AsthmaChronic Airflow Limitation

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Asthma(Chronic Airflow Limitation)

• Julie C. Gentry
• RN, MSN

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Definition

• Asthma is an inflammatory disorder of the
  airways, which causes attacks of wheezing,
  shortness of breath, chest tightness, and
  coughing.
• Causes airflow into and out of the lungs to be
  restricted.
• Asthma is a reversible disease, characterized by
  intermittent attacks

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Pathophysiological Changes

• The muscles of the bronchial tree become tight
• The lining of the air passages swells, reducing
  airflow and producing the characteristic wheezing
  sound

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Asthma (Illustration)
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Asthma Inflammation
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Asthma Attack
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Has Both Intrinsic and Extrinsic Factors
(Triggers)

• Intrinsic
• Uncertain
• Physical stress
• Psychological stress
• Exercise-induced
• Respiratory infections

• Extrinsic
• Allergens
• Air pollutants
• Cold
• Medications (ASA and NSAIDS)
• GERD
• Tobacco smoke

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Exercise induced asthma
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Inflammatory Process

• Mast cells and WBCs respond to allergens
• Histamine
• Results in immediate inflammation
• Leukotriene
• Results in prolonged inflammation
• Both cause blood vessel dilation with capillary
  leakage edema of airways increased secretions
  increased mucous production

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Symptoms

• Wheezing
• Usually begins suddenly
• Comes in episodes
• May be worse at night or in early morning
• Gets worse with cold air, exercise, and heartburn
  (reflux)
• May go away on its own
• Is relieved by bronchodilators (drugs that open
  the airways)
• Cough with or without sputum (phlegm) production
• Shortness of breath that gets worse with exercise
  or activity, low 02 sats
• Intercostal retractions (pulling of the skin
  between the ribs when breathing)

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Additional symptoms that may be associated with
this disease

• Nasal flaring
• Chest pain
• Tightness in the chest
• Abnormal breathing pattern --breathing out takes
  more than twice as long as breathing in
• Breathing temporarily stops

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Emergency Symptoms

• Extreme difficulty breathing
• Bluish color to the lips and face
• Severe anxiety due to shortness of breath
• Rapid pulse
• Sweating
• Decreased level of alertness, such as severe
  drowsiness or confusion, during an asthma attack

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Retractions During Dyspnea

• Tripod
• Positioning while sitting

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Retractions During Dyspnea

• Note abdominal, supra-clavicular, supra-sternal
  retractions
• Can also be around and under the scapulae

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Barrel Chest (occurs due to air trapping)
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Diagnosis

• Determined by
• Frequency of attacks
• Severity of attacks
• Mild intermittent lt 2 x week
• Mild persistent gt 2 x week, lt 1 x day
• Moderate persistent daily
• Severe persistent continuous symptoms

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Diagnostic Tools

• ABGs
• Pulmonary Function Tests (PFTs)
• The most accurate test for asthma
• Chest x-ray
• Clinical presentation

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Pulmonary Function Test
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Pulmonary Function Test
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Goals of Medical Therapy

• Decrease the bronchospasms
• Bronchodilators
• Albuterol
• Decrease inflammation
• Anti-inflammatory agents
• Steroids
• Non-steroidal
• Increase oxygenation
• Administer 02

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Bronchodilators (increase bronchial smooth muscle
relaxation)

• Long-acting Beta 2 agonists
• Long term controllers
• Prevents attacks
• Longer-acting effects
• Takes time to build up effect
• Serevent
• Foradil

• Short-acting Beta 2 agonists
• Rapid acting rescue drugs
• Usually inhaled
• Short term effects
• Proventil
• Ventolin
• Albuterol (most common)
• Xopenex
• Most useful if taken before attack begins or as
  premedication prior to beginning an activity that
  may induce an asthma attack
• (RESCUE MEDICATION)

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Bronchodilators

• Anti-cholinergic agents
• Increased bronchodilation
• Decreased secretions
• Most common drug used is
• Atrovent
• Comes as inhaler, nasal spray, and nebulizer

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Bronchodilators

• Theophylline (Methylxanthines)
• Used when other types of management are
  ineffective
• Includes Aminophylline
• Given systemically, have many side effects and
  narrow therapeutic level
• Blood levels need to be monitored

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Anti-inflammatory Agents

• Decreases the inflammatory response to allergens
  and irritants
• Corticosteroids
• Some are given systemically
• Short term use
• Used for moderate-severe asthma
• More side effects
• Inhaled sprays (prophylactic)
• Flovent, Flonase and Pulmicort, Azmacort

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Non-steroidal Anti-inflammatory Agents

• Inhaled
• Prevents attack
• Cannot reverse an acute attack
• Tilade

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Leukotriene Antagonists

• Prevent asthma attack
• Oral agents
• Blocks leukotriene receptors
• Accolate, Singular and Zyflo

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Asthma Medications to the Rescue

• Asthma mediations fall into two categories
• Long-term or maintenance medications
• Immediate-relief or rescue medications

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Maintenance Medications

• Corticosteroids counteract inflammation
• Prednisolone, and prednisone (oral)
• Inhalers
• Vanceril
• Pulmicort
• Advair (Flonase)
• Azmacort

• Non-steroidal anti-inflammatory inhaled drugs
• Intal mast cell stabilizer (Nasalcrom)
• Tilade

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Maintenance Mediations (continued)

• Beta2 antagonists, which act as bronchodilators
  can be oral or inhaled
• Sustained release Albuteral (oral)
• Serevent (inhaled)
• Advair (inhaled)
• Methylxanthines
• Theophylline (IV or PO)

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Maintenance Meds (continued)

• Leukotriene modifiers and leukotriene antagonists
• Accolate
• Singulair
• Zyflo

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Rescue Medications

• Used to reverse bronchodilation in acute asthma
  attacks
• Short acting Beta 2 agonists
• Maxair
• Tornalate
• Brethine
• Xopenex
• Corticosteroids
• Methylprednisolone and prednisone
• Anticholinergic
• Atrovent

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Additional Drugs Used to Treat Asthma

• Rescue Inhalers (Nebulizer Metered Dose
  Inhailers -- MDIs)
• Atrovent (anticholinergic)
• Xopenex
• Steroids (Inhaled, po IV) Prednisone,
  Aerobid, Asmanex, Flonase
• Combination Drugs (Steroid/Bronchodilator)
  Advair

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Management Plan

• Includes
• Patient Education
• Drug Therapy
• Lifestyle Management including exercise

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Nursing Interventions

• Patient needs to identify triggers and avoid
• Teach proper use of inhalers
• Use chamber when possible
• Educate patient on symptoms that are an emergency

• Peak flow meter use 2x/daily to assess symptom
  severity (measures ability to push air out of
  lungs)
• Adjust drugs to manage inflammation and
  bronchospasms
• Tailored drug plan

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Oxygen Therapy

• Supplemental 02 often needed during attack
• Delivered via cannula, mask, or endotracheal tube
• May need high flow rates if severe bronchospasm

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Status Asthmaticus

• Severe, life-threatening acute episode of airway
  obstruction
• Becomes more intense once it begins
• Often does not respond to treatment
• Medial emergency, if not treated promptly can
  lead to respiratory and cardiac arrest

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Treatment of Status Asthmaticus

• Immediate IV fluids
• Potent IV bronchodilators
• Steroids
• Epinephrine
• Oxygen
• Prepare for emergency intubation if necessary