Chapter 31
Nursing Management:
Obstructive Pulmonary Diseases
Focus on Asthma
Asthma—Definition

Chronic inflammatory disorder of airways
 Causes airway hyper-responsiveness leading to
wheezing, breathlessness, chest tightness, and
cough
31B-2
Significance
About 8.4% of Canadians over the age of 12 are
living with asthma.
 About 11% of people with asthma visit an
emergency department (ED) one or more times
a year.
 Morbidity is dramatic.

31B-3
Triggers of Asthma: Allergens

May be seasonal or year-round, depending on
exposure to allergen
 Animal dander
 House dust mites
 Cockroaches
 Pollens
 Moulds
31B-4
Triggers of Asthma: Exercise

Induced or exacerbated after exercise
 Pronounced with exposure to cold air
• Breathing through a scarf or mask may ↓ likelihood of
symptoms
31B-5
Triggers of Asthma:
Respiratory Infection

Major precipitating factor of an acute asthma
attack
 ↑ Inflammation hyper-responsiveness of the
tracheobronchial system
 Can last 2–8 weeks
 Influenza vaccines are recommended for children 6
months and older and for adults with asthma.
31B-6
Triggers of Asthma:
Nose and Sinus Conditions

Allergic rhinitis and nasal polyps
 Large polyps are removed.
 Sinus conditions are usually related to inflammation of
the mucous membranes.
31B-7
Triggers of Asthma:
Medications and Food Additives

Asthma triad: Nasal polyps, asthma, and
sensitivity to Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs)
 Wheezing develops in about 2 hours.
 Sensitivity to salicylates
• Found in many foods, beverages, and flavourings

β-Adrenergic blockers
31B-8
Triggers of Asthma: Medications
and Food Additives (Cont.)

Food allergies may cause asthma symptoms.
 Avoidance diets
31B-9
Triggers of Asthma:
Gastroesophageal Reflux Disease (GERD)

Exact mechanism is unknown.
 Reflux of acid could be aspirated into lungs, causing
bronchoconstriction.
31B-10
Triggers of Asthma: Air Pollutants

Can trigger asthma attacks
 Wood smoke
 Vehicle exhaust
 Diesel particulate
 Elevated ozone levels
 Sulphur dioxide
 Nitrogen dioxide
31B-11
Triggers of Asthma:
Emotional Stress

Psychological factors can worsen the disease
process.
 Attacks can trigger panic and anxiety.
 Extent of the effect is unknown.
31B-12
Pathophysiology

Early-phase response is characterized by
bronchospasm.
 Increased mucus secretion, edema formation, and
increased amounts of tenacious sputum
 Peaks in 30–60 minutes after trigger exposure
 Subsides in about 30–90 minutes
31B-13
Pathophysiology (Cont.)

Late-phase response can be more severe than
the early-phase response and is primarily
inflammation.
 Peaks in 5–12 hours
 May last several hours to days
 Corticosteroids are effective in preventing and
reversing this cycle.
31B-14
Early-Phase Response of Asthma
Triggered by Allergen
31B-15
Factors Causing Obstruction
31B-16
Pathophysiology (Cont.)

Late-phase response
 If airway inflammation is not treated or does not
resolve, it may lead to irreversible lung damage.
31B-17
Clinical Manifestations

Unpredictable and variable
 Recurrent episodes of wheezing, breathlessness,
cough, and tight chest
 Particularly at night or early morning (0200–0500
hours)
 May be abrupt or gradual
 Lasts minutes to hours
31B-18
Clinical Manifestations (Cont.)

Expiration may be prolonged.
 Inspiration-expiration ratio of normal, 1:2, is increased
to 1:3 or 1:4.
 Bronchospasm, edema, and mucus in bronchioles
narrow the airways
 Air takes longer to move out.
31B-19
Clinical Manifestations (Cont.)

Wheezing is unreliable to gauge severity.
 Severe attacks may have no audible wheezing.
 Usually begins upon exhalation
 “Silent chest”
31B-20
Clinical Manifestations (Cont.)

Cough variant asthma
 Cough is the only symptom.
 Bronchospasm is not severe enough to cause airflow
obstruction.
31B-21
Clinical Manifestations (Cont.)

Difficulty with air movement
 Patient may feel increasingly anxious
31B-22
Clinical Manifestations (Cont.)

An acute attack usually reveals signs of
hypoxemia.
 Restlessness
 ↑ Anxiety
 Inappropriate behaviour
31B-23
Clinical Manifestations (Cont.)

More signs of hypoxemia
 ↑ Pulse and blood pressure (BP)
 Pulsus paradoxus (drop in systolic BP during
inspiratory cycle >10 mm Hg)
 Respiratory rate >30 breaths/minute
31B-24
Complications

Status asthmaticus (form of acute asthma
attack)
 Common causes of severe, acute attacks include viral
illnesses, ingestion of Aspirin or other NSAIDs,
increases in environmental pollutants or other
allergen exposure, and discontinuation of medication
therapy.
 Clinical manifestations are similar to those of nonsevere asthma but are more serious and prolonged.
31B-25
Complications (Cont.)

