Asthma
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Outline
Overview
- Chronic inflammatory disease of the airways (bronchi and bronchioles)
Nursing Points
General
- Patho
- Abnormal, heightened airway reactivity
- Exposure to trigger →
- Inflammation + Mucus
- Bronchospasm (decreases size of airway)
- Airflow obstruction
- Airway remodeling (long-term changes to lungs, scarring)
- Triggers
- A- allergens (seasonal, animal, food)
- S- sport or smoking
- T-temperatures (change in season, cold air)
- H- hazards (chemicals)
- M- microbes (infection)
- A- anxiety
- Diagnosis and Clinical tests
- Clinical diagnosis
- No specific test is definitive
- Based on symptoms and history
- Confirmed with Spirometry
- Can be used with kids >5-6 years
- Helps assess effectiveness of treatment
- Done at least every year
- Peak Flow Meter
- Evaluates how much air they can blow out in 1 second
- Always double check child’s technique
- Establish personal best when asthma is stable
- Then use to assess severity of asthma exacerbation
- Green (80-100% of personal best) = no concerns
- Yellow (50-79% of personal best) = caution
- Red (<50% of personal best) = medical emergency
- Allergen Testing
- Skin and inhaled
- Others
- Exercise challenges
- Radiograph
- Clinical diagnosis
Assessment
- Acute Exacerbation
- Shortness of breath
- Unable to speak in complete sentences
- Cough
- Retractions
- Chest tightness
- Wheeze
- Prolonged expiration
- Silent chest – complete obstruction of airflow
- Obtain blood for ABG
- Shortness of breath
- Status asthmaticus
- Acute asthma attack that is resistant to treatment
- May result in respiratory failure or death
- Associated with “silent chest” on auscultation
- Chronic- poorly controlled asthma
- Frequent exacerbations
- Nighttime cough
- Barrel chest
- Elevated shoulders
- Use of accessory muscles
- Growth delay
- Puberty delay
Therapeutic Management
- Goals
- Prevention by reducing exposure to triggers
- Long-term suppression of inflammation
- Managing acute exacerbations
- Allergen Control
- Keep living environment clean (minimize dust, pet dander, mold, damp)
- Avoid
- Secondhand smoke
- Cleaning products
- Long-term Control
- Inhaled Corticosteroids
- Ex: Budesonide & Fluticasone
- Taken daily regardless of symptoms
- Rinse mouth out after inhalation (to prevent thrush!)
- B-Adrenergic agonist (short acting)
- Ex: Albuterol, Levalbuterol, Terbutaline
- Relaxes smooth muscles
- Stops bronchospasm
- Medications to add to step up treatment
- Leukotriene modifiers
- Ex: Montelukast sodium
- Block leukotrienes from over-responding to triggers
- Salmeterol (Long-Acting Bronchodilator)
- Used to help prevent Exercise-induced bronchospasms
- Leukotriene modifiers
- Inhaled Corticosteroids
- Acute Exacerbation
- ABC’s
- Supplemental O2
- B-Adrenergic agonist (short acting_
- Albuterol
- “Back-to-Back nebs”
- 3 doses given 20 minutes apart
- Corticosteroids (systemic)
- IV, IM, PO
- If initial efforts are ineffective the provider may add the following
- Ipratropium Bromide via neb
- Relieve bronchospasm
- Magnesium sulfide via IV
- Theophylline via neb or IV
- Ipratropium Bromide via neb
Nursing Concepts
- Oxygenation
- Gas Exchange
Patient Education
- Parents should keep emergency contact phone numbers available
- Instruct the family on the use of
- Nebulizers
- Metered-Dose Inhalers & Spacers
- Inhaled Corticosteroids
- Must be taken daily regardless of symptoms
- Rinse mouth out after to avoid oral thrush
- See this video as a resource: https://www.nationaljewish.org/treatment-programs/medications/inhaled-medication-asthma-inhaler-copd-inhaler/metered-dose/mdi-spacers
- Common issues
- Forgetting to shake inhaler
- Putting more than 1 puff in the chamber at a time
- Child breaths too rapidly
- Not using a spacer
- Kids embarrassed to carry it around
- Common issues
- Inhaled Corticosteroids
- Peak flow meters
- Proper use
- Interpreting findings
- Green/Yellow/Red
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ADPIE Related Lessons
Related Nursing Process (ADPIE) Lessons for Asthma
Transcript
Hey! In this lesson we are going to be talking about asthma which is a chronic inflammatory disease of the airways.
Asthma is a chronic problem in the airways that is caused by heightened reactivity. When the lungs are exposed to a variety of different triggers the airways become inflamed, mucus production increases and bronchospasms occur.
You can see in the photo here that this causes the airways to become much smaller, and airflow is obstructed. When this happens it’s called an asthma exacerbation.
If this kind of reaction occurs frequently, you end up with long term scarring and damage to the lungs which is called airway remodeling.
Triggers are going to be different for each person. Here’s a really easy way to remember common triggers for asthma- just use the mnemonic device A.S.T.H.M.A. Allergens (like pollen, pet dander, dust), Sports (exercise) and Smoking, Temperatures (extreme hot or cold), Hazards (occupational chemicals), Microbes (infections), Anxiety.
