Pathogenesis, Nursing Strategies, And Drug Management Of Acute Severe Asthma

Introduction to Asthma and Its Causes

References:

Chung, K. F., Wenzel, S. E., Brozek, J. L., Bush, A., Castro, M., Sterk, P. J., … & Boulet, L. P. (2014). International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. European respiratory journal, 43(2), 343-373. doi:1183/09031936.00202013

Apter, A. J. (2014). Advances in adult asthma diagnosis and treatment in 2013. Journal of Allergy and Clinical Immunology, 133(1), 49-56. Apter, A. J. (2014). https://doi.org/10.1016/j.jaci.2013.11.005

Teo, S. M., Mok, D., Pham, K., Kusel, M., Serralha, M., Troy, N., … & Bochkov, Y. A. (2015). The infant nasopharyngeal microbiome impacts severity of lower respiratory infection and risk of asthma development. Cell host & microbe, 17(5), 704-715. https://doi.org/10.1016/j.chom.2015.03.008

Griffiths, B., & Ducharme, F. M. (2013). Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Paediatric respiratory reviews, 14(4), 234-235. https://doi.org/10.1016/j.prrv.2013.08.002

Miguel-Montanes, R., Hajage, D., Messika, J., Bertrand, F., Gaudry, S., Rafat, C., … & Dreyfuss, D. (2015). Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Critical care medicine, 43(3), 574-583. doi: 10.1097/CCM.0000000000000743

Nievas, I. F. F., & Anand, K. J. (2013). Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit. The journal of pediatric pharmacology and therapeutics, 18(2), 88-104. https://doi.org/10.5863/1551-6776-18.2.88

Des Jardins, T., & Burton, G. G. (2015). Clinical Manifestations & Assessment of Respiratory Disease-E-Book. Elsevier Health Sciences. 7^th https://books.google.co.in/books?hl=en&lr=&id=PjQwBwAAQBAJ&oi=fnd&pg=PP1&dq=Des+Jardins,+T.,+%26+Burton,+G.+G.+(2015).+Clinical+Manifestations+%26+Assessment+of+Respiratory+Disease-E-Book.+Elsevier+Health+Sciences.&ots=f7QZzBcZLI&sig=p4yk9_-2ssTxxVFjcnaIA1tsUys#v=onepage&q=Des%20Jardins%2C%20T.%2C%20%26%20Burton%2C%20G.%20G.%20(2015).%20Clinical%20Manifestations%20%26%20Assessment%20of%20Respiratory%20Disease-E-Book.%20Elsevier%20Health%20Sciences.&f=false

Grosso, A., Locatelli, F., Gini, E., Albicini, F., Tirelli, C., Cerveri, I., & Corsico, A. G. (2018). The course of asthma during pregnancy in a recent, multicase–control study on respiratory health. Allergy, Asthma & Clinical Immunology, 14(1), 16. https://doi.org/10.1186/s13223-018-0242-0

Fergeson, J. E., Patel, S. S., & Lockey, R. F. (2017). Acute asthma, prognosis, and treatment. Journal of Allergy and Clinical Immunology, 139(2), 438-447. doi: 10.1016/j.jaci.2016.06.054.

Feldman, A. S., He, Y., Moore, M. L., Hershenson, M. B., & Hartert, T. V. (2015). Toward primary prevention of asthma. Reviewing the evidence for early-life respiratory viral infections as modifiable risk factors to prevent childhood asthma. American journal of respiratory and critical care medicine, 191(1), 34-44. https://doi.org/10.1164/rccm.201405-0901PP

One of the most prevalent obstructive lung diseases in Australia is asthma. Nearly about 10.2% people in Australia suffer from asthma (Chung et al., 2014). It has been found that indigenous population is more vulnerable to asthma as compare to the non-indigenous population, thus, rate of hospitalisation and mortality rate is also high due to asthma in this population (National Asthma Council of Australia (2015). Asthma is defined as the chronic inflammatory disease of lungs and it is characterised as the development of hyperresponsiveness and bronchospam which lead to the consequence of wheezing, coughing and breathlessness. Such clinical manifestation of asthma may create minimum nuisance in some non-acute cases, however, in severe cases it may lead to life threatening situation. Asthma is may be induced by some environmental factors such as allergic reaction to pollens, air pollutants, pet dander, exposure to chemicals and others (Feldman et al., 2015). On the other hand the illness may occur due to the interaction of several genes. Asthma has been found to be atopic in most of the cases. In such cases the clinical manifestations develops due to the personal or familial potentiality to produce IgE which interacts with the low doses of allergens and develops symptoms of atopic asthma and other allergic disorders as well (Teo et al., 2015). It has been reported that, asthma cannot be cured completely, especially the severe acute asthma. Nevertheless the clinical manifestations could be managed with effective nursing management and care plans. However, it is difficult to manage severe acute asthma with even with pharmacological treatment (Apter, 2014).