Status asthmaticus (form of acute asthma
attack) (Cont.)
 May include pneumothorax, pneumomediastinum,
acute cor pulmonale with right ventricular failure, and
severe respiratory muscle fatigue that leads to
respiratory arrest
 Respiratory arrest can be fatal.
31B-26
Diagnostic Studies
Detailed history and physical exam
 Pulmonary function tests
 Chest X-ray
 Arterial blood gases (ABGs)
 Oximetry
 Allergy testing
 Blood levels of eosinophils
 Sputum culture and sensitivity

31B-27
Interprofessional Care

Education
 Start at time of diagnosis
 Integrate throughout care
31B-28
Interprofessional Care (Cont.)

Self-management
 Tailored to needs of patient
 Culturally sensitive
31B-29
Interprofessional Care (Cont.)

Overall goal
 Achieve asthma control with minimum level of
pharmacotherapy while enhancing quality of life of
individuals living with asthma and reducing the
personal and social burdens inflicted by the condition
31B-30
Interprofessional Care (Cont.)

General management approach
 Confirming the diagnosis
 Monitoring level of asthma control
 Reducing exposure to environmental triggers

Providing appropriate medications
 Providing asthma education
 Providing written action plan
 Ensuring regular follow-up
31B-31
Interprofessional Care (Cont.)

Acute asthma exacerbation
 Often come to ED
 Respiratory distress
 Treatment depends on severity and response to
therapy.
• Severity measured with flow rates
31B-32
Interprofessional Care (Cont.)

Acute asthma exacerbation (Cont.)
 Oral corticosteroids
 Therapy may be started and monitored with pulse
oximetry or ABGs in severe cases.
31B-33
Interprofessional Care (Cont.)

Severe attack
 Most therapeutic measures are the same as for acute
episode.
• ↑ In frequency and dose of bronchodilators
 May require mechanical ventilation
31B-34
Interprofessional Care (Cont.)

Severe attack (Cont.)
 IV corticosteroids are administered every 4–6 hours,
then are given orally.
 Continuous monitoring of patient is critical.
31B-35
Interprofessional Care (Cont.)

Severe attack (Cont.)
 Supplemental O2 is given by mask or nasal cannula
for 90% O2 saturation.
• An arterial catheter may be used to facilitate frequent ABG
monitoring.
 IV fluids are given because of insensible loss of fluids.
31B-36
Medication Therapy

Controllers
 Achieve and maintain control of persistent asthma

Relievers
 Treat symptoms of exacerbations
31B-37
Medication Therapy (Cont.)

Three types
 Anti-inflammatory: Corticosteroids
 Antileukotrienes
 Biological therapy (monoclonal antibody to IgE)
31B-38
Medication Therapy (Cont.)

Corticosteroids (e.g., fluticasone, budesonide)
 Suppress inflammatory response
 Inhaled form is used in long-term control
 Systemic form to control exacerbations and manage
persistent asthma
31B-39
Medication Therapy (Cont.)

Corticosteroids (Cont.)
 Reduce bronchial hyper-responsiveness
 Decrease mucus production
 Taken on a fixed schedule
31B-40
Medication Therapy (Cont.)

Corticosteroids (Cont.)
 Oropharyngeal candidiasis, hoarseness, and a dry
cough are local adverse effects of inhaled medication.
• Can be reduced using a spacer or by gargling after each use
31B-41
Spacer
31B-42
Medication Therapy (Cont.)

Antileukotriene (e.g., zafirlukast, montelukast)
 Block action of leukotrienes—potent
bronchoconstrictors
31B-43
Medication Therapy (Cont.)

Antileukotriene (Cont.)
 Has both bronchodilator and anti-inflammatory effects
 Not indicated for acute attacks
 Used for prophylactic and maintenance therapy
31B-44
Medication Therapy (Cont.)

Biological therapy: Anti-IgE (e.g., omalizumab
[Xolair])
 ↓ Circulating free IgE levels
 Prevents IgE from attaching to mast cells, preventing
release of chemical mediators
 Subcutaneous administration every 2–4 weeks
31B-45
Medication Therapy (Cont.)

Three types of bronchodilators
 β2-Adrenergic agonists
 Methylxanthines
 Anticholinergics
31B-46
Medication Therapy (Cont.)

β-Adrenergic agonists (e.g., salbutamol,
terbutaline)
 Effective for relieving acute bronchospasm
 Onset of action in minutes and duration of 4–8 hours
31B-47
Medication Therapy (Cont.)

β-Adrenergic agonists (Cont.)
 Prevent release of inflammatory mediators from mast
cells
 Not for long-term use
31B-48
Medication Therapy (Cont.)

