Asthma- Mr Mulundano

KALULUSHI COLLEGE OF NURSING
Mr Mulundano M. L
BSCNs-UNZA
KCN-Lecture
ASTHMA

@KCN-Mulundano M. L
INTRODUCTION
Asthma is a chronic inflammatory
disease of the airways. This
inflammation leads to recurrent
episodes of asthma symptoms such
as cough, chest tightness, wheezing
and dyspnoea. Asthma differs from
other obstructive lung diseases in that
it is largely reversible either
spontaneous or with treatment.

@KCN-Mulundano M. L
GENERAL OBJECTIVES
• At the end of the lesson, you should
be able to manage a patient with
asthma.

@KCN-Mulundano M. L
SPECIFIC OBJECTIVES
At the end of the lesson, students should
be able to:
• Define asthma
• Outline the aetiology and types of asthma
• Outline the predisposing factors of asthma
• Outline common factors that trigger asthmatic
attacks
• Outline the pathophysiology of asthma
• State the signs and symptoms of asthma
• Describe the management of asthma

@KCN-Mulundano M. L
Contin..
• Define status asthmaticus
• Outline factors that contribute to status
asthmaticus
• Outline the pathophysiology
• State the signs and symptoms of status
asthmatic
• Describe the management of status
asthmaticus

@KCN-Mulundano M. L
DEFINITION
Asthma is a reversible chronic
inflammatory disease of the airways
characterised by widespread
narrowing of the bronchial airways,
paroxysms of wheezing and
dyspnoea.

@KCN-Mulundano M. L
AETIOLOGY AND
TYPES
Bronchial asthma may be
classified into:
1. Extrinsic (atopic)
2. Intrinsic (non atopic)
3. Combined asthma which is triggered
by both extrinsic and intrinsic

@KCN-Mulundano M. L
EXTRINSIC (ATOPIC)
ASTHMA
• This is caused by external agents eg
pollen, animal dander, etc
• It usually starts in childhood
• It has genetically determined
predisposition to developing atopic
hypersensitivity reactions to inhaled or
ingested extrinsic antigenic substances
(allergens) eg house dust

@KCN-Mulundano M. L
Contin..
• This atopic hypersensitivity reaction
is mediated by immunoglobulin E
(IgE) antibodies against the
provoking antigens/allergens

@KCN-Mulundano M. L
Aetiology and types
contin..
PREDISPOSING FACTORS TO
EXTRINSIC ASTHMA
1. Common allergens can predispose to or
cause asthma, these include:
– Animal dander
– Pollen
– Mould spores
– Feathers
– Some food stuff
– Some drugs eg aspirin(NSAID
hypersensitivity reaction)

@KCN-Mulundano M. L
Contin..
2. Asthma may be as a result of
inheritance

@KCN-Mulundano M. L
INTRINSIC (NON
ATOPIC) ASTHMA
• This usually develops later in adult
life (after 35 years) in individuals
without family history of atopic
hypersensitivity reactions

@KCN-Mulundano M. L
PREDISPOSING FACTORS
TO INTRINSIC ASTHMA
• Specific cause is not known, but it is
commonly associated with chronic
bronchitis. Often, the precipitating cause
is infection in the upper airway (eg in the
nose, sinuses) or lower airway (in the
bronchi or lungs)
• In intrinsic asthma, reaction is usually
caused by micro-organisms eg bacteria
infecting the bronchi. This means that
there is allergic reaction to specific micro-
organisms

@KCN-Mulundano M. L
COMMON FACTORS WHICH TRIGGER
OR EXACERBATE ASTHMATIC
ATTACKS
Secondary factors may perpetuate or
influence the frequency of the attacks.
These include:
• Allergic reactions which leads to
production of histamine thereby causing
an attack
• Strenous activities/exrecises as these
lead to fatigue and reduction in oxygen or
increases oxygen demand. This triggers
release of histamine from the bronchial
mucosa membrane

