Asthma

Pneumothorax:

A pneumothorax is a collection of free air in the chest outside the lung that causes the lung to collapse.

The inflammatory response of asthma involves what mechanisms?

Activated immunologic response: This stimulates production of IgE. Increased airway resistance: Mucus fills the airway and inhibits the movement of air. Decreased lung compliance: Increased swelling of tissue makes it more difficult to expand lungs with inspiration. Impaired mucociliary function: Increased mucus production covers cilia and inhibits their sweeping motion. Altered gas exchange: Air doesn't reach alveoli and cannot take part in gas exchange, resulting in decreased PaO2; this may result in increased PaCO2.

Airborne antigens and chemical mediators

Airborne antigens bind to mast cells coated with immunoglobulin E (IgE) antibodies lining the airways Chemical mediators are released and cause bronchoconstriction, mucosal edema related to increased permeability of mucosal blood vessels, and increased mucus secretions, which lead to a decrease in the diameter of the airways.

Albuterol + Ipratropium

Albuterol (e.g., Ventolin, Proventil) is a fast-acting, beta2 agonist that acts to relax and open airways and increase ciliary movement to help clear secretions. It may cause shakiness, nervousness, tachycardia, and/or increased BP, so B.T. should be closely monitored. Ipratropium is an anticholinergic that causes bronchodilation and inhibits secretions without causing systemic anticholinergic effects.

what is asthma?

Asthma is a disease characterized by chronic inflammation—infiltration of lymphocytes, eosinophils, and neutrophils. It causes epithelial desquamation (thickening and disorganization of the tissues of the airway walls), smooth muscle hypertrophy, and fibroblast proliferation in the airway. Obstruction caused by these changes is usually reversible spontaneously or with medication.

Pollens and mold

Avoid the use of humidifiers because humidity promotes mold growth. If you must use one, change the water every day and clean the inside two to three times per week to prevent mold growth. Humidity in the air should stay below 50%. Ventilate bathrooms, basements, and other dark, moist places that commonly grow mold. Consider using a dehumidifier in basements to remove air moisture. Air conditioning removes excess air moisture, filters out pollens from the outside, and circulates air throughout your home. Filters should be changed once a month. Use a weak bleach solution to clean bathrooms, which are notorious for mold growth. Keep windows and doors shut during pollen season.

S/S of impending respiratory failure

Breathlessness at rest Muteness Inability to recline Respiratory rate greater than 30 breaths/min Paradoxic thoracoabdominal movement Few or absent breath sounds Relative bradycardia Absent pulsus paradoxus (systolic BP should increase by at least 10 points during inspiration) PEF less than 50% predicted SaO2 less than 91% PaO2 less than 60 mm Hg PaCO2 greater than 42 mm Hg

Cor pulmonale

Cor pulmonale is one of the complications of COPDand is caused by an increase in blood pressure in the pulmonary artery, the vessel that carries blood from the heart to the lungs. This leads to enlargement and subsequent failure of the right side of the heart.

To control irritants:

Don't smoke or allow others to smoke in the house. Don't burn wood fires in fireplaces or wood stoves. Avoid strong odors from paint, chemical cleaners, disinfectants, perfume, and glues.

To control dust mites:

Don't use feather or down pillows and comforters; only use synthetic polyester fill. Encase pillows, mattresses, and box springs in zippered dust mite-proof covers. Wash sheets and blankets once a week in very hot water to kill dust mites. Dust and vacuum weekly. If possible, use a vacuum cleaner with a high-efficiency particulate air filter to collect and trap dust mites; use washable throw rugs and wash them in hot water weekly. Reduce the number of dust-collecting houseplants, books, and nonwashable knickknacks.

Asthma can be caused by

Either extrinsic (atopic or type 1 hypersensitivity) or intrinsic factors. Extrinsic factors include an allergic response to environmental allergens, such as dust mites, pollen, molds, and animal dander. Intrinsic factors may be related to viral respiratory infections; medications, such as aspirin, nonsteroidal anti-inflammatory drugs, or beta-adrenergic antagonists; or an irritant, such as chemicals or secondhand smoke.

Fluticasone!!!

Fluticasone is an inhaled steroid that decreases the inflammation of the airways, thereby reducing swelling, mucus production, and spasm in/of the airways. It decreases sensitivity of airways to irritants and allergens. There are few systemic effects because there is minimal systemic absorption. This drug should be used regularly and should not be used for fast relief of SOB.

