Asthma

this is helpful for students who wants to know general outline of asthma ad its medical and nursing management.

1. NIRMAL KUMAR MEENA NURSING TUTOR, AIIMS , JODHPUR.

2. Definition Asthma is a chronic inflammatory disease of the airways characterized by hyper-responsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea.

3. Definition Patients with asthma may experience symptom-free periods alternating with acute exacerbations that last from minutes to hours or days. Asthma, the most common chronic disease of childhood, can begin at any age.

4. Incidence Asthma affects an estimated 25,000,000 indians every year and this number is likely to increase by 50 % by the year 2016. COPDs and asthma accounts for nearly 1.5 % of total disease burden in the country. Among adults, women have a 30 % greater prevalence of asthma than men.

5. TIGGERS OF ACUTE ASTHMA ATTACKS Allergen inhalation Animal danders ( e.g cats , mice) House dust mite Pollens Air pollutants Exhaust fumes Perfumes Cigrarette smoke Areosol sprays Viral upper respiratory infection Sinusitis Exercise and cold , dry air Stress Drugs Aspirin Non steroidal anti inlammatory drugs occupational exposure metal salts industrial chemical and plastics pharmaceutical agents food additives hormones/menses gastroesophageal relux disease

6. Triggers( Infection , Allergens Exercise) Mast cell degranulation Immunization activation (IL-4, IgE production) Bronchospasm Vascular congestion Mucus secretion Impaired mucociliary function Thickening of airway walls Vasodilation Increased capillary permeability Inflammatory mediators Bronchial hyperresponsiveness Airway obstruction Cellular infiltration ( Neutrophils , lymphocytes, eosinophilis ) Autonomic nervous system effects Airway Remodeling

7. classification symptoms Step 1 Mild intermittent Symptoms ≤2 times/wk Asymptomatic and normal PEFR between exacerbations Exacerbations brief (hours to days) Intensity of excerbations varies Step 2 Mild persistent Symptoms >2 times/wk but <1 times /day Exacerbations may affect activity Step 3 Moderate persistent Daily symptoms Daily use of inhaled short acting β 2 - agonist Exacerbations affect activity Exacerbations at least 2 times/wk and may last for days Step 4 Severly persistent Continual symptoms Limited physical activity Frequent exacerbations.

8. Clinical Manifestations

9. Clinical Manifestations cough (with or without mucus production), wheezing ( first on expiration, then possibly during inspiration as well). Asthma attacks frequently occur at night or in the early morning. An asthma exacerbation is frequently preceded by increasing symptoms over days, but it may begin abruptly. Chest tightness and dyspnea. Expiration requires effort and becomes prolonged. As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur. Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure, may occur.

10. Complications Status Asthmaticus Cor pulmonale Severe respiratory failure Death

11. Collaborative Care : Diagnostic History and physical examination Pulmonary function studies including response to bronchodilators therapy Peak expiratory flow rate Chest X-rays Measurement of ABGs or oximetry (if severe exacerbation) Allergy skin testing (if indicated) Nitric oxide levels

12. Collaborative therapy Mild intermittent or persistent asthma Identification and avoidance /elimination of triggers Desensitization (immunotherapy) if indicated Patient and family teaching Drug therapy Asthma action plan

13. Collaborative therapy STATUS ASTHMATICUS Sao2 monitoring ABG’s Inhaled β 2 - adrenergic agonists or anticholinergic agents O2 by mask or nasal prongs IV or oral corticosteriods IV fluids IV magnesium Intubation and assisted ventilation

14. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY Anti-inflammatory agents Mast cell stabilizers Anticholinergics Ig E antagonist Leukotriene modifiers Leukotriene inhibitor β – adrenergic agonists Methylxanthines

15. Medical Management PHARMACOLOGIC THERAPY Anti-inflammatory agents Corticosteroids e.g. hydrocortisone, methyprednisolone, prednisone Mast cell stabilizers e.g. Cromolyn , nedocromil Anticholinergics Short acting Ipratropium Long acting Tiotropium Ig E antagonist Omalizumab

16. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY Leukotriene modifiers Leukotriene receptor blocker e.g. zafrilukast , montelukast leukotriene inhibitor zileuton

17. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY β – adrenergic agonists Inhaled Albuterol ( Proventil , Proventil HFA) Bitolterol Formoterol ( Foradil Aerolizer ) Levalbuterol ( Xopenex ) Pirbuterol ( Maxair Autohaler ) Salmeterol ( Serevent Diskus ) Oral Albuterol ( Proventil , Volmax ) Terbutaline ( Brethine )

18. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY methylxanthines e.g. aminophylline, theolair, theo-24 combination agents ipratropium and albuterol fluticasone and salmeterol.

19. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY methylxanthines e.g. aminophylline, theolair, theo-24 combination agents ipratropium and albuterol fluticasone and salmeterol.

20. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY BRONCHODILATORS Three classes of bronchodilator drugs currently used in asthma therapy are β – adrenergic agonists , methylxanthines, anticholinergics.

21. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY BRONCHODILATORS Sympathomimetic bronchodilators dilate the airways of the respiratory tree, making air exchange and respiration easier for the client, and relax the smooth muscle of the bronchi

22. PHARMACOLOGIC THERAPY BRONCHODILATORS Side Effects Of Bronchodilators Palpitations and tachycardia Dysrhythmias Restlessness, nervousness, tremors Anorexia, nausea, and vomiting Headaches and dizziness Hyperglycemia Decreased clotting time Mouth dryness and throat irritation with inhalers

23. TREATMENT FOR ASTHMA QUICK RELIEF MEDICATIONS Bronchodilators Short-acting inhaled bronchodilators Anticholinergics Anti-inflammatory medications Systemic glucocorticoids

24. TREATMENT FOR ASTHMA LONG-TERM CONTROL MEDICATIONS Anti-inflammatory medications Inhaled or oral glucocorticoids Cromolyn ( Intal ); nedocromil ( Tilade ) Leukotriene modifiers Omalizumab ( Xolair ) Oral and inhaled bronchodilators Theophylline

25. NURSING ASSESSMENT Subjective data Important health information Past health history :allergic , sinusitis , or skin allergies; previous asthma attacks and hospitalization or intubation ; symptoms worsened by pollen, dander , feathers, mold, dust, inhaled irritants, weather changes, exercise, smoke, menses; gastrophageal reflux; occupational exposure to chemical irritants (e.g. paints, dust) Medications: use of and compliance with corticosteroids, bronchodilators, cromolyn, antibiotics; pattern and amount of short acting β-adrenergic agonist used per week; medications that may precipitate an attack in susceptible asthmatics such as aspirin, non steroidal anti-inflammatory drugs, β-adrenergic blockers.

26. NURSING ASSESSMENT Subjective data Functional health patterns Health perception–health management: family history of allergies or asthma; recent upper respiratory infection or sinus infection Activity exercise: fatigue decreased or absent exercise tolerance ;dyspnea, cough(especially at night), productive cough with yellow or green sputum or sticky sputum ; chest tightness , feeling of suffocation , air hunger , talk in sentences or words/phrases , sitting upright in order to breathe Sleep-rest: awakened from sleep because of cough or breathing difficulties, insomnia Coping-stress tolerance: emotional distress, stress in work environment or the home.

27. NURSING ASSESSMENT OBJECTIVE DATA General Restlessness or exhaustion, confusion, upright or forward-leaning body position Integumentary Diaphoresis, cyanosis (circumoral, nail bed), eczema Respiratory Nasal discharge, nasal polyps, mucosal swelling; wheezing, crackles , diminished or absent breath sounds, and rhonchi on auscultation ; hyperresonance on percussion ; sputum (thick, white, tenacious), ↑ work of breathing with the use of accessory muscles; intercostal and supraclavicular retractions; tachypnea with hyperventilation; prolonged expiration Cardiovascular Tachycardia, pulsus paradoxus, jugular venous distention, hypertension or hypotension, premature ventricular contractions

28. NURSING ASSESSMENT OBJECTIVE DATA Possible findings Abnormal ABC’s during attacks, ↓ O 2 saturation, serum and sputum eosinophilia, ↑ serum Ig E , positive skin tests for allergens, chest X-ray demonstrating hyperinflation with attacks, abnormal pulmonary function tests showing ↓ flow rates; FVC, FEV 1 , PEFR , and FEV 1 /FVC ratio that improve between attacks and with bronchodilators.

29. NURSING DIAGNOSIS Ineffective airways clearance related to bronchospasm , excessive mucus production, tenacious secretions and fatigue as evidenced by ineffective cough, inability to raise secretions, adventitious breath sounds.

30. NURSING DIAGNOSIS INTERVENTIONS AND RATIONALES Asthma management Determine baseline respiratory status to use as a comparison point. Monitor rate, rhythm, depth, and effort of respiration to determine need for intervention and evaluate effectiveness of interventions. Observe chest movement, including symmetry, use of accessory muscles and supraclavicular and intercostals muscle retractions to evaluate respiratory status. Auscultate breath sounds, noting areas of decreased /absent ventilation and adventitious sounds, to evaluate respiratory status. Administer medication as appropriate and/ or per policy and procedural guidelines to improve respiratory function. Coach in breathing /relaxation technique to improve respiratory rhythm and rate. Offer warm fluids to drink to liquefy secretions and promote bronchodialtion .

31. NURSING DIAGNOSIS Anxiety related to difficulty breathing , perceived or actual loss of control and fear of suffocation as evidenced by restlessness, elevated pulse , respiratory rate and blood pressure.

32. NURSING DIAGNOSIS INTERVENTION AND RATIONALES ANXIETY REDUCTION Identify when level of anxiety changes to determine possible precipitating factors. Use calm, reassuring approach to provide reassurance. Stay with patient to promote safety and reduce fear. Encourage verbalization of feelings, perceptions and fear to identify problem areas so appropriate planning can take place. Instruct patient in the use of pursed lip breathing and relaxation techniques to relieve tension and to promote ease of respirations.

33. NURSING DIAGNOSIS Deficient knowledge related to lack of information and education about asthma and its treatment as evidenced by frequent questioning regarding all aspects of long term management.

34. NURSING DIAGNOSIS INTERVENTIONS AND RATIONALES Asthma management Determine patient/family understanding of disease and management to assess learning needs. Teach patient to identify and avoids triggers as possible to prevent asthma attacks. Encourage verbalization of feelings about diagnosis, treatment and impact on lifestyle to offer support and increase compliance with treatment. Educate patient about the use of the peak expiratory flow rate (PEFR) meter at home to promote self management of symptoms. Instruct patient/family on anti inflammatory and bronchodilator medications and their appropriate use to promote understanding of effects. Teach proper technique for using, medication and equipment (e.g. inhaler, nebulizer, peak flow meter) to promote self care. Establish a written plan with the patient for managing exacerbations to plan adequate treatment of future exacerbations.