week 10-asthma Flashcards
Asthma Definition
- Reactive airway disease
- Chronic inflammatory disorder of the airways
Inflammation causes varying degrees of obstruction in the airways
Hyperresponsiveness causes bronchial constriction leading to narrowing of the airway - Asthma is reversible in early stages
Stages of Asthma:
very mild, mild, moderate, moderately severe & severe
stats
- 8.5% of Canadians over 12 diagnosed with asthma (Statscan, 2010)
- Major cause of hospitalization for children in Canada
- 6 in 10 people with asthma have poor asthma control
High morbidity due to:
in asthma
- Underdiagnosis and inappropriate therapy
- Limited access to health care
- Inaccurate assessment of control
- Delays in seeking medical help
- Inappropriate medical therapy
- Non-adherence to prescribed therapy
most common triggers of asthma attacks. Increased reactivity can last 2-3 weeks after the infection in normal and asthmatic people.
Resp infections are the
Triggers of Asthma Allergens
– Exaggerated immunoglobulin IgE response • Animal dander • Dust mites • Cockroaches • Pollens • Molds • Rodents
Triggers of Asthma Exercise
– Characterized by bronchospasm, SOB, coughing, and wheezing
– When exercising in cold or dry climates, breathing through a scarf or mask may decrease likelihood of symptoms
– Can pre-treat with reliever inhaler 15-30 minutes prior to activity
Triggers of Asthma Respiratory Infections
– Most common precipitating factor of an asthma exacerbation
– Inflammation increases airway hyper-responsiveness
Triggers of Asthma Nose and Sinus Problems
– Nasal problems include allergic rhinitis and nasal polyps
• Large polyps are removed for the client with asthma to have good control
– Sinus problems are usually related to inflammation of the mucous membranes
Triggers of Asthma Drugs and Food Additives
Asthma triad: nasal polyps, asthma, and aspirin sensitivity
– Sensitivity to aspirin and NSAIDs
– Wheezing develops in about two hours
– Sensitivity to salicylates
• Inhibit adrenergic stimulation of the bronchioles
– ACE inhibitors
• Produces cough, making asthma symptoms worse
– Beta-blockers
• Can cause increased bronchial tone resulting in bronchoconstriction
Triggers of AsthmaGastroesophageal Reflux Disease
Exact mechanism is unknown
Aspiration of stomach acid causes vagal stimulation and bronchoconstriction
Can exacerbate nocturnal asthma symptoms
Clients with hiatal hernia and prior ulcer or reflux history may have GERD as an asthma trigger
Triggers of AsthmaEmotional Stress
- symptoms can trigger asthma response
- ( leading to panic and anxiety)
- Extent of psychological factors in inducing and continuing acute exacerbation is unknown
Strong emotions can trigger an asthmatic response- crying, laughter, fear and anger can lead to hyperventilation & hypocapnia, which can cause airway narrowing.
Asthma
• Characteristics:
Chronic disease
o Airway obstruction
Wheeze, cough, SOB **Individual presentation varies!
o Inflammation
Mast cells & macrophages damage lung lining
o Hyperresponsiveness
Environmental irritants, infections, cold air, exercise
1 in 20 have asthma.
The incidence has increased 60% since 1980, no explanation for this drastic increase
Morbidity: school attendance, occupational choices, physical activities, and other aspect of life.
Severe Asthma: S&S
Wheezing **Not reliable in severe attacks** Cough, dyspnea Chest tightness, prolonged expiration Indrawing, retractions, tracheal tug Tachypnea, low O2 Sats Diminished breath sounds
Make sure pt takes a deep breath in order to properly assess for wheezes.
Resps >30, O2 sats
AsthmaDiagnostic Studies
• Detailed history and physical exam • Pulmonary function tests -Spirometry (including response to bronchodilators) • Peak flow monitoring • Chest x-ray • Allergy skin testing • ABGs (acute phase) Oximetry Spirometry Allergy testing Blood levels of eosinophils Sputum culture and sensitivity
Clinical suspicion of asthma should be confirmed by objective measures of pulmonary function showing reversible airway obstruction (after a bronchodilator), variable airflow limitation over time or airway hyper-responsiveness in all patients able to reproducibly undergo lung function testing.Canadian .
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AsthmaDrug Therapy
• Controller medications
o Achieve and maintain control of asthma
o Taken on a regular basis *even without symptoms
o Depends on whether asthma is mild, moderate or severe or exercise induced
• Reliever medications
o For quick relief of symptoms
o “rescue medication”
o Taken only as needed for symptom relief
• Bronchodilators
o Short-acting 2-adrenergic agonists (SABA)
• (e.g., salbutamol)
Onset of action in minutes, duration: 4 - 8 hours
Quick relief of bronchoconstriction
Treatment of choice in acute exacerbations
Side Effects: tachycardia, feeling anxious
Usually max of q 4h
- Used to prevent bronchospasm induced by exercise and other stimuli
- Overuse may cause rebound bronchospasm
- Too frequent use (>3 times per week unless for pretreatment for exercise) indicates poor asthma control
• Long-acting ß2 agonist bronchodilators (LABA)
Salmeterol (Serevent)
Longer-acting; 12 hrs.