@KCN-Mulundano M. L
Contin..
• Respiratory tract infections such as
sinusitis, common cold, etc may
precipitate an attack
• Emotional stress- this can cause the
release of chemicals eg adrenaline
which cause vasoconstriction.
• Cold weather can also trigger the
release of histamine

@KCN-Mulundano M. L
Contin..
• Exposure to noxious fumes; eg
paints, chemicals, smoke,
perfumes, etc

@KCN-Mulundano M. L
• Key factors
–Allergen
–Dendritic cells
–Mast cells
–Immunoglobulin E (IgE)
–Eosinophils, neutrophils and
lymphocytes

@KCN-Mulundano M. L
PATHOPHYSIOLOGY OF
ASTHMA
• Triad:
– Bronchospasms
– Inflammatory response
– Bronchoconstriction
• Two phases;
– Early phases
– Late phase

@KCN-Mulundano M. L
• Individual inhales allergens eg pollen, animal
dander, etc or ingests allergen,
• Hypersensivity reaction occurs
– Cells that play a role in inflammation in asthma are
mast cells, eosinophils, neutrophils and
lymphocytes. Immunoglobulin E (IgE) have the
ability to attach to the surface of mast cells.

@KCN-Mulundano M. L
Pathophysiology
contin..
• When antigen eg pollen reaches the
mast cells, the immunoglobulin and
the antigen form complexes
(antigen antibody) resulting in the
release of some mediators

@KCN-Mulundano M. L
Contin..
• These chemicals include histamine, bradykinin,
prostaglandins and leukotrienes which
perpetuate the inflammatory response causing
increased blood flow, vasodilatation, fluid leak
from the vasculature (due to capillary
permeability) attraction of white blood cells to
the area, bronchial smooth muscle constriction
and excessive secretion of thick viscid mucus.
• These cause narrowing of the bronchi thus the
dyspnoea observed.
• With Chronic Exposure to allergens remodelling
takes place.

@KCN-Mulundano M. L
Illustrated
pathophysiology
Allergen
Dendritic cells
TH2 cells
Interleukins
Plasma B cells
IgE
Mast cells+IgE
Mast cells+IgE+Allergen
Histamine
Prostaglandines
Luekotriens
Bone marrow
Eosinophils
Asthmatic Attack
Delayed response Early response

@KCN-Mulundano M. L
Functions of chemicals
1. Histamine
– Smooth muscle contraction
– Blood vessels dilation
2. Leukotrienes
– Smooth muscle contraction
– Stimulate eosinophils production in the bone
marrow
3. Prostaglandins
– Vasodilation
– Vascular permeability
– Cytokines

@KCN-Mulundano M. L
CLINICAL FEATURES
OF ASTHMA
• Cough which may present with viscid
mucus or sputum due to irritation of the
airway
• Dyspnoea due to airway obstruction
caused by bronchial smooth muscle
constriction, vasodilatation and plugging
of the bronchi with thick viscid
mucus/sputum
• Chest tightness due to inflammatory
reaction that causes airway obstruction

@KCN-Mulundano M. L
Clinical features
contin..
• Wheezing – this is due to forcing air
out of the obstructed bronchi
• Chest pains due to the
inflammatory reaction
• Cyanosis – due to reduced tissue
perfusion caused by airway
obstruction.

@KCN-Mulundano M. L
MANAGEMENT
DIAGNOSIS AND INVESTIGATIONS
• History of s/s e.g. dyspnoea. Also history
of allergens and familial tendance
• During acute episodes, sputum and
blood tests may disclose increased
levels of Mast cells in the blood.
• There could also be increased serum
levels of immunoglobulin E

@KCN-Mulundano M. L
Management contin..
• Arterial blood gases show –
reduced oxygen partial pressure
and increased carbon dioxide partial
pressure.
• Chest x-ray to rule out other
respiratory infection

