Bronchoconstriction occurs when a patient inhales a substance to which they are hypersensitive. Allergens interact with immunoglobulin E (IgE) on mast cells, triggering their degranulation within the bronchial walls.

This release of chemical mediators such as histamine, bradykinin, leukotrienes, and prostaglandins induces inflammation, leading to bronchoconstriction, increased vascular permeability, and fluid leakage, contributing to edema and mucus secretion.

Consequently, the airway experiences mucosal thickening and swelling, resulting in increased rigidity and obstruction of airflow. Symptoms, including dyspnea and wheezing, arise due to mucus secretion and bronchospasms.

In persistent asthma, a chronic and intricate response occurs, marked by the infiltration of various inflammatory cells, alterations in airway structural cells, and the release of numerous cytokines, chemokines, and growth factors. These processes lead to swelling, inflammation, excessive mucus production, and the formation of mucus plugs.

Additionally, structural changes such as hypertrophy and hyperplasia of the airway smooth muscle contribute to the stimulation of mucous membrane secretion, further narrowing the bronchial passages.

Airway remodeling refers to the progressive and permanent structural changes that can develop in the airways with the increasing severity and chronicity of asthma. These changes lead to a gradual loss of lung function that cannot be fully prevented or reversed by current therapies.

Structural alterations may include thickening of the sub-basement membrane, fibrosis beneath the epithelium, hypertrophy and hyperplasia of airway smooth muscle, proliferation and dilation of blood vessels, and hyperplasia and excessive secretion of mucus glands.

Goblet cells produce thick mucus that is challenging to expel through coughing, leading to mucus accumulation in the lungs, hindering alveolar ventilation. Despite blood being redirected to other parts of the lungs, it cannot compensate for reduced ventilation, resulting in respiratory acidosis.

Inflammation of the bronchial walls may damage the epithelium, triggering nerve endings and initiating neural reflexes that exacerbate bronchospasms. This ultimately leads to fixed narrowing of the airways and reduced responsiveness to bronchodilators.

Signs and symptoms

Wheezing respirations are characterized by a whistling sound produced during expiration when the airways become obstructed or compressed. This occurs due to bronchospasms, which cause forced and prolonged expiration, along with hyperinflated lungs and trapped alveolar air.

A dry cough or cough producing thick, clear, or yellow sputum may result from irritation of the airways due to inflammation and mucus production.

Chest tightness arises from bronchial constriction, which restricts airflow and leads to a sensation of pressure or discomfort in the chest.

Extreme anxiety can accompany breathlessness, as individuals struggle to inhale enough air, leading to feelings of panic and distress.

Sweating (diaphoresis) occurs as a response to labored respiration, as the body attempts to regulate temperature and cope with increased exertion.

Dyspnea, or difficulty breathing, can occur due to the presence of thick mucus, mucosal edema, and smooth muscle spasms, which obstruct small airways and impede airflow, resulting in labored breathing.

Orthopnea refers to dyspnea that is alleviated in the upright position. Patients may find it difficult to lie flat and may adopt a three-point position to facilitate breathing, indicating severe respiratory distress.

Peripheral cyanosis, characterized by bluish discoloration of the skin, occurs due to reduced oxygen levels in the blood, signaling the onset of life-threatening asthmaticus and respiratory failure.

Hypoxia results from decreased oxygen circulating in the blood due to impaired gas exchange in the lungs, leading to inadequate oxygenation of tissues and organs throughout the body.

Hypercapnia refers to an elevated level of carbon dioxide in the blood, which occurs when there is difficulty in exhaling due to bronchospasm, leading to inadequate elimination of carbon dioxide from the body.

Tachycardia, or an increased heart rate, is a compensatory mechanism in response to hypoxia (low oxygen levels) and hypercapnia. The heart beats faster in an attempt to deliver more oxygenated blood to tissues and remove excess carbon dioxide.

If there is no response to treatment, exhaustion may occur. This exhaustion results from the body’s prolonged efforts to breathe despite compromised lung function. It can manifest as extreme fatigue, weakness, and a sense of overall physical depletion.

Medical Management

Medical History

Detailed history of presenting symptoms, including frequency, duration, and severity of asthma attacks.

Ask about the past medical history, including any previous diagnoses of asthma or other respiratory conditions, allergies, or atopic conditions such as eczema or allergic rhinitis,.

Ask about a family history of asthma or other allergic diseases.

Ask about your history of smoking or exposure to environmental tobacco smoke.

Finally, ask about the medication history, including current and previous use of asthma medications and any known triggers or exacerbating factors.