Clinical Manifestations of Acute Severe Asthma in an 18-year-old male

In the given scenario, the patient Jackson Smith has been found to be diagnosed with asthma in childhood and at the age of 18 years he has been admitted to the emergency department with the clinical manifestation of severe breathing problem or dyspnoea. Dyspnoea has been considered as the one of the common suffering during asthma attack (Des Jardins & Burton, 2015). In case of asthma the airways of lungs become narrow and swelling and tightening of muscle develops. On the other hand, the lungs produce excessive mucus. Such consequences develop because the high production of IgE results in the binding of allergens with the IgE in the mucosal lining containing sensitized mast cells (Fergeson, Patel & Lockey, 2017). Such condition results in the releasing of various inflammatory mediators for example, prostaglandins, interleukins, leukotrienes and histamine. Excessive release of such inflammatory mediators leads to the constriction of smooth muscle, hence tightening and swelling of muscles occur. Additionally, the constriction of smooth muscle results in the increasing vascular permeability which leads to high secretion of mucus. Such condition causes problem in breathing as the air becomes trapped in the narrow air passages (Des Jardins & Burton, 2015).

In addition the auscultation has indicated presence of diminished breath sound and wide spread wheeze. As mentioned before that in case of asthma constriction of smooth muscle occurs which leads to the narrow airways of lungs. When air moves through such narrow and constricted air passage, vibration occur which results in wheezing (Feldman et al., 2015). The assessment of vital sign of the patient has indicated high blood pressure (150/85 mmHg) and high respiratory rate such as 32 breaths per minute. Further the blood gas test has reported about low partial pressure of oxygen which is 60 mmHg whereas the normal range is 75-100 mmHg and high partial pressure of carbon dioxide such as 50 mmHg, whereas the normal range is 38-42 mmHg. Hence, poor oxygen intake has been identified (Fergeson, Patel & Lockey, 2017). On the other hand, the chest x-ray report has indicated the presence of hyper-inflated lungs as well. Due to the narrowing of airways the air trapped behind the air passages, hence the air could enter the lungs but it becomes difficult to expel the inhaled air. Such condition leads to the consequence of hyper-inflated lungs (Des Jardins & Burton, 2015). In case of poor oxygen intake results in mismatch of ventilation and perfusion which leads to the development of hypoxemia. In such condition the heart needs to work harder in order to compensate and overcome the tension which leads to elevation of BP and respiratory rate (Feldman et al., 2015). Hence, the patient needs to guide with proper nursing management to cope up with the current severe condition.

Evidence-based Nursing Strategies for Managing Acute Severe Asthma

In order to help Jackson to manage the symptoms of severe acute asthma it is important to introduce effective nursing strategies. The patient has been found to be suffering from severe dyspnoea or breathlessness and due to poor oxygen intake consequence of hypoxemia may be developed. In such cases oxygen therapy is the most relevant nursing strategy in order to reduce such complications (Miguel-Montanes et al., 2015). In this regards it is important to provide adequate amount of oxygen in order to meet the oxygen requirement of the patient. Research has recommended that oxygen could be administered through mask or nasal cannula based on the comfort level of the patient. If nasal cannula is used to provide the oxygen therapy it is required to provide 1-6 LPM oxygen while maintaining the flow of oxygen at 4% per litter. On the other hand, if mask is used for oxygen therapy 5-8 LPM oxygen needs to be provided and the flow of oxygen should same as nasal cannula (4% per litter) (Mayfield et al., 2014). Such nursing strategy would help to reduce the complication associated with breathlessness in an effective manner.

Another important factor in case of Jackson is the increase in BP and respiratory rate due to high struggle of heart. Hence, it is required to facilitate the ventilation in order to help the patient to reduce the muscular fatigue and reduce the BP and respiratory rate to a normal range. In this regards the non-invasive ventilation would be helpful as per the recommendation of research (Alves et al., 2014). The process aims to improve the functional residual capacity hence, reduces the struggle for breathing. Air trapping is one of the most common issues during asthma attack. In this case inspiratory pressure support which is provided through PEEP helps to reduce the effort for breathing. Such process helps to reduce the complications due to poor alveolar ventilation (Nanchal et al., 2014). Effective ventilation and oxygen therapy would help the patient to manage his situation in a better manner.

