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Asthma, classification, diagnosis, complications, prevention, medical and nursing management

airway-under-asthma-attack

CLASSIFICATION

classification-of-asthma-severity

DIAGNOSIS

  • History and physical examination.
  • Pulmonary function studies including response to bronchodilators. A 12% improvement in forced expiratory volume in one second (FEV1) after inhaled administration of air beta-agonist bronchodilator implies a reversible airflow obstruction, that is, by definition asthma.

o   Peak expiratory flow rate. Decreased.

o   Functional Residual Capacity (FRC), Total Lung Capacity (TLC), and Residual Volume (RV) are increased because air is trapped within the lungs.

  • Chest X-ray.
  • Pulse oximetry and ABG. Pulse oximetry usually reveals low oxygen saturation. ABG results often show some degree of hypoxemia, with elevated partial pressure of arterial carbon-dioxide in severe cases.
  • Allergy skin testing if indicated.
  • Blood level of eosinophils amd IgE.

COMPLICATIONS

Main complication is status asthmaticus.

STATUS ASTHMATICUS

Status Asthmaticus is a severe, life-threatening complication of asthma that is refractory to usual treatment. It is an acute episode of bronchospasm that tends to intensify. With severe bronchospasm, the work load of breathing increases 5 to 10 times which can lead to acute cor-pulmonale (right sided heart failure resulting from lung disease). When air is trapped, a severe paradoxical pulse (i.e. drop in blood pressure > 10 mmHg during inspiration) develops as venous return is obstructed. Pneumothorax commonly develops. If status asthmaticus continues, hypoxemia worsens and acidosis begins. If the condition is untreated or not reversed, respiratory or cardiac arrest ensues.

Others are:

  1. Pneumothorax.
  2. Atelectasis.
  3. Pneumonia.
  4. Rib fractures.
  5. Pneumomediastinum.

MANAGEMENT

Essential component of asthma care is avoidance

Allergens and occupational factors are considered to be the most important triggers of asthma. For successful long-term management of asthma, these triggers must be identified and the prevention of exposures should be the first line of defence. Improvement in asthma symptoms occurs when allergen exposure is reduced.

Avoiding asthma triggers: Effective Environmental Control

  • Stop smoking and avoid exposure to second-hand smoke.
  • Use insecticides to eliminate cockroaches from the house (if the patient can stay away for some time).
  • Shake mattresses, pillows, bedspreads and blankets and expose them to the sun as often as possible.
  • Remove carpets from the bedroom; minimize number of stuffed toys for children and wash them weekly.
  • Avoid piling up books, toys, clothes, shoes and other items that accumulate dust in the bedroom.
  • When cleaning the house: Sprinkle the floor with water before sweeping to avoid raising dust, clean furniture with a damp cloth.
  • Wash the sheets and blankets on the patient’s bed weekly in hot water. A temperature of more than 130 deg F is necessary for killing house dust mites. Cold water and detergent/bleach wash is also acceptable.
  • If available, encase pillow and mattress with allergen impermeable cover.
  • If possible, avoid exposure to gas stoves and appliances that are not vented to the outside, fumes from wood burning appliances or fire places, sprays and strong odors.

Medical Management

Management of asthma is based on the severity of the disease.

Drug Therapy

Long term control medications:

ANTI-INFLAMMATORY DRUGS:
Corticosteroids-Hydrocortisone, Methylprednisolone, Beclomethasone, Flunisolide, Budesonide etc.

MAST CELL STABILIZER:
Cromolyn and nedocromil.

LEUKOTRINE MODIFIERS:
Zafirlukast, ziluton. Used only for prophylactic & maintenance therapy and not in acute asthma attacks.

IgE ANTAGONIST:
Omalizumab-prevents IgE from attaching to mast cells.

LONG ACTING INHALED β2-ADRENERGIC AGONISTS

Salmeterol and formoterol

METHYLXANTHINES:
Theophylline

Quick-relief Medications:

SHORT ACTING INHALED β2-ADRENERGIC AGONISTS:
Albuterol, metaproterenol, bitolterol, pirbuterol, terbutaline.

ANTICHOLENERGICS:
Ipratropium

Combination Agents:

Ipratropium and albuterol.
Fluticasone and salmeterol.
Budesonide and formoterol.

NURSING MANAGEMENT

Initially assess the client for clinical manifestations of airway distress. If present, they constitute an emergency that must be managed before a detailed history of the disease or other health problems is obtained.

Nursing diagnosis

Ineffective breathing pattern related to impaired exhalation and anxiety

  • Assess the client frequently, observing respiratory rate and depth.
  • Assess the breathing pattern for shortness of breath, pursed-lip breathing, nasal flaring, sternal and inter-costal retractions, or a prolonged expiratory phase.
  • Place the client in the fowler position and give oxygen as ordered.
  • Monitor ABG and oxygen saturation levels to determine the effectiveness of treatments.

Ineffective airway clearance related to increased production of secretions and bronchospasm

  • Assess the airway, if compromised, the client’s secretions may require suctioning.
  • Some clients may experience asthma as a result of pulmonary infection. So, monitor the color and consistency of the sputum and assist the client to cough effectively.
  • Encourage oral fluids to thin the secretions and to replace fluids lost through rapid respiration.
  • The humidity in the room may be increased slightly.
  • Postural drainage, lung percussion and vibration, expectorants, and frequent position changes are helpful if secretions are thick.
  • Give frequent oral care to remove the taste of secretions and remoisten the oral mucous membranes that have dried from mouth breathing.
  • Asthma medications as ordered.

Impaired gas exchange related to air trapping

  • Assess lung sounds every hour during acute episodes to determine the adequacy of gas exchange.
  • Assess skin and mucous membrane color for cyanosis.
  • Monitor pulse oximetry for oxygen saturation levels.
  • Administer oxygen as ordered to maintain optimal oxygen saturation.

Knowledge deficit related to use of inhaled and nabulized medications

  • Assess the client’s knowledge and ensure the proper use of nabulizer to ascertain whether the medication is entering the airway.
  • Client education guide and asthma action plan should be provided to the patient.

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