ASTHMA

ASTHMA

 Introduction- Asthma is a chronic

inflammatory disease of the airways that
causes hyperresponseveness, mucosal
edema and mucus production.
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 This inflammation ultimately leads to
recurrent episodes of asthma symptoms
such as cough, chest tightness,
wheezing and dyspnoe.
 Asthma can occur at any age and it is
the most common chronic disease of
childhood.
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Definition
 Asthma is a chronic inflammatory disorder of
the airways that is characterized by an
exaggerated bronco constrictors response to
a wide variety of stimuli.
 Asthma is a reversible airway obstruction
characterised by recurrent attacks of
wheezing and dyspnoea.
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 It is an inflammatory disorder of the
airway which causes attacks of
wheezing, shortness of breath, chest
tightness and coughing.
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 It is an inflammatory condition
of the bronchiole airway, which
causes the normal functioning of
the airway to become excessive
and over reactive, producing
increased mucus levels, mucosal
swelling and muscle contraction.
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Classifications of asthma

i. Extrinsic, Allergic or Atopic asthma: -

This is the type of asthma with a definite
external cause.
 It occurs mostly in atopic individuals who show
positive skin-prick reaction to common
inhalant allergens.
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 It starts in childhood and is caused by
allergens like pollen, dust, animal
dander, feathers, foods etc. patients
usually have a history of asthma or
allergies in the family, past medical
history of eczema or allergic rhinitis is
also common.
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Intrinsic or Non allergic Non Atopic Asthma: - This
occurs where no causative agent can be identified.

 It’s non allergic and occurs secondary to respiratory

tract infections.

 It develops in adulthood with no history of asthma in

the family.

 This can be more severe than atopic Asthma.

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 Mixed Asthma – this is a combination
of extrinsic and intrinsic asthma
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 COMMON FACTORS THAT MAY TRIGGER AN

ASTHMATIC ATTACK

1.Environmental factors

- Change in temperature especially cold air

- Change in humidity dry air

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2. Atmospheric pollutants

- Cigarette and industrial fumes

- Ozone sulphur dioxide

- Formaldehyde
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3. Strong odors

- Perfume
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4. Allergens bring about exaggerated IgE response to
certain allergens, it brings about spasms within the airway

- Feathers

- Animal dander

- Dust mites

- Mold

- Salads shellfish

- Fresh and dried fruits

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5. Exercise- vigorous exercises cause an
individual to breathe through the mouth in order
to respond to the body’s increased oxygen
demand. This will allow intake of cold air which
will cause muscle spasms.
6. Stress and emotional upset – stress
stimulates the Vegas nerve causing increased
secretions.
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7. Medication

- Nosteroidal anti-inflammatory Drugs( NSAIDS)

Aspirin drugs they bring about altered
sensitivity to leukotrienes and abnormal
release of cytotoxic compounds that constrict
the airway.
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- Beta blockers-they block the sympathetic
drive resulting in bronchoconstriction.

- Cholinergic – They bind to airway muscarinic

receptors to trigger bronchoconstriction,
mucus secretion and inflammation.
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8. Chemicals (as a result of high
concentration of irritating and reaction)

- Toluene

- Paints

- Rubber

- Plastics
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Factors associated with asthma
May be intrinsic or extrinsic
Intrinsic factors
a. Infections
 Viral RTIs
b. Psychological factors
 Sudden emotional stress.
c. Genetic
 Family history of allergy, parents, siblings, close
relatives.
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Extrinsic factors
a. Allergens
b. House dust
c. Animal fur
d. Pollen
e. Moulds
f. Physical factors
 Cold weather
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Pathophysiology of asthma

 In asthma, the dominant physiological event leading to

clinical symptoms is airway narrowing and a subsequent
interference with airflow.
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 When the patient inhales a substance to
which he/she is hypersensitive, allergens
interact with the Immune Globuline IgE on
the mast cells.
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 This causes degranulation of the mast cells
in the bronchial walls leading to rupture of
mast cells releasing chemical mediators
such as histamine, bradykinin, leukotrienes
and prostaglandin.
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 These mediators of inflammation lead to
bronchoconstriction, increased vascular
permeability and leakage contributing to oedema
and mucous secretion.