Helpful for control of nocturnal asthma
Not to be used as a monotherapy
Used only in combination with an inhaled corticosteroid
Used for clients who continue to have break through symptoms and poorly controlled asthma despite taking inhaled corticosteroids
– Inhaled Corticosteroids (e.g., budesonide, fluticasone)
- First line therapy
- Suppress inflammatory response
- Inhaled route preferred
- Do not block immediate response to allergens, irritants, or exercise
- Taken daily, continue even without symptoms**
- Teaching Tips:
- Rinse mouth after use to prevent oral thrush (Candida) infection
- Inspect tongue regularly for whitish coating
Anti-inflammatory drugs
– Oral (PO) Corticosteroids
• e.g., Predisone
• Short term use for acute exacerbations, long term use for severe asthma not responsive to other treatment
• Suppresses immune system
• Has systemic effects***
• Long term treatment effects:
– Osteoporosis, hyperglycemia, increase risk of infection (masked), cataracts, poor wound healing
Combined inhaled corticosteroid and LABA
(e.g., fluticasone/Flovent and salmeterol/Serevent (Advair) Or Budesinide/Pulmicort and Formoterol/Oxeze ( Symbicort)
– For patients not well controlled on ICS alone
– 12 hour relief with bronchodilator
– LABAs NOT considered rescue medications but…
– *Symbicort recently approved as both a controller AND rescue medication **only as part of an individual’s asthma management plan
• Leukotriene Receptor Antagonist
o Eg: Montelucast (Singulair)
o PO medication taken daily to reduce inflammation
o May be used as monotherapy in mild cases of asthma
Proper use of puffer/ aerochamber
– Shake inhaler – Breathe out all the way – Give 1 puff, and inhale slowly – Hold breath as you count to 10 – Take additional breaths if required – Wait 1 minute between puffs – Use Ventolin(blue) puffer prior to Flovent (red or orange) puffer • Ventolin will open the lungs up so that Beclovent can reach deep into the lungs
Control the triggers:
Clean, dust free environment Isolate from people with URIs Take Ventolin puffs 15-30 min prior to exercise Avoid cold, dry air Take control of stress/ anxiety Pets may be triggers
seek medical help
Seek medical help:
Continuous coughing, wheezing unrelieved by Ventolin puffs, SOB
Tugging or indrawing present, severe chest tightness
Trouble speaking full sentences, difficulty walking and talking
Lips and nail beds are blue (call 911)
Evidence of Good Asthma ControlRNAO BPG: Asthma Fact Sheet (2004)
you are using your “short-acting” puffer less than 4 times per week (unless for exercise);
• you are having daytime asthma symptoms less than four times per week;
• you are having night time asthma symptoms less than once per week;
• you have normal physical activity levels;
• you have no absence from work or school related to your asthma; and
• asthma attacks are infrequent and mild.
Asthma Education
Education should include as a minimum, the following:
basic facts about asthma;
roles/rationale for medications;
device technique(s);
self-monitoring; and
Individualized asthma action plan**
See Canadian Lung Association website for sample
Indicators for Immediate Medical Attention
- respiratory rate greater than 25 breaths/min
- pulse greater than 110 beats/min
- accessory muscle use
- unable to complete a sentence between breaths
- person is distressed (fatigue, exhaustion) and agitated (if person says they are in trouble or anxious, or have an impending sense of doom)
- confusion and
- altered level of consciousness
What to do? Asthma Treatment Stat
- Place pt in high fowlers position
- Continuously monitor O2 sats-keep between 94-98%
- Auscultate chest* silent chest
- History of asthma, and meds in last 24 hours
- Give Ventolin(0.03ml/kg) and Atrovent (1ml) in 3ml NS via nebulizer mask
- Reassess lungs after treatment!
- Solumedrol IV stat, and q6h
- Pursed lip breathing may help
- Does the pt look tired, circumoral cyanosis, delayed cap refill?
- Bilateral sounds with good A/E, inspiratory or expiratory wheeze. *NO WHEEZING CAN BE BAD NEWS IF IT MEANS NO AIR ENTRY
- Prior admission to the ICU or intubation for asthma is an ominous sign
- Po dexamethasone or prednisone is ok if pt is not at risk for status asthmaticus.
Nursing Management- acute assessment
– Monitor respiratory and cardiovascular systems
• RR/HR/BP
• Peripheral circulation, skin temperature and colour
• Cyanosis: nail beds or circumoral
• Accessory muscle use
• Lung expansion
