ASTHMA
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Affects an estimated 20.4 million adult Americans
Women are 62% more likely to have asthma than men
More than 3,300 people die yearly from asthma
Clinical Manifestations
Exposure to risk factor or trigger leads to:
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Wheezing on Auscultation
Cough, productive or non-productive
Dyspnea (breathlessness) difficult or labored breathing
Chest Tightness - Air trapping in lungs. Lungs get bigger making the chest bigger (barrel chest)
Early sign: hyperventilation (Respiratory Alkalosis)
Late sign: hypoventilation (Respiratory Acidosis)
Silent chest – cannot auscultate lung sounds. Wheezing at the top and nothing at the bottom
which means nothing is moving, can lead to resp failure (stops breathing)
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ASTHMA CLASSIFICATIONS
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Mild Intermittent
• Symptomatic <2 days per week
• Nighttime awakenings < 2 nights per month
• SABA use < 2 days per week
• No interference with normal activity
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Mild Persistent
• Symptomatic > 2 days per week (not daily)
• Nighttime awakenings 3-4 nights per month
• SABA use > 2 days per week (not daily)
• Minor limitation
Moderate Persistent
• Symptomatic daily
• Nighttime awakenings > 1 night per week (not nightly)
• SABA use daily
• Some limitation
Severe Persistent – HAVE SYMPTOMS ALL THE TIME
• Symptomatic continuously
• Nighttime awakenings often 7 nights per week
• SABA use several times per day
• Extreme limitation
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Complications of Asthma
• Status Asthmaticus – NOT IMPROVING WITH INTERVENTIONS
• Life-threatening medical emergency
• Hypoxia ( oxygen levels)
• hypercapnia ( CO2 caused by inadequate resp)
• acute respiratory failure
• Hypotension, bradycardia, and respiratory and or cardiac arrest could occur if symptoms
not recognized
• Must be intubated and mechanical ventilation is started – EPI First (peds class lecture)
• Hemodynamic monitor, sedation, analgesics to decrease the WOB (Work Of Breathing)
• IV magnesium is given (bronchodilator) is given for very low FEV1
Respiratory failure is a serious condition that develops when the lungs can’t get enough oxygen into the
blood. Buildup of carbon dioxide can also damage the tissues and organs and further impair oxygenation of
blood and, as a result, slow oxygen delivery to the tissues.
Diagnostics
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History and physical
Incentive spirometry – measure air that can be exhaled
Bronchodilator therapy response – if they do not have asthma will not have any changes. Those
with asthma will have improvements in the amount of air that they can expire.
CXR – will show if the lings are hyperinflated (black b/c of the the increased air)
Oximetry
Allergy skin testing
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NURSING MANAGEMENT
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Acute Asthma Exacerbation
• O2 therapy
• SaO2 (oxygen saturation) monitoring
• Keep HOB up
• ABGs resp therapist to determine if resp acidosis
• Bronchodilator
• B2-adrenergic agonists Short- and long-acting beta-agonists
• Inhaled anticholinergics Ipratropium
• Corticosteroids (fluticasone, prednisone)
• inhaled corticosteroids
• Fluticasone/salmeterol (Advair)
• Budesonide/formoterol (Symbicort)
• IV fluids
• IV magnesium (bronchodilator effect)
• Decrease anxiety
• Intubation and assisted ventilation
DRUG THERAPY
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Acute Asthma Exacerbation
• O2 therapy
• SaO2 (oxygen saturation) monitoring
• Keep HOB up
• ABGs resp therapist to determine if resp acidosis
• Bronchodilator
• B2-adrenergic agonists Short- and long-acting beta-agonists
• Inhaled anticholinergics Ipratropium
• Corticosteroids (fluticasone, prednisone)
• inhaled corticosteroids
• Fluticasone/salmeterol (Advair)
• Budesonide/formoterol (Symbicort)
• IV fluids
• IV magnesium (bronchodilator effect)
• Decrease anxiety
• Intubation and assisted ventilation
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic inflammation in the airway and the lungs
a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema
(alveolar membranes breakdown) and chronic bronchitis (inflammation and excess mucus).