Methylxanthines (e.g., theophylline)
 Less effective long-term bronchodilator
 Controller after trying inhaled corticosteroid (ICS),
long-acting β2 agonist (LABA), and leukotriene
receptor antagonists (LTRAs)
 Narrow toxic/therapeutic ratio and frequent adverse
events
31B-49
Medication Therapy (Cont.)

Anticholinergic medications (e.g., ipratropium)
 Block action of acetylcholine
 Usually used in combination with a bronchodilator
 Most common adverse effect is dry mouth
31B-50
Patient Teaching Related to
Medication Therapy

Correct administration of medications is a major
factor in success.
 Inhalation of medications is preferable to avoid
systemic adverse effects.
• Metered-dose inhalers (MDIs) (with and without spacers), dry
powder inhalers (DPIs), and nebulizers are devices used to
inhale medications.
31B-51
Patient Teaching Related to
Medication Therapy (Cont.)

Correct administration of medications
 Using an MDI with a spacer is easier and improves
inhalation of the medication.
 A DPI requires less manual dexterity and
coordination.
31B-52
Example of DPI
31B-53
Nursing Management: Assessment

Health history
 Especially of precipitating factors and medications
ABGs
 Lung function tests

31B-54
Nursing Management:
Assessment (Cont.)

Physical examination
 Use of accessory muscles
 Diaphoresis
 Cyanosis
 Lung sounds
31B-55
Nursing Management: Diagnoses
Inadequate airway clearance
 Anxiety
 Inadequate knowledge

31B-56
Nursing Management: Planning

Overall goals
 Participate in activities of normal life (including
exercise and other physical activity) with little to no
interference
 Normal or near-normal pulmonary function
 Have the asthma under control
31B-57
Nursing Management:
Planning (Cont.)

Overall goals (Cont.)
 Few or no adverse effects from medication
 Adequate knowledge and skills to participate in and
carry out management
31B-58
Nursing Management:
Implementation

Asthma education
 Develop partnership with family
 Provide information and education
 Collaborate with family to develop skills necessary for
controlling asthma
 Self-management education programs can reduce the
number of ED visits, hospitalizations, urgent care
visits, nocturnal awakening, and days of interrupted
activity.
31B-59
Nursing Management:
Implementation (Cont.)

Asthma education (Cont.)
 Asthma education programs can be cost-effective.
 See Table 31.9 for a detailed basic education
program.
31B-60
Nursing Management:
Implementation

Environmental control
 Reduce triggers (allergens and irritants)
 House dust mites; focus on bedroom and keeping
relative humidity below 50%, laundering bed linens in
hot water, and removing carpets
 Pet dander strategies for reduction
 Eliminate environmental tobacco smoke
 Exercise within patients’ limits
 Work-related asthma
31B-61
Nursing Management:
Implementation (Cont.)

Self-monitoring and action plans
 Every person with asthma should have an action
plan.
 Include self-monitoring, by symptoms and peak
expiratory flow (PEF), regular medical review
 Involve the patient’s family for increased adherence to
the plan.
31B-62
Nursing Management:
Implementation (Cont.)

Inadequate airway clearance
 Monitor respiratory and cardiovascular systems.
• Lung sounds
• Respiratory rate
• Pulse
• BP
 Position patient to maximize ventilation
31B-63
Nursing Management:
Implementation (Cont.)

Anxiety
 An important goal of nursing is to ↓ the patient’s
sense of panic.
• Stay with the patient.
• Encourage slow breathing using pursed lips for prolonged
expiration.
• Position the patient comfortably.
31B-64
Nursing Management:
Implementation (Cont.)

Inadequate knowledge
 Patient education
 Asthma plan
 Must learn about medications and develop self-
management strategies
 Patient and health care provider must monitor
responsiveness and adverse events to medication
31B-65
Nursing Management
Nursing Implementation (Cont.)

Peak flow results
 Green Zone
• Usually 80% to 100% of personal best
• Remain on medications.

Peak flow results
 Yellow Zone
 Usually 50% (60%) to 79% of personal best
 Indicates caution
 Something is triggering asthma.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
66
Nursing Management
Nursing Implementation (Cont.)

Peak flow results

Red Zone
• 56% to 60% or less of personal best
• Indicates serious problem
• Definitive action must be taken with health care provider.
Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.
67
Case Study
Case Study
A 30-year-old patient comes to the emergency
department with severe wheezing, dyspnea, and
anxiety.
 The patient recently had a cold that did not
resolve.

31B-69
Case Study (Cont.)
Has taken a new job at a dry cleaners and
laundromat
 Has been having regurgitation of food after
eating, which the patient related to the stress
from her recent divorce

31B-70
Case Study (Cont.)
Upset that the children had just brought home a
stray cat
 Does not know if they are allergic to the cat

31B-71
Discussion Questions
1.
2.
What possible asthma triggers may the patient
be experiencing?
Are there any possible triggers that the patient
can avoid or manage?
31B-72
Discussion Questions (Cont.)
3.
4.
What are the priorities of care?
What patient teaching topics should the nurse
cover with the patient?
31B-73