Physical Examination

Get the vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation.

Inspect the chest for any signs of respiratory distress, such as increased respiratory effort, the use of accessory muscles, or paradoxical chest movements.

Auscultation of lung sounds to identify wheezing, decreased breath sounds, or other abnormal sounds indicative of airway obstruction.

Examination of the skin for signs of cyanosis or diaphoresis.

Evaluation of nasal passages for signs of allergic rhinitis or nasal congestion.

Assessment of the oropharynx for signs of mouth breathing or throat irritation.

Examination of the thorax for signs of chest deformities or abnormalities.

Evaluation of the abdomen for signs of respiratory muscle fatigue or paradoxical abdominal movement during breathing.

Assessment of overall general appearance and level of consciousness for signs of respiratory distress or exhaustion.

Investigations for Asthma

Lung Function Testing

Pulmonary function tests (PFTs), including spirometry, are used to evaluate the degree of impairment, obstruction, and reversibility of airflow limitation, as well as to establish baseline ventilator function.

Chest X-ray

Examination of chest radiographs to identify possible signs of hyperinflation and focal atelectasis, which may indicate airway obstruction and inflammation.

Skin Sensitivity Testing

Allergy skin testing to identify allergens or other triggers responsible for triggering asthma symptoms.

Arterial Blood Gas Analysis

Analysis of arterial blood gases to assess for the presence of hypoxemia and respiratory acidosis, indicating the severity of gas exchange abnormalities and respiratory compromise.

Treatment

Beta-adrenergic receptor agonists are the preferred medications for relieving sudden asthma attacks and preventing exercise-induced attacks. Commonly used rapid-acting bronchodilators include:

Salbutamol: This medication is the fastest and most effective, making it the drug of choice. It can be administered via nebulizer or orally at a dose of 2mg three times daily. Salbutamol selectively stimulates beta receptors, leading to bronchodilation.

Side effects may include tachycardia, changes in blood pressure, nervousness, palpitations, muscle tremors, nausea, vomiting, insomnia, dry mouth, and headaches.

Nursing implications include avoiding use in patients with angina or cardiac disorders and encouraging patients to take the medication regularly, even when feeling well.
Metaproterenol: Similar to salbutamol, metaproterenol stimulates beta-adrenergic receptors to produce bronchodilation and increase mucociliary clearance. Side effects and nursing implications are similar to those of salbutamol.

When administered intravenously, aminophylline acts by relaxing bronchial smooth muscles and enhancing the contractility of a fatigued diaphragm.

Side effects such as tachycardia, changes in blood pressure, arrhythmias, anorexia, nausea and vomiting, nervousness, irritability, headache, muscle twitching, epigastric pain, diarrhea, palpitations, and insomnia.

Nursing implications include instructing patients to lie down if they experience dizziness, a common side effect of aminophylline administration.

It’s important to monitor patients closely for any adverse reactions and to provide appropriate care and support as needed.

Corticosteroids – Prednisolone, administered orally, exerts anti-inflammatory and immunosuppressive effects. They reduce edema in the bronchial airways, thereby decreasing mucus secretion.

Side effects may include skin changes, osteoporosis, increased appetite, obesity, immunosuppression, and muscle weakness.

Nursing implications involve advising patients to take the medication on alternative days to minimize side effects. It should be taken with food or milk in the morning to prevent peptic ulcers.

Long-acting bronchodilators – Epinephrine, administered subcutaneously, is typically used in emergency treatment of acute reactions.

The recommended dose is 0.2–0.5 mg as a single dose. Side effects may include headaches, dizziness, palpitations, tremors, restlessness, hypertension, and tachycardia.

Oxygen Therapy: Administer oxygen at a flow rate of 4-6 liters per minute to optimize oxygenation and support respiratory function. Oxygen therapy is essential for patients experiencing asthma exacerbations to ensure adequate oxygen delivery to tissues and organs.

Fluid Therapy: Initiate intravenous fluid therapy to maintain hydration and support circulation. Adequate fluid intake is crucial during asthma exacerbations to prevent dehydration and facilitate mucous clearance.

Antibiotics: Consider prescribing antibiotics such as Amoxicillin 500mg three times daily for 5 to 7 days in cases of suspected bacterial respiratory infections or exacerbations complicated by bacterial pneumonia.

Antibiotics are not routinely recommended for uncomplicated asthma exacerbations but may be necessary if there are signs of bacterial infection or pneumonia.

It’s important to follow local guidelines and consider bacterial culture and sensitivity results when selecting antibiotics.

