Chapter 28 Obstructive Pulmonary Diseases Flashcards
- Asthma is a heterogenous disease characterized by a combination of clinical manifestations along with?
- The variability of signs and symptoms can include episodes of?
- These episodes are associated with widespread but variable airflow obstruction that is usually reversible, either spontaneously or with treatment. The clinical course of asthma is unpredictable, ranging from?
- reversible expiratory airflow limitation or bronchial hyperresponsiveness.
- wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning.
- periods of adequate control to exacerbations with poor control of symptoms
What is asthma?
Asthma is a chronic inflammatory disorder of the airways that results in recurrent episodes of airflow obstruction that it is usually reversible
The primary pathophysiologic process in asthma is persistent but variable?
inflammation of the airways. The airflow is limited because the inflammation results in bronchoconstriction, airway hyperresponsiveness (hyperreactivity), and edema of the airways
1) Although the exact mechanisms that cause asthma remain unknown, often exposure to a trigger, such as an allergen or irritant, initiates the?
2) precipitating factors of an acute asthma attack.
3) Asthma is not a?
1) inflammatory cascade.
2) Respiratory infections are also precipitating factors of an acute asthma attack.
3) Asthma is not a psychosomatic disease.
Genetics and?
one’s immune responses may influence asthma development.
Common allergens include?
tree or weed pollen, dust mites, molds, furry animals, and cockroaches.
exercise-induced asthma
Asthma that is induced or exacerbated after physical exertion
Various air pollutants, cigarette or wood smoke, vehicle exhaust, elevated ozone levels, sulfur dioxide, and nitrogen dioxide can trigger asthma attacks. The role of outdoor air pollution as a cause of asthma is controversial.
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Occupational asthma occurs?
after exposure to agents in the workplace. These agents are diverse and include wood dusts, laundry detergents, metal salts, chemicals, paints, solvents, and plastics.
- Most patients with asthma have a history of?
- what is more common in persons with asthma?
- allergic rhinitis.
- Gastroesophageal reflux disease (GERD) is more common in persons with asthma.
Certain drugs may?
precipitate asthma
The characteristic clinical manifestations of asthma are?
wheezing, cough, dyspnea, and chest tightness, particularly at night or early in the morning. Expiration may be prolonged. Examination of the patient during an acute attack usually reveals signs of hypoxemia
Asthma can be classified as?
intermittent, mild persistent, moderate persistent, or severe persistent, based upon current impairment of the patient and their risk for exacerbations.
Severe exacerbations of asthma can result in complications such as?
severe hypoxia, “silent chest,” and peak flow less than 40% of personal best.
A diagnosis of asthma is usually made based upon the?
presence of various indicators (i.e., clinical manifestations, health history, spirometry, peak flow variability)
- The goal of asthma treatment is to?
- Established guidelines give direction on the classification of severity of asthma at initial diagnosis and help determine?
- achieve and maintain control of the disease.
- which types of medications are best suited to control the asthma symptoms.
Asthma: A stepwise approach to drug therapy is based initially on the?
- Persistent asthma requires?
- Even persons with intermittent asthma should always carry?
- asthma severity and then on level of control.
- long-term (controller) therapy in addition to appropriate medications to manage acute symptoms (rescue).
- rescue medication
Asthma Medications are divided into two general classifications:
(1) long-term–control medications to achieve and maintain control of persistent asthma
(2) quick-relief (rescue) medications to treat symptoms and exacerbations
Because chronic inflammation is a primary component of asthma, what drugs are used?
inhaled corticosteroids are more effective in improving asthma control than any other long-term drug. Inhaled (ICS) agents, such as fluticasone (Flovent) and budesonide (Pulmicort), are first-line therapy for patients with persistent asthma.
Orally administered corticosteroids are indicated for?
acute exacerbations of asthma. Maintenance doses of oral corticosteroids may be necessary to control asthma in a minority of patients with severe chronic asthma.
Short-acting inhaled β2-adrenergic agonists, including albuterol, are?
the most effective drugs for relieving acute bronchospasm. They are also used for acute exacerbations of asthma.
Long-acting inhaled β2-adrenergic agonists, including salmeterol (Serevent) and formoterol (Foradil), are?
never to be used as monotherapy in asthma due to an increased risk of death. However, they are quite safe when combined with ICS such as fluticasone/salmeterol (Advair) or budesonide/formoterol (Symbicort).
