management of asthma

1. MR.GOPAL ,..MSC (N),
MEDICAL SURGICAL NURSING
ASSISTANT PROFESSOR
GANGA COLLEGE OF NURSING
COIMBATORE

3. CONTENT OVERVIEW
• Introduction
• Anatomy & physiology
• Definition
• Incidence
• Etiological factors
• Types of asthma
• Stages of Asthma
• Pathophysiology
• Signs & symptoms
• Diagnostic evaluation
• Complication
• Management

4. INTRODUCTION
Bronchial asthma is a medical condition which
causes the airway path of the lungs to swell and
narrow. The disease is chronic and interferes with daily
working. The disease is curable and inhalers help
overcome asthma attacks.
Bronchial Asthma can affect any age or gender
and depends upon environmental and hereditary
factors at large. When ignored, disease proves fatal
claiming lives in many cases.

5. ANATOMY & PHYSIOLOGY

6. DEFINITION
Bronchial asthma is a chronic , inflammatory
disease of the airways, characterized by airflow
obstruction, bronchial hyperactivity, and a mucous
production.

7. INCIDENCE
Worldwide, it is estimated that approximately
334 million people currently suffer from asthma, and
250,000 deaths are attributed to the disease each
year. The prevalence of the disease is continuing to
grow, and the overall prevalence is estimated to
increase by 100 million by 2025.

9. ETIOLOGY
• Genetic factors
• Environmental factors
a) House dust mites
b) Exposure to tobacco smoke.
c) Predisposed to animals, pollens mould and dust.
• Dietary changes – junk food and fast food
contain Mono-Sodium Glutamate

10. ETIOLOGY
• Atopic diseases – Eczema and allergic rhinitis.
• Maternal status – both physical and mental
conditions like anemia and depression in the mother
are associated with asthmatic stress for the child.
• Early antibiotic use – babies who are given
antibiotics may be 50% more likely to develop
asthma by the age of six

11. COMMON TRIGGERING FACTORS
Extrinsic (Allergic)
Triggers:
• Dust mites
• Mould
• Certain foods
• Animal dander
• Pollen
Intrinsic (Non-Allergic)
Triggers:
• Exercise & Stress
• Infections (cold and flu)
• Cold or humid air
• Medications (aspirin)
• Hormones & Air pollution
• Occupational irritants

12. TYPES OF ASTHMA

13. STAGES OF ASTHMA
The four stages of asthma are:
• Mild intermittent asthma: Mild symptoms of
asthma occur no more than two days per week or
two times per month.
• Mild persistent asthma: Mild symptoms occur
more often than twice per week.

14. • Moderate persistent asthma: Increasingly severe
symptoms of asthma occur daily and at least one
night each week.
• Severe persistent asthma: At this stage,
symptoms occur several times per day almost every
day. You may also experience symptoms many
nights each week. This stage of asthma may not
respond well to treatment.
STAGES OF ASTHMA

15. PATHOPHYSIOLOGY

16. SIGNS & SYMPTOMS
Common symptoms of asthma

17. MILD SYMPTOMS
1. Coughing
2. Mild difficulty breathing during normal activities
2. Wheezing
4. Difficulty sleeping
5. Hiccups
6. Peak expiratory flow rate (PEFR) is 70 to 90% of
personal best

18. MODERATE SYMPTOMS
1. Severe cough
2. Moderate wheezing
3. Shortness of breath
4. Chest tightness
• Usually worsens with exercise
5. Inability to sleep
6. Nasal congestion
7. PEFR is 50 to 70% of personal best
8. Clubbing of finger

19. SEVERE SYMPTOMS
1. Severe wheezing
2. Severe difficulty breathing
3. Inability to speak in complete sentences
4. Inability to lie down
5. Signs of severe difficulty breathing
 Rib retractions: ribs are visible during each breath
 Nasal flaring: nostrils open wide during each breath
 Use of accessory muscles: neck muscles are prominent
during each breath

20. SEVERE SYMPTOMS
6. Chest pain
Sharp, chest pain when taking a breath, coughing
7. PEFR is <50% of personal best
8. Confusion
9. Rapid pulse
10. Fatigue
11. Rapid breathing rate

21. DIAGNOSTIC EVALUATION
• The Medical history
• Physical Examination
• Differential Diagnosis
• Laboratory Investigations

22. HISTORY COLLECTION
• A complete family history
• Environmental Factors
• occupational history is essential.
to establish the diagnosis

23. PHYSICAL EXAMINATION
• Hyper-expansion of the thorax
• Sounds of wheezing during normal breathing or a
prolonged phase of forced exhalation Increased
nasal secretions, mucosal swelling, sinusitis,
rhinitis, or nasal polyps
• Rales, Rhonchi,
• Tachypnea &Orthopnea
• Chest constriction

24. LABORATORY INVESTIGATIONS
• Arterial blood gas analysis
• Spo2 monitoring
• Elevated IgE level
• Complete blood count
• Blood levels of eosinophil

