ongoing patient monitoring

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Nursing ManagementNursing Implementation

• An important goal of nursing is to decrease the
  patients sense of panic
• Stay with patient
• Encourage slow breathing using pursed lips for
  prolonged expiration
• Position comfortably

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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

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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

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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

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Nursing ManagementNursing Implementation

• Counseling may be indicated to resolve problems
• Relaxation therapies may help relax respiratory
  muscles and decrease respiratory rate

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Nursing ManagementNursing Implementation

• Peak Flow Results
• Green zone
• Usually 80-100 of personal best
• Remain on medications

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Nursing ManagementNursing Implementation

• Peak Flow Results
• Yellow zone
• Usually 50-80 of personal best
• Indicates caution
• Something is triggering asthma

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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