Leukotriene modifiers can be used in?
milder asthma successfully as add-on therapy to reduce the dose of inhaled corticosteroids.
The only anti-IgE drug, which is omalizumab (Xolair), is used for?
difficult to treat moderate to severe asthma unable to be controlled by inhaled corticosteroids.
Methylxanthine (theophylline) preparations are?
less effective long-term control bronchodilators as compared with β2-adrenergic agonists and carry a high incidence of side effects.
Anticholinergic agents are?
not used in asthma treatment, except for ipratropium (Atrovent), which is only used in the ED for acute attacks.
The overall goals are that the patient with asthma will have asthma control as evidenced by?
minimal symptoms during the day and night, acceptable activity levels (including exercise and other physical activity), maintenance greater than 80% of personal best peak expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEV1), few or no adverse effects of therapy, no recurrent exacerbations of asthma, and adequate knowledge to participate in and carry out management.
Asthma: Education remains the cornerstone of asthma management. Your role in preventing asthma attacks or decreasing the severity focuses primarily on?
teaching the patient and caregiver.
One of the major factors determining success in asthma management is the correct administration of drugs.
♣ Inhalation devices include?
♣ Teaching should include information about medications, including the?
♣ Several nonprescription combination drugs are available over the counter. An important teaching responsibility is?
♣ Inhalation devices include metered-dose inhalers, dry powder inhalers, and nebulizers.
♣ Teaching should include information about medications, including the name, purpose, dosage, method of administration, schedule, side effects, appropriate action if side effects occur, how to properly use and clean devices, and consequences for breathing if not taking medications as prescribed.
♣ Several nonprescription combination drugs are available over the counter. An important teaching responsibility is to warn the patient about the dangers associated with nonprescription combination drugs.
A goal in asthma care is to maximize the ability of the patient to safely manage acute asthma episodes via an asthma action plan developed in conjunction with the HCP. An important nursing goal during an acute attack is to?
decrease the patient’s sense of panic.
Develop written asthma action plans together with the patient and family, especially those with?
moderate or severe persistent asthma or a history of severe exacerbations.
Asthma
- What is it?
- common manifestation
- Chest?
- Cough
- Risk factors
- Chronic airway inflammation
- Wheezing
- Chest tightness
- Cough
- Risk factors
- Immune response
- Allergens
- Exercise
- Pollutants
- Occupational factors
- Respiratory infections
- Nose and sinus problems
Patho of asthma
- Bronchospasm
- Narrows air passage
- Airflow further interrupted by increased mucous
- Swelling of bronchial tubes
- In an attack- airflow decreases
- Trapping gas
- Alveoli hyper inflate
- Atelectasis can occur
- Increased airway resistance-
- Labored breathing
Diagnostic tests for asthma
1) Pulmonary function tests
- Reveal signs of obstructive airway disease, vital capacity
2) ABG’s
- Determines CO2
3) Chest xray
- Shows lung hyperinflation, atelectasis
4) Skin testing
- allergens
Asthma treatment
- Rapid acting epinephrine
- Long or short acting beta agonists- serevent/maxair
- Theophylline
- Corticosteroids
- Leukotriene receptor modifiers to block inflammation- Singular
The primary pathophysiologic process in asthma is persistent but variable airway inflammation. The airflow is limited because the inflammation results in?
Bronchoconstriction, airway hyperresponsiveness (hyperactivity), and airway edema. Exposure to allergens or irritants initiates the inflammatory cascade
1) As the inflammatory process begins, mast cells in the broncial wall release multiple inflammatory mediators including leukotrienes, histamine, cytokines, prostaglandins, and nitric oxide
2) Inflammatory mediators have effects on the (1) blood vessels, causing vasodilation and increasing capillary permeability (running nose) (2) nerve cells, causing itching (3) smooth muscle cells, causing broncial spasms and airway narrowing (4) goblet cells causing mucous production
3) the early phase response in asthma can occur within 30-60 minutes after exposure to a trigger or irritant
4) Symptoms can occur 4-6 hours after the early response because of the influx of many inflammatory cells and the further release of more inflammatory mediators. This late phase response occurs in about 50% of people with asthma
5) Bronchoconstriction with symptoms persist for 24 hours or longer. Corticosteroids are effective in treating this inflammation
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Asthma: Chronic inflammation may result in structural changes in the bronchial wall known as remodeling. A progressive loss of?
lung function occurs that is not prevented or fully reversed by lung therapy.