25. DIFFERENTIAL DIAGNOSIS
• Peak Expiratory Flow Rate
• Spirometry
• Chest X-ray
• Skin Prick Testing
• Measurement of Airway Hyper responsiveness
• Sputum Examination
• Pulmonary function test

26. PEFR is used to assess
the severity of wheezing in
those who have asthma.
PEFR measures how quickly
a person can exhale air from
the lungs
PEAK EXPIRATORY FLOW RATE

27. INCENTIVE SPIROMETRY
• It measures how much air you can exhale.
• FEV1(force expiratory volume) > 80% = normal
• Confirms the presence of airway obstruction and
measure the degree of lung function impairment.
• Monitor your response to asthma medications

28. PULMONARY FUNCTION TEST
S.No Paprameter
s
NORMAL VALUES ABNORMAL VALUES
1. FEV1/FVC – >75% Normal • 60%‐75% Mild obstruction
• 50‐59% Moderate obstruction
• <49% Severe obstruction
2. Forced
midexpiratory
flow
25‐75% (FEF25‐
75)
Interpretation of % predicted:
• >60% Normal
• 40‐60% Mild obstruction
• 20‐40% Moderate obstruction
• <10% Severe obstruction
3. Peak
expiratory
flow rates
Male : 450 ‐ 700 l/min
Females: 300 ‐ 500 l/min
<200/mins

29. PARAMETERS OBSTRUCTIVE RESTRICTIVE
Vital capacity Normal or decreased decreased
Total lung capacity Normal or increased decreased
Residual volume Increased decreased
FEV1/FVC decreased Normal or increased
Maximum mid
expiratory flow
decreased Normal
Maximum breathing
capacity
decreased Normal or decreased
PULMONARY FUNCTION TEST

30. CHEST X-RAY

31. ALLERGY-SKIN TEST
• A drop of liquid containing the allergen in placed on
your skin
• A small lance with a pinpoint is poked through the
liquid into the top layer of skin (prick test).
• If you are allergic to the allergen, after about 2
minutes the skin begins to form a reaction (red,
slightly swollen, and itchy.
• The size of the hive is measured and recorded. The
larger the hive, the more likely it is that you are
allergic to the allergen tested.

32. COMPLICATIONS OF ASTHMA
STATUS ASTHMATICS RESPIRATORY FAILURE
PNEUMONIA ATELECTASIS

33. MANAGEMENT
• Medical management
• Pharmacological management
• Surgical management
• Nursing management

34. MEDICAL MANAGEMENT
• Fowlers/ semi fowlers position
• Oxygen administration
• Incentive spirometry exercise
• Deep breathing exercises
• Pursed-lip breathing
• Steam inhalation

35. PHARMACOLOGICAL MANAGEMENT
• Bronchodilators – rapid relief, by relaxation of
airway smooth muscle
– β2 Agonists & Methylxanthines
– Anticholinergic Agents
• Controllers – inhibit the inflammatory process
– Glucocorticoids
– Leukotrienes pathway inhibitors
– Cromones & Anti-IgE therapy

36. β2 Agonists in asthma
• Potent bronchodilators.(TOC)
• Usually given by inhalation route.
• MOA:
– Relaxation of airway smooth muscle
– Non-bronchodilator effects
• Inhibition of mast cell mediator release
• Reduction in plasma exudation
• Increased mucociliary transport
• Inhibition of sensory nerve activation
• Inflammatory cells express β2 receptors but these
are rapidly down regulated.
• No effect on airway inflammation and AHR

37. β2 Agonists in asthma
• Short-Acting β2 Agonists :3-6 hours
– Albuterol /salbutamol
– Levalbuterol, the (R)-enantiomer of albuterol
– Metaproterenol & Terbutaline
– Pirbuterol & Bambuterol
• Long-Acting β2Agonists : >12 hours
– Salmeterol
– Formoterol

38. ADRs – β2 agonists
• Muscle tremors(direct effect on skeletal muscle
β2 receptors)
• Tachycardia(direct effect on atrial β2 receptors)
• Hypokalemia(direct β2 effect on skeletal muscle
uptake of K+)
• Hypoxemia
• Restlessness

39. Anticholinergic agents
• Ipratropium bromide, Tiotropium.
– Prevent cholinergic nerve induced
bronchoconstriction.
– Block M3 receptor on bronchial smooth muscles.
– Less effective than β2 agonists
• Ipratropium- slow, bitter taste, precipitate glaucoma,
paradoxical broncho –constriction (hypotonic
nebulizer sol. & antibacterial additive)
• Tiotropium – longer acting, approved for treatment
of COPD. Dryness of mouth

40. Methylxanthines
• Medium potency bronchodilator
• Theophylline, Theobromine, Caffeine
Mechanism of action
a) Inhibition of several members of the
phosphodiesterase (PDE) enzyme family
b) Inhibition of cell-surface receptors for adenosine
c) IL-10 release-anti inflammatory action
d) Prevents translocation of NF-kB into nucleus
e) Activation of histone deacetylation. (HDAC2)