 Mucosal thickening and airway swelling interferes

with air flow.

 Dyspnoea results as well as wheezing due to

mucus secretion and bronchospasm.
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 In persistent asthma a chronic and complex
response ensues, which is characterized by
an invasion of numerous inflammatory cells,
the transformation and participation of airway
structural cells and the secretion of an array
of cytokins, chemokines and growth factor.
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 This results in the formation of mucus
plugs, as well as structural changes such
as hypertrophy and hyperplasia of the
airway smooth muscles stimulating the
mucous membrane to secrete excessive
mucus, further narrowing the bronchial
lumen.
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Clinical manifestations
 Wheezing respirations which is whistling sound made
during expiration when the airways are blocked or
compressed.
 Expiration is forced and prolonged due to broncho
spasms, hyper inflated lungs and trapped alveolar air.
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 Dry cough or cough which may produce thick,
clear or yellow sputum.
 Chest tightness due to bronchial constriction

 Extreme anxiety due to breathlessness.

 Sweating(diaphoresis)- results from labored

respiration
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 Orthopnoea – difficulties in breathing that is relieved in the
upright position. Child fails to lie flat but rather maintain a
three point position.

 Peripheral cyanosis which is due to reduced oxygen in the

blood and this may indicate the onset of life- threatening
status asthmaticus and respiratory failure.
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 Dyspnoea due to thick mucus, mucosal oedema and
smooth muscle spasm causing obstruction of small
airways resulting in labored respiration
 Hypoxia due to reduced oxygen circulating in the
blood as result of reduced gaseous exchange.
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 Hypercapnia – greater than normal carbon dioxide in the
blood which results from difficulty in expirations as a
result of broncho spasm.

 Tarchycardia in attempt to compensate for hypoxia and

hypercapnoea

 If there is no response to treatment there is exhaustion

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Management

Medical Management

Aims

1. To prevent chronic symptoms

2. To maintain near normal pulmonary function

3. To prevent hypoxia.
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Investigations

 History of exposure to specific allergens

 Physical examination to reveal typical clinical

presentation.
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 Lung function test to establish a degree of
impairment, degree of obstruction and its
reversibility and also to establish baseline
ventilator function.
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 Chest x-ray will show possible hyperinflation with areas of
focal atelectasis.

 Skin sensitivity test done to identify allergen or other

triggers responsible for onset of asthma symptoms

 Arterial blood gas analysis- obtained to identify presence of

mild to severe hypoxemia and mild to severe respiratory
acidosis.
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 Haematological tests, Serum for IgE may
reveal elevated levels due to allergic
reaction.
 Full blood count will show increased
levels of WBCs in presence of an
infection.
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Treatment/Drugs
 Beta-adrenergic receptor agonist –are the best
drugs for relieving sudden attacks of asthma and
prevents attacks that might be triggered by
exercise.
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 Drugs used include rapid acting bronchodilators such as ;

 Salbutamol- this is the fastest and most effective, hence remain the
drug of choice. It is given through a nebulizer or orally 2gm TDS. Action
– selectively stimulate beta receptors producing bronchodilatation.

- Children 2- 6 years 1-2gm 3- 4 times daily.

- 6-12years 2mg 3-4 times daily

- 12- 18 years 2-4 mg 3-4 times daily

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- Side effects – tachycardia, Blood pressure changes,
nervousness, palpitation, muscle tremors, nausea, vomiting,
insomnia, dry mouth, headache.

- Nursing implication – should not be used in patients with

angina or cardiac disorders. Encourage the child to take the
drug even when feeling well.
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 Metaproterenol – stimulates beta adrenergic
receptors, producing bronchodilatation.
Increases mucocilliary clearance.
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 Aminophyline given intravenously. Action – relaxation of
bronchial smooth muscle and improve contractility of fatigued
diaphragm.