During an asthma attack, decreased perfusion and ventilation of the alveoli and increased alveolar gas pressure lead to ventilation perfusion abnormalities in the lungs.
- The patient is hypoxemic early on, with decreased partial pressure of CO2 in arterial blood (PaCO2) and increased pH caused by hyperventilation (respiratory alkalosis)
- As the airflow limitation worsens with air trapping, the PaCO2 increases to produce respiratory acidosis, which is an ominous sign of respiratory failure
Clinical manifestations of asthma
S/S differ for each patient. The most common manifestations include
cough, SOB, dyspnea, wheezing, chest tightness, and variable airflow obstruction. Presence of any of these (usually in combination) can indicate that an asthma episode or attack is occurring. Attacks may last for a few minutes to several hours.
Characteristic manifestations of asthma are?
Wheezing, cough, dyspnea, and chest tightness. Expiration may be prolonged, with an inspiratory/expiratory ratio of 1:3 or 1:4
Asthma: Wheezing is an unreliable sign to gauge the severity of an attack because?
Many patients with minor attacks wheeze loudly, whereas others with severe attacks do no wheeze
In some patients with asthma, what is the only symptom?
Cough. The cough may be non-productive because secretions may be so thick, tenacious, and gelatinous that their removal is difficult
During an acute asthma attack, the patient usually?
Sits upright or slightly bent forward, using accessory muscles of respiration. The more difficult the breathing becomes, the more anxious the patient feels
Asthma: Signs of hypoxemia include?
Restlessness, increased anxiety, inappropriate behavior, and increased pulse and BP
Asthma: Percussion reveals?
Hyperresonance of the lungs. Auscultation indicates inspiratory or expiratory wheezing
Asthma: Diminished breath sounds may indicate?
A significant decrease in air movement. Severely diminished breath sounds or a “silent chest” is an ominous sign, indicating severe obstruction and impending respiratory failure
Classification of asthma
Can be classified as intermitten, mild persistent, moderate persistent, or sever persistent. This system is used to determine the Tx. Patients may have different asthma classifications over the course of the disease.
Asthma complications
In severe asthma exacerbations, the patient is dyspneic at rest and speaks in single words because of the difficulty breathing.
- The patient is often agitated, sitting forward to maximize the diaphragmatic movement and using accessory muscles in the neck to lift the chest wall. Respiratory manifestations are?
- Prominent wheezing may progress to?
- rate may be >30 breaths/min and pulse >120 beats/min. The peak flow (PEFR [Peak expiratory flow rate]) is 40% of the patients personal best, or <150 mL
- no apparent wheezing if the airflow is exceptionally limited. The absence of a wheeze (i.e. silent chest) in a patient who is obviously struggling to breath is a life-threatening situation that may require mechanical ventilation
Asthma diagnostic studies:
Underdiagnosis of asthma is common. In general, the HCP should consider a diagnosis of asthma if various indicators (i.e. clinical manifestations, health history, peak flow variability, or spirometry readings) are positive.
- Detailed history helps to identify asthma triggers
- Spirometry determines the reversibility of bronchoconstriction and thus establishes the diagnosis of asthma
- Sputum specimen can be used to rule out bacterial infection
- Serum immunoglobulin E (IgE) levels and eosinophil count, when elevated, are highly suggestive of allergic tendency
- Chest X-Ray during an attack shows hyperinflation
- Spirometry, oximetry, and arterial blood gases (ABGs) provide information about the severity of the attack and response to treatment
- Allergy skin testing can be used to determine sensitivity to specific allergens
Interprofessional care for asthma
The goal of asthma treatment is to achieve and maintain control of the disease. At initial diagnosis, a patient may have severe asthma and require asthma medication. After treatment, the patient is assessed for?
- Achieving rapid control of the symptoms is the goal in order to return the patient to daily functioning at the best possible level. The level of control is determined by the?
- level of asthma control. The HCP steps down the medication as the patient achieves control of the symptoms or steps it up as the symptoms worsen
- patients spirometry results and any exacerbations or adverse treatment effects
Intermittent and persistent asthma
The classification of asthmas severity at initial diagnosis helps determine which types of medications are best suited to control the symptoms
- Patients in all classifications of asthma require a?
- Patients with persistent asthma must also be on a?
- for long-term control of moderate to severe persistent asthma, what medications are used?