Discharge teaching for asthma ptn

Have his wife join him if he'd like before giving B.T. any instructions. Review and reinforce the information given by the physician for the benefit of B.T. and his wife. The physician told B.T. that his inhalers are OK for day-to-day control but they act slowly and are not adequate to open his airways during an asthma attack. The physician gave B.T. a prescription for a fast-acting inhaler to help him open his airways and advised him to see a pulmonary specialist in the clinic. Encourage B.T. and his wife to make and keep the pulmonary clinic appointment. Educate the patient and wife on medications, dosage, and use. Demonstrate both MDI/spacer and peak flow techniques. Have a written plan for exacerbations. Have B.T. keep a journal to identify triggers (heat, humidity, cold, dry air, dust, animal dander, different pollens, perfumes, etc.). Once the patient is aware of the diagnosis, triggers become more evident.

Animal dander

If allergic to a pet, it might be advisable to find a new home for the animal. It may help to wash the animal at least once a week to remove excess dander.

4 categories of asthma:

Intermittent: The patient experiences cough and shortness of breath or wheezing on 2 days of the week or less and on less than 2 nights per month. Mild persistent: daytime symptoms more than twice per week but less than once per day. In general, nighttime symptoms occur more than twice per month. Experiences minor limitations of normal activity due to symptoms. Moderate persistent: Asthma symptoms every day and on more than 1 night per week. Experiences some limitations of normal activities due to symptoms. Severe persistent: Continuous daytime symptoms and frequent nighttime symptoms. Extreme limitations of normal activity due to symptoms.

Ipratropium bromide!!!

Ipratropium bromide is an anticholinergic that relaxes smooth muscles (bronchodilation) but takes effect more slowly than fast-acting, beta2 agonists, such as albuterol. Ipratropium may cause headache, nervousness, or dry mouth.

radioallergosorbent test

May include a radioallergosorbent test for an elevation of allergen specific IgE and a complete blood cell count for an elevated eosinophil count, both of which may indicate the patient is experiencing asthma due to an allergic response.

Pursed lip breathing

Pursed lip breathing is one of the simplest ways to control shortness of breath. It slows the pace of breathing, narrows the airway, moves "old air" out, and each breath is more effective. What does pursed lip breathing do? Improves ventilation Releases trapped air in the lungs Keeps the airways open longer and decreases the work of breathing Prolongs exhalation to slow the breathing rate Improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs Relieves shortness of breath Causes general relaxation

Pursed lip breathing technique

Relax your neck and shoulder muscles. Inhale slowly through your nose for two counts, keeping your mouth closed. Don't take a deep breath; a normal breath will do. It may help to count to yourself: inhale, one, two. Pucker or "purse" your lips as if you were going to whistle or gently flicker the flame of a candle. Exhale slowly and gently through your pursed lips while counting to four. It may help to count to yourself: exhale, one, two, three, four.

Interventions

Remove or loosen constrictive clothing. Promote a quiet environment with minimal stimulation. Initiate albuterol treatment as ordered to relieve bronchoconstriction and increase ciliary efficiency. Give cool mist nebulized albuterol with saline. There is some debate that an MDI of albuterol with spacer is as effective as the nebulizer. Elevate the HOB or have B.T. sit in a chair to promote maximum lung expansion. Give supplemental O2 to relieve hypoxemia. Hydration will help thin pulmonary secretions and facilitate expectoration. This can be achieved by increasing the IV rate and encouraging PO fluids. Coach B.T. to cough effectively to facilitate airway clearance. Coach B.T. in pursed-lip breathing to increase pressure throughout the airways and facilitate expiration.

Diagnostic tests

Spirometry sputum and nasal cytology bronchial methacholine challenge test, skin sensitivity tests chest X-ray

signs and symptoms include:

Sudden dyspnea, wheezing, and tightness in thechest. diminished breath sounds Coughing thick, clear, or yellow sputum rapid pulse Tachypnea use of accessory muscles for breathing.

FEV1

The FEV1 value indicates the patency of large airways and measures the amount of air forcefully exhaled during the first second of the effort. : It gives some indication of large and small airways.

FVC

The FVC value indicates the degree of lung and chest expansion. : It measures the total amount of air that can be blown out as rapidly and forcefully as possible.

Patient education

The nature of asthma as a chronic inflammatory disease The purpose and action of each medication Triggers to avoid, including information about types of indoor and outdoor allergens that can aggravate asthma, and how to do so. Environmental control measures that limit allergens and irritants are imperative. Teach your patient how to control dust mites, pollen and mold, animal dander, and other irritants.

Treatments based on categories of asthma

Use a "step up" or "step down" approach Step 1. If a patient is diagnosed as having intermittent asthma, a short-acting beta2-agonist may be used to control symptoms. Step 2. If a patient has mild persistent asthma, treatment should include a low- to medium-dose inhaled corticosteroid. Step 3. If a patient has moderate persistent asthma, treatment should include a low- to medium-dose inhaled corticosteroid and a long-acting inhaled beta2-agonist. A leukotriene modifier may be added if the patient is unable to tolerate a beta2-agonist or if he/she doesn't respond to treatment. Step 4. At this stage, the patient may be given recombinant humanized monoclonal anti-IgE antibody if she meets the criteria of hospitalizations and exacerbations in 1 year. A patient at this stage should be referred to specialty care.