@KCN-Mulundano M. L
TREATMENT
1. Salbutamol inhaler - I puffy can
be given which is a bronchodilator.
2. Aminophylline - a bronchodilator
can be given intravenously to
relieve the attack fast.
3. Oxygen therapy – 0.5 to 1 litres
per minute to relieve the dyspnoea

@KCN-Mulundano M. L
Treatment contn..
4. Adrenaline – can be given when there
is severe allergic and anaphylactic
reaction in asthma. This acts as an
antihistamine
5. Anti-inflammatory – such as
hydrocortisone can be given
6. Antibiotics eg amoxyl can be given if
the attack has been caused by respiratory
infection

@KCN-Mulundano M. L
Management contin..
AIMS
• To relieve dyspnoea
• To improve oxygen tissue perfusion
• To prevent complications

@KCN-Mulundano M. L
Management contin..
ENVIRONMENT
• Nurse in a clean and well ventilated
environment to prevent infection which
can irritate the bronchi and worsen the
condition. The environment should be well
dusted to prevent worsening the condition
since dust can predispose or worsen an
attack.
• The environment should be free from
strong smells to prevent worsening the
condition

@KCN-Mulundano M. L
Management contin..
- Resuscitative equipment should be
within reach e.g. oxygen cylinder in
case patient needs oxygen
- Nurse in a warm environment to
promote recovery as cold
environment may precipitate or
worsen an attack
- Nurse close to the nurses’ table for
easy observations

@KCN-Mulundano M. L
Management contin..
ADEQUATE VENTILATION AND
POSITION
. Position the patient in a semi fowlers
position to promote lung expansion
when dyspnoeic.
. If dyspnoeic, administer oxygen 4 to
6 litres per minute in an adult.

@KCN-Mulundano M. L
Contin..
REST AND ACTIVITY
. In acute stage, pt. should be on
complete bed rest to prevent
increased demand for oxygen.
. As the condition improves, pt. can
do mild exercises

@KCN-Mulundano M. L
Management contin..
OBSERVATIONS
• Monitor vital signs; temperature, pulse
respirations and blood pressure 2 to
4hourly. High temperature may denote
infection. Check respirations to monitor
dyspnoea.
• Check for any cyanosis to determine
severity of the attack and monitor
response to treatment

@KCN-Mulundano M. L
Management contin..
• Check for restlessness which may
as a result of dyspnoea due to the
obstruction. Therefore, administer
oxygen.
.Observe the patient’s general
condition
• Check the level of diaphoresis
(profuse sweating)

@KCN-Mulundano M. L
Management contin..
PSYCHOLOGICAL CARE
. Explain the disease process to the
patient/caregiver as may be
apprehensive due to eg dyspnoea
. Pt. may be anxious due to the
dyspnoea, so explain the disease
process to alley anxiety
. Allow the patient to ventilate her fears
and concerns

@KCN-Mulundano M. L
Contin..
• Explain every procedure to allay
anxiety
• Answer questions truthfully to win
patient trust
• Act confidently to win patient trust
• If relatives are around, allow them in
to provide emotional support

@KCN-Mulundano M. L
Management contin..
HYGIENE
• Change soiled linen to promote comfort
• Wipe patient off the sweat to promote
comfort
• Ensure patient is nursed in a clean
environment to promote comfort
• When condition improves, give a bath for
comfort and improve blood circulation
• Assist with oral toilet to refreshen the
mouth and prevent infection

@KCN-Mulundano M. L
Management contin..
ELIMINATION
• Provide urinal/bed pan when need
arises to promote rest and reduce
the demand for oxygen by the
tissues

@KCN-Mulundano M. L
Management contin..
INFORMATION, EDUCATION AND
COMMUNICATION (IEC)
. Advise patient to avoid exposure to
environmental pollutants such as
fumes, dust, chemicals, etc that can
predispose to the condition

