NIRMAL KUMAR

MEENA
NURSING TUTOR,
AIIMS , JODHPUR.
 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.
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.

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.

 TIGGERS OF ACUTE ASTHMA ATTACKS

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

Immunization activation Mast cell degranulation

(IL-4, IgE production)

Inflammatory mediators

Vasodilation Cellular infiltration

Increased capillary permeability (Neutrophils, lymphocytes, eosinophilis)

Bronchospasm
Vascular congestion
Mucus secretion Autonomic nervous system
Impaired mucociliary function effects
Thickening of airway walls

Airway
Bronchial hyperresponsiveness
Remodeling
Airway obstruction
classification symptoms
Step 1 Symptoms ≤2 times/wk
Mild intermittent Asymptomatic and normal PEFR between
exacerbations
Exacerbations brief (hours to days)
Intensity of excerbations varies

Step 2 Symptoms >2 times/wk but <1 times /day

Mild persistent Exacerbations may affect activity

Step 3 Daily symptoms

Moderate persistent Daily use of inhaled short acting β2 -
agonist
Exacerbations affect activity
Exacerbations at least 2 times/wk and may
last for days

Step 4 Continual symptoms

Severly persistent Limited physical activity
Frequent exacerbations.
Clinical Manifestations
 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.
Complications

 Status Asthmaticus

 Cor pulmonale

 Severe respiratory failure

 Death
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

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

Collaborative therapy
STATUS ASTHMATICUS
 Sao2 monitoring
 ABG’s
 Inhaled β2 - adrenergic agonists or anticholinergic agents
 O2 by mask or nasal prongs
 IV or oral corticosteriods
 IV fluids
 IV magnesium
 Intubation and assisted ventilation
MEDICAL MANAGEMENT

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

PHARMACOLOGIC THERAPY
Leukotriene modifiers

 Leukotriene receptor blocker

 e.g. zafrilukast , montelukast

leukotriene inhibitor

 zileuton
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)
MEDICAL MANAGEMENT

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

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

BRONCHODILATORS

Three classes of bronchodilator drugs currently

used in asthma therapy are β – adrenergic

agonists , methylxanthines, anticholinergics.

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

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
TREATMENT FOR ASTHMA
 QUICK RELIEF MEDICATIONS
Bronchodilators
 Short-acting inhaled bronchodilators
 Anticholinergics
 Anti-inflammatory medications
 Systemic glucocorticoids
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
 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-
 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
 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,
 NURSING ASSESSMENT
OBJECTIVE DATA

Possible findings

 Abnormal ABC’s during attacks, ↓ O2 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, FEV1 , PEFR , and FEV1 /FVC ratio that
improve between attacks and with bronchodilators.
 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.

 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.
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.

 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.
 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.

 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.