41. Adverse effect of theophylline
• Anorexia, nausea, vomiting, abdominal discomfort,
headache, and anxiety – start at >20 mg/L.(PDE4
inhibition)
• Seizures or arrhythmias at conc.>40 mg/L(A1
receptor antagonism)
• Diuresis(A1 receptor antagonism)

42. Corticosteroids – asthma
• Effective drugs for treatment of asthma.
• Development of inhaled corticosteroids is a major
advance in asthma therapy.
• Used prophylactically as a controller therapy.
• Benefit starts in 1week but continues upto several
months.
• If asthma not controlled at low dose of ICS then
addition of long acting β2 agonist is more effective
than doubling steroid dose.

43. Inhaled corticosteroids( ICS)
Use of β2Agonists >2 times a week indicates need of
a ICS
• Beclomethasone & Budesonide
• Fluticasone
• Triamcinolone
• Flunisolide
• Ciclesonide

44. Side effect of inhaled corticosteroids
• Oropharyngeal candidiasis, dysphonia –
frequent at high doses. Reduced by using spacer
device.
• Decreased bone mineral density.
• Hypothalamic-pituitary-adrenal axis
suppression- >2000µg/d of beclomethasone.
• Skin thinning, purpura- dose related effect.
• Growth retardation in children

45. Leukotrienes pathway inhibitors
• Two approaches to interrupt the leukotriene
pathway have been pursued
– Inhibition of 5-lipoxygenase, thereby preventing
leukotriene synthesis. Zileuton.
– Inhibition of the binding of LTD4 to its receptor on target
tissues, thereby preventing its action. Zafirlukast,
montelukast.
– Oral route.
ADR
• Liver toxicity
• Churg –Strauss synd.(vasculitis with eosinophilia)

46. Cromones
• Cromolyn sodium & nedocromil sodium
• On chronic use (four times daily) reduce the overall
level of bronchial reactivity.
• These drugs have no effect on airway smooth
muscle tone and are ineffective in reversing
asthmatic bronchospasm; they are only of value
when taken prophylactically.
• Inhalation route

47. Anti-IgE therapy
• Omalizumab - recombinant humanized monoclonal
antibody targeted against IgE.
• MOA - IgE bound to omalizumab cannot bind to IgE
receptors on mast cells and basophils, thereby
preventing the allergic reaction at a very early step
in the process.

48. NEBULIZATION
• Nebulised salbutamol(5mg) in oxygen given
immediately
• Ipratopium bromide(0.5mg) + salbutamol(5mg)
nebulised in oxygen,who don’t respond within 15-30 min
• Terbutaline -s.c.(0.25-0.5mg) or i.v (0.1μg/kg/min)
excessive coughing or too weak to inspire adequately.
• Hydrocortisone hemisuccinate 100mg i.v.stat,
followed by 100-200mg 4-8 hrly infusion.
• ET intubation & mechanical ventilation if above Tt fails

49. SURGICAL MANAGEMENT
Bronchial thermoplasty
• Invasive procedure for severe asthma
• Is not painful (no nerves inside airways)
• Risks : mainly lung collapse, bleeding and
additional breathing problems, mostly related to the
bronchoscope.
• Precaution: Pt. must be at least 18 y/o to have the
procedure.
• Pt. still need to use their asthma-maintenance
medications after the procedure
• Benefits: Pt. may use rescue inhalers less often
and are able to engage strenuous physical activity
than before

50. NURSING MANAGEMENT
• Ineffective airway clearance related to obstruction
of the airway, increased mucus secretion as
evidenced by secretion, decreased spo2 level,
tachypnea
• Ineffective breathing pattern related to
obstruction of airway, excessive mucus secretion
as evidenced by tachypnea and hypoxia.

51. • Acute pain on chest related to increased effort of
breath as evidenced by pain scale
• Impaired gas exchange related to decreased
oxygen level, bronchospasm as evidenced by
decreased spo2 level
• Impaired tissue perfusion related to v/q
mismatch, hypoxia as evidenced by delayed
capillary refills

52. • Activity intolerance related to impaired
respiratory function as evidenced by daily
activities
• Disturbed sleeping pattern related to breathing
difficulty as evidenced by redness of eyes.

53. REFERENCE
• Lewis & dirksen (2015); textbook of medical –
surgical nursing, 2nd South asian edition, vol:1;
elsevier publication.
• Brunner & suddarth’s (2014); textbook of
medical – surgical nursing, 13th edition, wolters
kluwer publications.

54. • Jennifer E. Helms, Claudia P. Barone, (2008)
physiology And Treatment Of Skin Disease, critical
Care Nurse, 4th edition; Vol 28; Philadelphia
publications.
Website :
• https://www.bing.com/images/search?q=asthma+infla
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• https://thumbs.dreamstime.com/x/asthma-chronic-
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