- Side effects – tachycardia, Blood Pressure changes,

arrhythmias, anorexia, nausea and vomiting, nervousness,
irritability, headache, muscle twitching, epigastric pain,
diarrhea, palpitation, insomnia.
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 Nursing implication- instruct child to lie down if they
experience dizziness.
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Corticosteroids
 Hydrocortisone
 Beclomethasone
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 Predinisolone given orally. Action- it has anti-
inflammatory and immunosuppressive effects.

 Decrease edema in bronchial airway thus decreasing

mucus secretion.

- Side effects- skin changes, osteoporosis, increased

appetite, obesity, immunosupression, catabolism, muscle
weakness.
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- Nursing implication – Advise child to take drug
on alternative days as it reduces side effects;
drug should be taken with food or milk in the
morning as it causes peptic ulcers.
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
Long acting bronchodilators- epinephrine given
subcutaneously, usually in emergency treatment of
an acute reaction.
 Dose 0.2- 0.5 as a single dose.

 Side effects- headache, dizziness, palpitation,

tremors, restlessness, hypertension and tachycardia.
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 Oxygen therapy 0.5 - 4 liters as prescribed

 Fluid therapy for hydration

 Antibiotics such as Amoxicillin 125- 250mg 8

hourly for 5 to 7 days.

 Modified postural drainage can also be done.

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Nursing care

Aims

 PRIMARY SURVEY / CARE DURING AN ACUTE ASTHMATIC

ATTACK

 An asthmatic attack should be treated as quickly as possible to

open airways.
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 A – Airway- in an asthmatic attack secretions tend to become viscous and
can plug airway.

 Intervention – The nursing role in improving breathing patterns and gas

exchange, is to help child assume a position of comfort, administer
medications as ordered and monitor for both therapeutic and adverse
effects of medications.

 Child should be nursed in an upright position well supported with pillows or

lean forward on the cardiac table.
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 Administer nebulised salbutamol 2.5 -5 gm or a short acting
medication such as aminophyline 250mg IV bolus over
10minutes or 750mg in 1 liter 10% dextrose over 8hours, and
50% dextrose to prevent hypoglycaemia as these patients lose
a lot of energy due to exhaustion caused by labored breathing.

 Administer steroids such as hydrocortisone 100mg

intravenously to reduce local oedema.
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 B – Breathing – assess for ventilation by looking at the chest movements
associated with breathing and also listen or feel for air being expired
through the nose and mouth.

 Child may present with slow laborious wheezing sound on expiration, there
will be use of accessory muscles such as abdominal muscles for breathing.

 Expiration is always more strenuous and prolonged than inspiration which

forces the child to sit upright and use every accessory muscle.
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 Intervention –Administer humidified oxygen by
nasal cannular at 2 liters /minute to ease breathing,
later adjust oxygen according to the patient’s vital
functions and Arterial Blood Gas measurements.
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 C – Circulation will not be altered but the partial oxygen pressure due to
altered gaseous exchange in the lungs.

 The child will have tachycardia due to impaired gaseous exchange in the
lungs. The pulse will be fast and thread.

 Intervention – commence intravenous fluids to rehydrate the child thus

improving circulation continue with oxygen therapy.
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SUBSEQUENT CARE

 Environment – Nurse child in a quiet, clean environment

near to Nurse’s bay for ease observation. The room should be
well ventilated and free from dust.

 It should contain all resuscitative equipment such as oxygen

cylinder; suctioning machine in case of child needs
resuscitative.
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 Position – Place the child in the semi fowler’s
position for maximum lung expansion and
encourage diaphragmatic breathing to allow enough
air intakes.
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 Psychological care- Create a therapeutic relationship with the child so
that the child can have confidence in you.

 Reassure the parents or guardians during an asthmatic attack to allay

anxiety.