Long-term control medications

Used to achieve and maintain control of persistent asthma symptoms. Inhaled corticosteroids (ICSs)—most effective medications for longterm control of asthma. Long-acting beta2-agonists—may be used as combined therapy with ICSs for control of moderate or severe persistent symptoms. Cromolyn sodium or neocromil—not considered preferred treatment, but may be used as an alternative treatment for mild persistent asthma symptoms. Leukotriene modifiers—not considered preferred therapy, but may be used as an alternative treatment for moderate persistent symptoms.

Quick relief medications

Used to treat acute symptoms and exacerbations of asthma. •Inhaled short-acting beta2-agonist—treatment of choice for acute symptoms. Anticholinergics—used in the emergency care setting and may be beneficial when administered concomitantly with an inhaled short-acting beta2-agonist. Systemic corticosteroids—used for moderate and severe asthma exacerbations.

The ratio of FEV1/FVC indicates

how much of the FVC is blown out during the first second. A reduced FEV1/FVC ratio (less than 80%) may indicate airway obstruction. Spirometry also allows the healthcare provider to evaluate the progression of the disease.

Nursing care priorities for late stage asthma response

include monitoring her respiratory and cardiovascular function, assessing her work of breathing, notifying the physician if her condition deteriorates, administering oxygen and drugs as prescribed, and evaluating Mrs. S.'s response to treatment. Monitoring respiratory and cardiovascular function requires assessment of lung sounds, pulse rate, respiratory rate, and blood pressure, in addition to monitoring ABGs, pulse oximetry, FEV1 (forced expiratory volume), and PEFR (peak expiratory flow rate). Another priority is to decrease Mrs. S.'s sense of panic, helping her to relax and encouraging slow, pursed-lip breathing.

A bronchial methacholine challenge test :

is performed by giving the patient a nebulized inhalation of methacholine in increasing doses in an attempt to produce at least a 20% drop in FEV1.

Sputum and nasal cytology

may be used to determine if nasal eosinophils and sputum mast cells are elevated, typically seen in airway hyperresponsiveness.

Spirometry

measures forced vital capacity(FVC), forced expiratory volume in 1 second (FEV1), and FEV1/FVC values.

late-phase response in asthma

peaks 5 to 6 hours after the initial trigger of an asthma attack. When Mrs. S. was admitted earlier, she was experiencing an early-phase response of asthma characterized by bronchial smooth muscle constriction, mucus secretion, and mucosal edema that responded to treatment with the bronchodilator albuterol. The late-phase response occurring hours later is characterized by inflammation with infiltration of the airways by eosinophils and neutrophils. The cells subsequently release mediators that cause mast cells to release histamine and other mediators that eventually set up a self-sustaining cycle of bronchial hyperreactivity and inflammation. Bronchodilators are not as effective at this point because the primary problem is inflammation.

In a skin sensitivity test,

small amounts of suspected allergy causing substances are placed on a scratched area of the patient's skin or injected to determine allergic reaction.

Complications in late phase asthma response case may include:

status asthmaticus, in which the manifestations she is experiencing become more severe and more prolonged; hypoxemia resulting in hypertension, sinus tachycardia, and ventricular arrhythmias; pneumothorax; Pneumomediastinum; Air leaks from any part of the lung or airways into the mediastinum. Most often, one of the small air sacs (alveoli) ruptures and leaks air. acute cor pulmonale with right ventricular failure; and severe respiratory muscle fatigue leading to respiratory arrest.

A discharge plan for Mrs. S. should include establishing her as an active partner in the management of her asthma. Review and instruction related to the following topics should be included in her discharge teaching:

the pathophysiology of asthma, especially early and late responses the relationship of pathophysiology to signs and symptoms problems in asthma treatment and control correlation of pulmonary function tests and peak expiratory flow rate identification and avoidance of triggers the need to maintain good hydration types and mechanisms of actions of her prescribed medications establishment of a medication schedule correct use of metered-dose inhaler, spacer, and nebulizer breathing techniques of pursed-lip breathing and diaphragmatic breathing correct use of peak flow meter•

Proper inhaler technique

use spacer take slow, deep breath angle inhaler to spray straight back to throat hold breath for 10sec clean inhaler after each use rinse mouth after using steroid inhaler

Immunotherapy

used as an alternative therapy for patients 12 years of age and older with severe persistent symptoms. Requires referral to a specialist.

The acute or early response of asthma typically occurs ...

within 10 to 20 minutes of exposure to an allergen.