- rescue medication for short-term, immediate control of symptoms. Short acting B2-adrenergic agonists (SABA) (e.d. albuterol, proventil, ventolin) are the most effective class of drugs used as rescue medications.
- long term or controller medication. Inhaled corticosteroids (ICSs) (e.g. fluticasone) are the most effective class of drugs to treat the inflammation.
- long-acting B-adrenergic agonists (LABAs) are added to daily ICS. ICSs are the most effective class of drugs to treat inflammation
Acute asthma exacerbations:
Asthma exacerbations may be mild to life-threatening. With mild exacerbations, patients have difficulty breathing only with activity and may feel that they “can’t get enough air”. What are the medications
Peak flow is >70% of personal best, and symptoms often are relieved at home promptly with an SABA such as albuterol delivered by a nebulizer or metered dose inhaler (MDI) with a spacer.
Acute asthma exacerbations:
With a moderate exacerbation, dyspnea interferes with usual activities and peak flow is 40-60% of personal best. In this situation, the patient usually comes to the ER or an HCP’s office to get help. Relief is provided with?
SABA and oral corticosteroids. Symptoms may persist for several days even after corticosteroids are started. Oxygen can be used with both mild and moderate exacerbations.
Severe and Life-Threatening Asthma Exacerbations:
Management of the patient with severe and life-threatening asthma focuses on?
correcting the hypoxemia and improving ventilation. The goal is to keep the O2 saturation >/- 90%. Continuous monitoring of the patient is critical.
Severe and Life-Threatening Asthma Exacerbations:
Many therapeutic measures are the same as those for acute asthma. Repetitive or continuous SABA administration is provided in the emergency department (ED). Initially?
three treatments of SABA (spaced 20-30 min. apart) are given. Then more SABA is given depending on the patient’s airflow, improvement, and side effects from the SABA.
Severe and Life-Threatening Asthma Exacerbations:
In life-threatening asthma, what medications are given?
IV corticosteroids are administered and are usually tapered rapidly. IV corticosteroids (methylprednisolone) are administered every 4-6 hours. Adjunctive medications such as IV magnesium sulfate may be administered for bronchodilation in patients with very low forced expiratory volume at 1 minute (FEV1) or peak flow (<40% of predicted or personal best at presentation) or those who fail to respond to initial treatment.
Severe and Life-Threatening Asthma Exacerbations:
Supplemental O2 is given by?
mask or nasal prongs to achieve a PaO2 of at least 60mm Hg or an O2 saturation >90%
Asthma: Occasionally, asthma exacerbations are life-threatening, with impending respiratory arrest. The patient requires?
intubation and mechanical ventilation if there is no response to treatment. The patient is provided with 100% oxygen, hourly or continuously nebulized SABA, IV corticosteroids, and other adjunctive therapies
Asthma drug therapies:
A stepwise approach to drug therapy is based initially on asthma severity and then on level of control. Persistent asthma requires daily long-term therapy in addition to appropriate medications to manage acute symptoms. Medications are divided into two general classifications
1) Quick-relief or rescue medications to treat symptoms and exacerbations, such as SABAs
2) Long-term control medications to achieve and maintain control of persistent asthma such as ICS. Some of the controllers are used in combination to gain better asthma control (e.g fluticasone/salmeterol)
Asthma patient teaching:
Patient teaching about medications should include?
- Name
- Purpose
- Dosage
- Method of administration
- Schedule (taking into consideration ADLs such as bathing) that require energy expenditure and thus oxygen
- Also include side effects, appropriate actions for side effects, and how to properly use and clean devices
Nursing management for asthma
The patient with asthma will have minimal symptoms during the day and night, acceptable activity levels (including exercise and other physical activity), greater than 80% of personal best PEFR, few or no adverse effects of therapy, no acute exacerbations, and adequate knowledge to participate in and carry out the plan of care.
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Asthma nursing diagnosis
- Ineffective airway clearance
- Anxiety
Nursing interventions for asthma
A goal in asthma care is to maximize the patient’s ability to safely manage?
acute asthma exacerbations via an asthma action plan developed in conjunction with the HCP
Nursing interventions for asthma
The patient can take 2-4 puffs of an SABA every 20 minutes three times as a rescue plan. Depending on the response with alleviation of symptoms or improved peak flow, continued SABA use and/or oral corticosteroids may be a part of the home management plan. If symptoms persist or if the patient’s peak flow is <50% of the personal best, the?
HCP or emergency medical services need to be immediately contacted