The diagnosis of asthma is based on clinical symptoms and the patient’s history.
Spirometry can be used to help determine the effectiveness of treatment and Peak Flow Meters are used to help patients assess how severe an asthma exacerbation is.
Peak flow meters tell us how how much air can be forcefully pushed out of the lungs in 1 second. So when asthma is well controlled you use the Peak flow meter to establish their baseline. If they check their peak flow and they are 50-79% of their normal they are yellow, this means they should be cautious and they may be having an exacerbation. If they are <50% of their normal they are in the red and this signals that they have severe airway narrowing and need to do something!
For your nursing assessment during an acute exacerbation we are looking for signs of the airway obstruction that is occuring.
The patient may feel short of breath, so they are breathing and can’t seem to catch their breath and may not be able to speak in complete sentences- if you see this it’s a red flag and a sign of a very severe asthma exacerbation.
The patient will likely have a cough that is hacking and usually non-productive.
If they are old enough to, they may complain of feeling like their chest is tight.
They will be working extra hard to move air through their lungs so you will see signs of this like retractions and nasal flaring.
When you listen to the chest your will hear wheezing because they are having to force the air out and through these narrowed airways.
Now, if you listen to breath sounds on an asthma patient and don’t hear any air moving in our out of the lungs, this is called a “silent chest” and it’s a medical emergency. It means the airways are completely obstructed and no air can move. This is usually a sign of something called Status asthmaticus which we’ll talk about in a second.
Treatment of an asthma exacerbation always starts with our ABC’s. Don’t forget the simple things than can really help our patient’s breathe- so elevate that head of bed, provide suction if their nose is blocked, and try to calm or distract the child because remember anxiety can trigger and really worsen their symptoms. Simple things that can make a huge difference.
Most kids are going to need oxygen, this could be via nasal cannula or a face mask.
Then they are going to need some albuterol. Albuterol is a short acting beta adrenergic agonist and what it does is relax the smooth muscle in the lungs, which relieves the bronchospasms and opens up those airways. Make sure to reassess after doses to see if it’s working.
They also need a systemic corticosteroid, either given PO, IV, or IM, which they will take for several days to get control of the inflammation.
If a patient doesn’t respond to treatment and you hear that silent chest that we talked about- this indicates status asthmaticus. It’s a medical emergency and you should get a provider to the bedside ASAP because additional medications are going to have to be added to the treatment. Atrovent may be added to the inhaled albuterol and they will likely be given magnesium sulfate IV which is a pretty intense muscle relaxant that will help their breathing.
Alright, let’s move on to talk about how these kids are managed day to day to try and prevent these exacerbations from happening.
Long term management starts with assessing the child’s environment and minimizing exposure to triggers, so things like, keeping a house very clean, not having pets, and avoiding secondhand smoke- are some pretty common things we advise.
To reduce inflammation, patients will be prescribed an inhaled corticosteroids. The most important thing to note about these inhaled steroids is that they should be taken every single day, regardless of symptoms for them to be effective.
The next thing patients need are short acting bronchodilators like albuterol. This will given through an MDI (metered dose inhaler) and kids under 4-6 will need to use a spacer because it’s really difficult for kids to get the timing right with inhalers! A lot of times this is called their rescue inhaler because they are only used when the patient is symptomatic.
Now, like I said other meds can be added (like long acting bronchodilators to help with exercise-induced asthma, or leukotriene modifiers like singular to help with allergies) , but the things listed here are the first steps.
If a child is having to use their bronchodilator more than twice a week, they are waking up with a night time cough frequently or are being seen in hospital every other month, we know that their asthma is poorly controlled!
If they are poorly controlled you need to check compliance. Are they avoiding allergens? Taking steroids daily? Using their inhaler and spacer correctly? If not, then they aren’t actually getting the medication into their body! So always double check their technique. There’s a video linked in the the resources that goes through patient education for MDI and spacer use.
Your priority nursing concepts when caring for a pediatric patient with asthma are oxygenation, gas exchange and health promotion.
Alright, lets recap and identify the most important points for this lesson. Asthma is a chronic disease where the airways overreact to stimuli. This causes the airways to get smaller, spasm and fill with mucus. This is called an acute exacerbation.
Common triggers are allergens, sports and smoke, extreme temperatures, hazards, microbes or infections and anxiety.
Symptoms to be aware of with an acute exacerbation are, wheezing, chest tightness, a cough and shortness of breath. Don’t forget that a silent chest means no air is moving and this is a medical emergency.
Acute management starts with ABC’s. Then, give oxygen, bronchodilators and a systemic corticosteroid.
Long term management is focused on decreasing exposure to triggers and reducing inflammation with inhaled corticosteroids. Albuterol inhalers are prescribed to help manage exacerbations and remember compliance is key!
That’s it for our lesson on asthma in pediatric patients. It’s a big topic and guys, so make sure you checkout all the resources attached to this lesson that will help you put it all together! Now, go out and be your best self today. Happy Nursing!
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