Nursing Management

Aims

1. To prevent chronic symptoms

2. To maintain near normal pulmonary function

3. To prevent complications

Immediate Care During An Acute Asthmatic Attack

A-Airway

During an asthmatic attack, secretions can become thick and obstruct the airways.

Nursing interventions aimed at improving breathing patterns and gas exchange involve assisting the patient in assuming a comfortable position, administering medications as prescribed, and closely monitoring for both therapeutic and adverse effects.

Patients should be positioned upright and well-supported with pillows or encouraged to lean forward on a cardiac table to facilitate optimal airflow.

Nebulized salbutamol (5mg) or a short-acting medication like aminophylline (250mg IV bolus over 10 minutes or 750mg in 1 liter of 10% dextrose over 8 hours) should be administered as directed.

Additionally, 50% dextrose may be given to prevent hypoglycemia, as patients may expend significant energy due to the exhaustion caused by labored breathing.

Steroids such as hydrocortisone (200mg intravenously) may be administered to reduce local edema, further aiding in relieving airway obstruction and promoting improved respiratory function.

B. Breathing

Assessment of ventilation involves observing chest movements associated with breathing and listening to or feeling for air being expired through the nose and mouth.

Patients with asthma may exhibit slow, laborious wheezing sounds during expiration, accompanied by the use of accessory muscles such as the abdominal muscles for breathing.

Expiration tends to be more strenuous and prolonged than inspiration, leading patients to adopt an upright position and utilize every accessory muscle for respiration.

Intervention: Administer humidified oxygen via nasal cannula at a rate of 2 liters per minute to alleviate breathing difficulties.

Oxygen delivery should be adjusted later based on the patient’s vital signs and arterial blood gas measurements to ensure optimal oxygenation.

C- Circulation

While overall circulation may not be significantly altered during an asthmatic attack, there can be changes in partial oxygen pressure due to impaired gas exchange in the lungs. Tachycardia may occur as a compensatory response to impaired gas exchange.

Intervention: Initiate intravenous fluid therapy to rehydrate the patient, which can help improve circulation.

Additionally, continue oxygen therapy to optimize oxygenation and support cardiovascular function.

Subsequent Care

Environment

Ensure the patient is nursed in a calm and hygienic environment, preferably close to the nurse’s station for easy observation.

The room should be well-ventilated, free from dust, and equipped with all necessary resuscitative equipment, including oxygen cylinders and suction machines.

Maintaining a clean and quiet environment helps promote patient comfort and facilitates effective monitoring and intervention during asthma exacerbations.

Positioning

Position the patient in the semi-Fowler’s position, which involves elevating the head of the bed to a 30-45 degree angle.

This position helps optimize lung expansion and ventilation by reducing pressure on the diaphragm and facilitating easier breathing.

Encourage the patient to practice diaphragmatic breathing techniques, which involve deep inhalation and exhalation using the diaphragm muscle.

Diaphragmatic breathing promotes more efficient air intake and can help alleviate respiratory distress during asthma attacks.

Psychological Care

Establish a therapeutic relationship with the patient to build trust and confidence. Provide reassurance and comfort during an asthma attack by staying with the patient and offering support.

Explain the disease process, the cause of wheezing, and labored breathing to alleviate anxiety.

Encourage the patient to express their fears and concerns to help alleviate anxiety further.

Explain all procedures and equipment being used to promote cooperation and understanding. Clarify the purpose and function of the oxygen machine to alleviate fear and anxiety related to its use.

Involve the patient’s relatives in their care by explaining the patient’s condition and treatment plan to them. This helps ensure that everyone involved understands what is happening and can provide support to the patient.

Hygiene

Maintain frequent patient hygiene by regularly wiping away sweat, as patients may perspire heavily due to labored breathing.

Change the soiled linen promptly to ensure the patient’s comfort and cleanliness.

Additionally, assist with personal hygiene activities such as bathing and oral care as needed to promote overall cleanliness and well-being.

Fluids and Nutrition

Encourage the patient to take adequate fluid intake to prevent dehydration and help loosen secretions.

Offer the patient water, electrolyte solutions, and other hydrating beverages regularly to ensure proper hydration.

Give a patient nutritious meals and snacks to support the patient’s nutritional needs and overall health during the asthma exacerbation.

Monitor intake and output closely to assess hydration status and adjust fluid and nutrition interventions as necessary.

Elimination

Monitor the patient’s urine output regularly to assess renal function and hydration status.

Adequate urine output indicates proper kidney function and hydration levels, while decreased output may suggest dehydration or renal impairment.