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Preventable and treatable disease
Characterized by persistent airflow obstruction
Progressive, associated with enhanced chronic inflammatory response in the airways and lungs
Primarily caused by cigarette smoking
COPD MANIFESTATIONS
Early signs
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Chronic, intermittent cough
Unproductive cough
Lifestyle modifications
Fatigue
“I’m getting older” or “I’m out of shape”
Interference with daily activities
Dyspnea with exertion
Late signs
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Dyspnea at rest
Accessory muscle use
Wheezing and chest tightness
Weight loss and Anorexia
Excessive fatigue
Coughing spells
Barrel chest and tripod positioning
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COPD COMPLICATIONS
• Cor pulmonale
• Right sided HF
• Late manifestation of COPD
• Acute exacerbation
• “Different from daily pattern”
• Bacterial or viral infections
• Acute respiratory failure may require ventilation with acute exacerbation
• Peptic ulcers and GERD
• pulmonary micro aspiration of gastric contents from gastroesophageal
dysfunction.
• Anxiety and depression
Poliomyelitis: disabling and life-threatening disease caused by the
poliovirus.
Pulmonary fibrosis: Scarring throughout the lungs
Pulmonary hypertension: when the pressure in the blood vessels
leading from the heart to the lungs is too high.
pulmonary embolism (PE) is a sudden blockage in a lung artery.
DIAGNOSTICS
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History and physical
Spirometry
• Confirms airflow obstruction
• Have them blow on a peek flow
Bronchodilator response test
Six-minute walk test
• SaO2 <88% at rest
• Room air
• Qualifies for supplemental O2 at home
ABGs
• to determine if there is resp acidosis
• Done by resp therapist
CXR
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Collaborative care
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Prevent or slow progression
Breathing and airway clearance exercises
• Pursed-lip breathing and huff cough (helps to loosen secretions)
Energy conservation (extreme fatigue)
Medications (management)
Home oxygen
• O2 toxicity
• Prolonged exposure to high levels of
• Do not increase O2, instead check cap refill, LOC, etc.
Nutritional support – bronchodilator before they eat
• High calorie high protein high fat
• Colder foods
• Avoid gas (bloater from gas suppress lungs and makes ot harder for them to breathe.
• Sitting in high fowlers
Recognize exacerbations - increased SOB
Improve quality of life
Respiratory Care
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Pursed-lip breathing
Diaphragmatic (abdominal) breathing – tell them take a deep breath
Chest physiotherapy – resp therapist
Postural drainage – reposition to facilitate drainage
NURSING MANAGEMENT OF COPD
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Smoking cessation – allows lungs to heal and stops progression, time your smoking and if you
crave one try distractions eating fruit, walking, etc.
Early detection Recognition of exacerbations
Drug therapy
Self-management
Coping strategies
Oxygenation
Susceptible to infection, practice good hand washing
PT/OT can help them with physical management of disease to prevent exertion
OKAY to exercise to strengthen muscles nothing too exerting, walking is an example. Should be able to go
back to normal breathing 5 minutes after exercise.
Maintain good quality sleep often retain more CO2 than they should
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DRUG Therapy
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Bronchodilators
• SABA – albuterol
• LABA – inhaled corticosteroids
• Fluticasone/salmeterol (Advair)
• Budesonide/formoterol (Symbicort)
• Corticosteroids
• (fluticasone, prednisone)
• Anti-leukotrienes - singular
• Anticholinergics - Bronchodilator
• Tiotropium and ipratropium
Bronchodilators
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Duoneb (Ipratropium and albuterol)
Beta-adrenergic agonists
Reduce airway constriction
Relaxes smooth muscles
Used for acute asthma attacks “rescue”
Contraindicated for cardiac dysrhythmias
Anticholinergics Bronchodilator (ipratropium and tiotropium)
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Causes local bronchodilation
Can’t see, can’t pee, can’t spit, can’t sh**
Atrovent (preventative)
Theophylline – must be closely monitored or can have toxicity
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Resembles properties of caffeine
Bronchodilation with vasoconstriction
Must be monitored for toxicity or subtherapeutic dose
Controversial
Many drug-drug interactions
Normal range is 5-15 mcg/mL
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SUMMARY
FEV1 60% to 80%
Bronchodilators (SABA)
• Short-acting
• Albuterol + ipratropium (DuoNeb)
FEV1 <60%
Bronchodilators (LABA)
• Long-acting
• Salmeterol and formoterol
Inhaled corticosteroids (ICS) + LABA
• Fluticasone/salmeterol (Advair)
• Budesonide/formoterol (Symbicort)
Anticholinergics bronchodilators
• Tiotropium and ipratropium
Bronchodilator (SABA)
• “Rescue” inhaler
FEV1 60% to 80%
Bronchodilators (SABA)
Albuterol + ipratropium (DuoNeb)
FEV1 <60%
Bronchodilators (LABA) Salmeterol and formoterol
Inhaled corticosteroids (ICS) Advair and Symbicort
Anticholinergics Tiotropium and ipratropium
Bronchodilator “Rescue” inhaler
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