Salbutamol: Salbutamol is one of the effective drugs that the physicians recommend for a patient with asthma. The drug binds actively with the beta-2-adrenoreceptors of the smooth muscle on bronchi and stabilizes the receptors in an effective manner. Hence, open up the blocked air ways in the lungs. Such activity of the drug helps to relief the symptom of asthma such as breathlessness, wheezing and coughing (Nievas & Anand, 2013).

Drug Management for Acute Severe Asthma

Ipratropium bromide: Ipratropium bromide is another recommended drug which effectively reliefs the complications during asthma attack. Acetylcholine is a potential factor that triggers the allergic reaction during asthma and contributes to the consequence of narrow air passages in lungs. The drug has anti-cholinergic activity which helps to reduce the effect of acetylcholine, hence, improves the condition of the patient in an effective manner (Griffiths & Ducharme, 2013).

IV hydrocortisone: High production of IgE is associated with the release of inflammatory mediator which leads to the constriction of smooth muscle and narrowing of airways. The drug hydrocortisone has the anti-inflammatory action. It binds with the serum albumin and corticosteroid binding globulin, hence, enhances the binding of free cortisol with receptors and inhibits the release of inflammatory mediators. Thus, helps in reducing the complications associated with inflammation of lungs (Nievas & Anand, 2013).

In addition to such effectiveness of these drugs, there are some side effects of these drugs as well which may lead to adverse events. For example, Ipratropium bromide may cause increase the breathing issue and dry mouth, in contrast, Salbutamol may lead to the consequence of chest pain, rapid heartbeat and headache (Griffiths & Ducharme, 2013). On the other hand, hydrocortisone may cause high BP, nausea, vomiting and depression. Hence it is important to provide proper doses of these drugs to the patient and monitor the patient in order to identify any adverse effect, so that adequate measure could be taken to manage such condition. Such awareness while administering the drugs would help to avoid medical error (Nievas & Anand, 2013).

References:

Alves, D., Freitas, A. S., Jacinto, T., Vaz, M. S., Lopes, F. O., & Fonseca, J. A. (2014). Increasing use of non-invasive ventilation in asthma: a long-term analysis of the Portuguese national hospitalization database. Journal of Asthma, 51(10), 1068-1075. https://doi.org/10.3109/02770903.2014.939280

Des Jardins, T., & Burton, G. G. (2015). Clinical Manifestations & Assessment of Respiratory Disease-E-Book. Elsevier Health Sciences. 7^th edition. https://books.google.co.in/books?hl=en&lr=&id=PjQwBwAAQBAJ&oi=fnd&pg=PP1&dq=Des+Jardins,+T.,+%26+Burton,+G.+G.+(2015).+Clinical+Manifestations+%26+Assessment+of+Respiratory+Disease-E-Book.+Elsevier+Health+Sciences.&ots=f7QZzBcZLI&sig=p4yk9_-2ssTxxVFjcnaIA1tsUys#v=onepage&q=Des%20Jardins%2C%20T.%2C%20%26%20Burton%2C%20G.%20G.%20(2015).%20Clinical%20Manifestations%20%26%20Assessment%20of%20Respiratory%20Disease-E-Book.%20Elsevier%20Health%20Sciences.&f=false

Fergeson, J. E., Patel, S. S., & Lockey, R. F. (2017). Acute asthma, prognosis, and treatment. Journal of Allergy and Clinical Immunology, 139(2), 438-447. doi: 10.1016/j.jaci.2016.06.054.

Mayfield, S., Bogossian, F., O’Malley, L., & Schibler, A. (2014). High?flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. Journal of paediatrics and child health, 50(5), 373-378. https://doi.org/10.1111/jpc.12509

Nanchal, R., Kumar, G., Majumdar, T., Taneja, A., Patel, J., Dagar, G., … & Whittle, J. (2014). Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database. Respiratory care, 59(5), 644-653. DOI: 10.4187/respcare.02505

National Asthma Council of Australia (2015). Australian asthma handbook. Retrieved from: https://www.asthmahandbook.org.au/download-order

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