@KCN-Mulundano M. L
Management contin..
• Advise the patient to seek treatment for URTI
early to prevent recurrence of the condition
• Encourage intake of warm fluids as cold fluids
can cause an attack
• Encourage the patient to keep warm in winter
to prevent exacerbation of the condition
• Advise the patient to avoid overcrowded
places where she is at risk of URTI which can
lead to irritation of the bronchi

@KCN-Mulundano M. L
Management contin..
SUMMARY ON PREVENTION OF
ASTHMA
• Avoid badly ventilated and overcrowded
places
• Avoid cold, advise patients to keep warm
always
• Avoid foggy and dusty areas
• Keep away from industrial and mining areas
to avoid pollution

@KCN-Mulundano M. L
COMPLICATION OF
ASTHMA
• Status asthmaticus – this can
occur when asthmatic attack has
persisted and pt. not being able to
respond to conventional therapy.
• Atlectasis

@KCN-Mulundano M. L
DEFINITION
• This is severe asthma that does not
respond to conventional therapy
and lasts more than 24 hours

@KCN-Mulundano M. L
FACTORS CONTRIBUTING
TO STATUS ASTHMATICUS
• Infection
• Anxiety
• Nebulizer abuse
• Dehydration
• Hypersensitivity reaction to aspirin
• Non specific irritants

@KCN-Mulundano M. L
PATHOPHYSIOLOGY
• In status asthmaticus, there are a combination
of factors that include bronchial smooth
muscle constriction, swelling of bronchial
mucosa, and thickened secretions which are
persistent and contribute to bronchial
obstruction.
• There is ventilation perfusion abnormality that
results in hypoxemia and respiratory acidosis.
• The partial pressure of oxygen is reduced
while that of carbon dioxide is increased
meanwhile, the pH falls leading to respiratory
acidosis

@KCN-Mulundano M. L
CLINICAL
MANIFESTATIONS
• These are the same as in severe
asthma; laboured breathing,
dyspnoea, wheezing, etc. However,
with greater airway obstruction,
wheezing may disappear, a sign of
respiratory failure

@KCN-Mulundano M. L
MANAGEMENT
DIAGNOSIS AND INVESTIGATIONS
. History of patient being in severe
asthmatic attack for more than
24hours
. Arterial gas analysis – will reveal a
low partial pressure of oxygen, a high
partial pressure of carbon dioxide and
a low pH showing respiratory acidosis

@KCN-Mulundano M. L
TREATMENT
• Beta adrenergic agonists – such as albuterol are
given to patients in emergency settings
• Corticosteroids – such as hydrocortisone injection
can also be given to counteract the inflammation
• Oxygen administration – 4 to 6 litres per minute can
also be given
• If the levels of oxygen partial pressure in the arterial
blood is worsening, mechanical ventilation may be
necessary.
• Intravenous fluids can also be given for rehydration

@KCN-Mulundano M. L
NURSING CARE -
SPECIFIC
. Nurse pt. in an environment free
from respiratory irritants such as
pollen from flowers, cigarette smoke,
perfumes or odours from chemicals or
fumes.
. Position pt. in semi fowlers position
to promote lung expansion
.Nurse the pt. in a quiet environment
to promote rest

@KCN-Mulundano M. L
Nursing care contin..
• Monitor the pt. constantly; hourly, 2 hourly
or 4hourly, the first 12 to 24 hours or until
the status asthmaticus is halted. Check
the vital signs, temperature, pulse,
respirations and BP. Check the skin for
cyanosis, also assess the pt’s skin turgor
for signs of dehydration.
• Fluid intake is essential to combat
dehydration, to loosen secretions and to
facilitate expectoration.

@KCN-Mulundano M. L
REFERENCES
1. Berkow R. (1997), Merck Manual of
Medical Information, Home edition,
Merck and company, United States
2. Lewis S. etal (2004), Medical
Surgical Nursing, 6th edition,
Mosby, United States
3. Smeltzer S. C. and Bare B. G.
(1999), Medical Surgical Nursing,
9th edition, Lippincott, Washington

Asthma- Mr Mulundano

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