ASTHMA Asthma is a chronic inflammatory disease of the airways that causes airway hypresponsiveness, mucosal oedema and mucus

production. The inflammation ultimately leads to recurrent episodes of asthma symptoms; cough, chest tightness, wheezing and dyspnoea. Asthma is an obstructive disease that is reversible , either spontaneously or with treatment. It is the most common chronic disease of childhood and can occur at any age. Causes Allergy is the strongest predisposing factor for asthma Chronic exposure to airway irritants or allergens also increases the risks of asthma Common allergens include: Grass, weed, pollens, dust, animal dander. Common triggers for asthma symptoms and exacerbations include Airway irritants (e.g air pollutants, cold, heat weather changes, strong odours or perfumes, smoke,), exercise, stress, emotional upset, medications, viral respiratory tract infections and gastroeosophageal reflux.

Pathophysiology Asthma results from reversible and diffuse airway inflammation. The exposure of the hypersensitive individuals to allergen causes the mast cell to release chemical histamines, bradykinin, prostaglandins and leukotrines which perpetuate the inflammatory response. The inflammation leads to obstruction due to the following factors 1. Swelling of the membranes(mucosal oedema) which reduces airway diameter. 2. Contraction of the bronchial smooth muscle (bronchospasm) which causes further narrowing and 3. Increased mucus production, which diminishes airway size and may entirely plug the bronchi. The bronchial muscles and mucous glands enlarge and thick tenacious sputum is produced and the alveoli hyperinflate. There is cough with or without mucus production. At times the mucus may be tightly stocked to the narrowed airway that the patient cannot cough it up. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expectoration and then possibly during inspiration as well. Generalized chest tightness and dyspnoea occur due to narrowed airway, mucosal oedema and obstruction of the airway. Expiration requires effort and becomes prolonged. As exacerbation progresses, diaphoresis, tachycardia, hypoxaemia and central cyanosis may occur. An asthma attack often occurs at night or early in the morning.

Manifestations Cough Dyspnoea Wheezing Diaphoresis Tachycardia

Complications Dehydration Hypoxaemia Cental cyanosis Status asthmaticus Respiratory failure Pneumonia Atelectasis

Assessment and diagnostic findings Complete family, environmental and occupational history Establish symptoms of airflow obstruction and that airflow is partially reversible Exclude other causes of airflow obstruction During acute episode, sputum and blood tests may include: oesinophilia, serum levels of IgE may be elevated if allergy is present. Arterial blood gas analysis and pulse oximetry will reveal hypoxaemia during acute attack. In severe attack, PaCO2.

Prevention Identification of offending substances through test Instruct patient to avoid them whenever possible Educate patient on care modalities, even on the correct use of nebulizers

Management Pharmacologic Therapy Two classes of drugs - Quick relief medications for immediate treatment of asthma symptoms and exercabation - Long-acting medications to achieve and maintain control of persistent asthma. 1. Control of asthma is achieved primarily with regular use of anti inflammatory medications. Long acting control medications include corticosteroids.

Long-acting beta2-adrenergic agonists are used with anti-inflammatory medications to control asthma symptoms particularly those that occur during the night. - Leukotriene modifiers (inhibitors)or antileukotrienes, act by interfering with the leukotriene synthesis or bybblocking the receptors where leukotriene synthesis exert their action. Example of systemic corticosteroids include prodnisolone. Long acting inhaled Beta-Agonists Salmetrol, Leukotriene modifiers montelukast. Theophylline is a mild to moderate bronchodilator that is usually used in addition to inhaled corticosteroids mainly for relief of night time asthma symptoms. Quick relief medications consists of beta2-adrenergic agonists. Examples include ventolin, Alipent. Anticholinergic agents such as Ipratropium bromide(Atrovent) and methylxanithines such as aminophylline and theophylline are common types of bronchodilators medications. Nursing management The nurse assesses the patients respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs. The nurse should obtain a history of allergic reactions to medications before administering medications, identify the medications the patient is currently taking, administer medications as prescribed and monitor the patients responses to those medications and fluids if the patient is dehydrated. Teaching patient self care The patient must understand the following: The nature of asthma as a chronic inflammatory disease The definition of inflammation and bronchoconstriction Triggers to avoid and how to do so Proper inhalation technique When to seek assistance and how to do so. STATUS ASTHMATICUS Severe and persistent asthma that does not respond to conventional therapy, usually lasting more than twenty four hours. It is considered as a medical emergency. The attacks can occur with little or no warning.

Risk factors/ triggers Infection, anxiety, nebulizer abuse, dehydration, increased adrenergic blockade and non- specific triggers. Pathophysiology The occurrences in asthma are characteristic of status asthmaticus. The most common problem is severe bronchospasm. Mucus plugs the bronchi, leading to asphyxia. There is ventilation-perfusion abnormality which results in hypoxaemia and respiratory alkalosis initially, followed by respiratory acidosis. The respiratory acidosis occurs worsening status asthmaticus, when partial pressure of carbon dioxide (PaCO2) increases and the Ph decreases. Clinical Manifestations The clinical manifestations are the same with those of asthma. The signs and symptoms include labored breathing, prolonged exhalation, engorged neck veins and wheezing. Assessment and Diagnostic findings Arterial blood gas measurements are obtained. Respiratory alkalosis (low PaCO2) is the most common finding in patient with asthma. An increasing PaCO2(to normal levels or levels indicating respiratory acidosis) is a danger sign indicating respiratory failure.

Medical management Clinical monitoring and objective reevaluation for response to therapy are important factors in managing status asthmaticus In the emergency setting, patient is treated initially with a short-acting beta adrenergic agonist and subsequently with systemic corticosteroids. Corticosteroids are used to decrease airway inflammation and swelling. The patient requires supplemental O2 and IV fluids for hydration. Oxygen therapy is used to treat dyspnoea, central cyanosis and hypoxaemia. Sedative medications are contraindicated Magnesium sulphate , a calcium anatagonist may be administered to induce smooth muscle relaxation.

Nursing management The main goal of nursing management is to actively assess the airway and patients response to treatment. The nurse should monitor the patient for the first 12 to 24 hours until status asthmaticus is under control. Assessment of the skin tugor for signs of dehydration should be done.

IV fluids should be monitored as prescribed up to 3 4 litres per day is required unless it is contraindicated. Fluid helps o combat dehydration, loosen secretions, and facilitate expectoration. Blood pressure and cardiac rhythm should be monitored continuosly during the acute phase and until patient stabilizes and responds to therapy. Rest should be encouraged to The patients room should be quite and free of triggers such as tobacco smoke, perfumes or odours of cleaning agents.