Additionally, ensure accessibility to bathroom facilities and assist the patient with toileting as needed to promote comfort and maintain urinary continence.

Exercises

Educate and support the patient and their family members on performing diaphragmatic breathing exercises, which can help improve respiratory function and alleviate symptoms of asthma.

Encourage the patient to engage in relaxation exercises such as deep breathing, meditation, or guided imagery to reduce stress and promote overall well-being.

Plan activities and rest periods to balance energy expenditure and prevent fatigue.

Adjust activity levels based on the patient’s tolerance and respiratory status, aiming to minimize exertion and conserve energy while still promoting mobility and independence.

Medication Management

Ensure the timely administration of prescribed medications according to the healthcare provider’s instructions.

Monitor the patient closely for any adverse effects or complications related to medication administration.

Educate the patient and their caregivers on the purpose, dosage, and potential side effects of each medication to promote understanding and compliance.

Document medication administration accurately, and report any concerns or unexpected reactions promptly to the healthcare team for further evaluation and management.

Additionally, provide ongoing support and counseling to address any questions or concerns the patient may have regarding their medication regimen.

Information, Education, and Communication

Inhaler Technique: Educate the patient on how to properly use an oral inhaler and warn about potential adverse reactions associated with the prescribed medications. Demonstrate inhaler use and ensure the patient understands the correct administration technique.

Deep Breathing and Coughing Techniques: Teach the patient deep breathing exercises to improve lung function and instruct on effective coughing to clear secretions accumulated overnight. Provide demonstrations and encourage practice to enhance proficiency.

Allergen Avoidance: Instruct the patient and their family to avoid known allergens and irritants such as smoking, dust, perfumes, pet fur, and cold weather to reduce asthma triggers. Emphasize the importance of creating a clean and allergen-free environment.

Medication Compliance: Stress the importance of taking only prescribed medications, highlighting the potential for certain drugs like aspirin to precipitate asthma attacks. Emphasize the need for adherence to the prescribed treatment regimen to effectively manage asthma symptoms.

Hydration and Nutrition: Encourage the patient to drink plenty of fluids, aiming for at least 3 liters per day, to help loosen secretions and maintain hydration. Promote a well-balanced diet rich in fruits, vegetables, and lean proteins to support respiratory health, prevent infections, and combat fatigue.

Review Dates: Explain the significance of review dates for medications and treatment plans. Encourage regular follow-up appointments with healthcare providers to monitor asthma control, adjust medications as needed, and address any concerns or changes in symptoms.

Recognition of Asthma Symptoms: Educate the patient on the signs and symptoms of an impending asthma attack and stress the importance of seeking medical attention promptly if symptoms worsen or if they experience difficulty breathing, chest tightness, wheezing, or persistent coughing. Prompt intervention can help prevent severe asthma exacerbations and complications.

Complications

Status Asthmaticus: This represents a severe asthma attack that is unresponsive to standard medications.

It occurs when impaired gas exchange and increased airway resistance intensify the work of breathing.

Symptoms persist despite attempts to alleviate them, posing a serious threat to the patient’s respiratory function and overall health.

Respiratory Failure: This condition signifies the lungs’ inability to maintain the balance between oxygen and carbon dioxide levels in the blood.

It results in inadequate oxygenation of tissues and impaired removal of carbon dioxide, leading to potentially life-threatening consequences.

Tension Pneumothorax: Tension pneumothorax arises from the rupture of a subpleural bleb, causing air to accumulate in the pleural space under pressure.

This condition compresses the lung and mediastinal structures, impairing respiratory function and circulation.

Cardiac Arrest: Respiratory failure can progress to cardiac arrest as the body’s oxygen supply becomes severely compromised.

Without adequate oxygenation, the heart cannot function properly, leading to a cessation of cardiac activity and a life-threatening emergency.

Emphysema: Emphysema results from irreversible air trapping in the alveolar spaces, often stemming from repeated asthma attacks.

This condition reduces the total lung capacity, impairs gas exchange, and contributes to chronic respiratory symptoms and complications.

Atelectasis: Atelectasis occurs when a portion of the lung collapses due to the accumulation of air in the alveoli.

This can result from various factors, including airway obstruction, lung compression, or decreased surfactant production, leading to impaired gas exchange and respiratory compromise.

Asthma | Classifications | Risk Factors | Sign and symptoms | Pathophysiology | Nursing Management

What is asthma?

Classifications Of Asthma

Extrinsic asthma

Intrinsic asthma

Common Triggers of Asthmatic Attacks

Pathophysiology