 Provide comfort by being with the patient.

 Explain the disease process, the cause of the wheezing and labored
respiration to the mother to allay anxiety.
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 Allow the child to verbalize his fears to allay anxiety if the
child is old enough.

 Explain to the parents or guardians every procedure and

machines that are being used to promote cooperation.

 Explain the use the oxygen machine to allay fear and anxiety.

 Involve the relative in the care and explain what is happening

to the child to promote the sense of belonging.
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Observations
 Vital signs TPR and BP are done first as baseline data and the concurrently as
the condition dictates so as to detect deviations from normal.
 Observe for labored breathing, therapeutic effects, any changes in condition
whether improving or not and act accordingly.
 Observe for the color of the extremities for cyanosis and check for oxygen
flow, whether adequate or not.
 Observe for hydration status and maintain the input and output.
 Observe the general condition of the patient and institute measures
accordingly.
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 Hygiene – Wipe the child frequently to remove sweet as the child sweets
a lot due to labored breathing to promote comfort. Change linen whenever
soiled to make child comfortable and prevent bad odour.

 Fluids and nutrition- Give plenty of fluids to combat dehydration and

loosen secretions.

 Elimination – Monitor the urine output to ascertain the renal function.

Observe the bowel movement to rule out constipation.
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 Exercises/Rest – Help the child’s family to perform
diaphragmatic breathing to allow enough air intake.
Encourage the child to perform relaxation exercises as
needed. Plan activity and rest to minimize patient’s energy
expenditure as activity increases metabolic rate and oxygen
requirements.

 Medication – Administer drugs as prescribed and observe for

any adverse effects.
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 INFORMATION EDUCATION AND COMMUNICATION

• Teach the mother how to use an oral inhaler and caution her
about the possible adverse reactions associated with the
medications he is receiving.

• Show child how to breathe deeply. Instruct him how to cough

secretions accumulated overnight.
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• Teach the child and the family to avoid known
allergens and irritants such as smocking, dust
perfumes, fur and cold weather etc.
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• Emphasize the importance of taking only prescribed drugs as
certain drugs such as aspirin may precipitate an asthmatic
attack.

• Give the child plenty of fluids at to help loosen secretions and

maintain hydration.

• Encourage the mother to be giving the child well balanced diet

to prevent respiratory infection and fatigue.
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• Explain the importance of review dates so that the
child can be monitored.

• Teach the mother signs and symptoms of an

impending asthmatic attack and encourage them to
seek medical attention as soon as possible.
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COMPLICATION

1. Status asthmaticus- This is a severe asthmatic attack which cannot be

controlled with usual medications. This arises when impaired gas
exchange and heightened airway resistance increase the work of
breathing. Symptoms of acute asthmatic attack continue despite measures
to relieve them.

2. Respiratory failure- This is the impairment of the lung’s ability to

maintain balance between oxygen and carbon dioxide.
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3. Tention pnemothorax -This occurs due to rupture of the sub pleural bleb

4. Cardiac arrest- Occurs secondary to respiratory failure

5. Emphysema –Irreversible accumulation of air in the alveolar spaces due to

repeated asthmatic attacks which results in decrease in total breathing capacity.

6. Atelectasis- lung collapse due to accumulation of air in the alveoli.

7. Respiratory acidosis- due to increased lactic acid production by respiratory

muscles as a result of prolonged and increased work of breathing.
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 Assignment
 Chewe aged 8 years old boy, is brought to children’s ward with complaints
of sudden onset of difficulties in breathing and wheezing sounds which are
audible when the child exhales. Upon examination, the diagnosis of asthma
is made.

a. i. Define asthma 5 marks

 ii. With the aid of the diagram explain the functions of the respiratory
system 10 marks
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b. i. State three classifications of asthma 9
marks

 ii. State five triggers of asthma 15

marks

 iii. State five signs and symptoms of asthma 10

marks

c. Discuss the management of asthma 41

marks

d. State five complications of asthma 10

marks