Asthma is a chronic allergic, immune mediated and inflammatory disease. Main signs and symptoms of asthma comprises of shortness of breath, increased respiratory rate, difficulty in breathing, coughing and wheezing. Occurrence of asthma is more in children which is known as childhood asthma. Etiological factors of asthma include cold air, exercise, pollen, viruses, genetic factors, drugs like aspirin and beta blockers. Asthma attacks can occur in many occasions in a single day or on few days in a week. Approximately, 1 in 9 people in Australia have asthma. It is more common in male below 14 years of age, however it is more common in female above 14 years of age. Asthma is prevalent in the older and Indigenous Australians also. Asthma is more prevalent in people with low socioeconomic class. Asthma is a huge financial and social burden in Australia. 451 per 100,000 population children fewer than 15 years age are hospitalized due to asthma. Approximately 400 deaths per year occurs due to asthma in Australia in last 10 years. 34 % people reported interference in daily activities due to asthma and 21 % children reported off form school or work due to asthma (AIHW, 2016). In this essay, case of 6 years old Zachy is discussed, who is suffering through coughing, wheezing and difficulty in breathing. Signs and symptoms of Zachy are correlated with pathphysiological changes of asthma.
Asthma pathophysiology can be studied in four different categories like bronchoconstriction, airway edema, airway hyperresponsiveness and airway remodeling. Inflammation of the airways leads to the bronchoconstriction. Type 1 hypersensitivity reactions are responsible for the initiation of the asthma attack. Allergens are processed by antigen presenting cells and these are presented to the naïve T lymphocytes like Th0 cells. Th0 cells switch to the Th2 cells after presentation of the allergens. Th2 cells release different cytokines like IL-4 and IL-13. These cytokines act on the B lymphocytes to produce immunoglobulin E. These IgE bind to the Fc receptors present on the mast cells. Binding of the IgE to the receptors on the mast cells is termed as the sensitization phase of asthma (Bonini and Usmani, 2015). When there is repeated attack of same allergens in the same person, newly entered allergens bind to the IgE and Fc receptors complex on the mast cells. This binding leads to the degranulation of the mast cells. This degranulation of the mast cells lead to the release of different mediators like histamine, leucotrines and prostaglandins. These mediators produce contraction of the airway smooth muscle and consequently narrowing of airways and bronchoconstriction. These mediators can also be released by IgE independent pathway. Aspirin and non-steroidal anti-inflammatory drugs are responsible for the IgE independent pathway. Bronchoconstriction can also be induced by physical factors like cold, excercise and irritants. Stress is also responsible for bronchoconstriction in asthma (Erjefält, 2010).
Inflammation in the asthma can be produced due to inflammatory cells like Th2 lymphocytes, mast cells, eosinophils, dendritic cells, epithelial cells, macrophases and resident cells of airway. Progressive and chronic inflammation of the airways can result in the edema formation in the airways. Mucus hypersecretion and deposition of mucus plugs in the airways can occur due to inflammation. Sustained inflammation leads to the hypertrophy and hyperplasia of the airways. This results in the reduced airflow through the airways. Sustained inflammation and the structural changes in the airways lead to the airway hyperresponsiveness (Patadia et al., 2014).
Airway remodeling comprises of permanent structural changes in the airways which can lead to the loss of lung function. Features of airway remodeling are sub-basement membrane thickening, subepithelial fibrosis, hypertrophy and hyperplasia of airway smooth muscle, proliferation and dilation of blood vessels, mucous gland hyperplasia and mucus hypersecretion. Due to loss of lung function, there can be insufficient breathing. Insufficient breathing lead to the less exchange of oxygen at the alveoli and blood capillaries interface. As a result, there is less oxygen in the blood and less oxygen saturation. In case of Zachy also, less oxygen saturation observed. In children of Zachy’s age oxygen saturation should be above 95 %, however in case Zachy oxygen saturation level is 92 %. Due to low level of oxygen in the blood, lung tries to compensate it by inhaling more air which leads to increase in breathing rate. As a result, there is increase in respiratory rate in asthma patients. In case of Zachy also, there is increased respiratory rate. In children of Zachy’s age respiratory rate should be below 20 breath per minute, however it was observed that in case of Zachy respiratory rate is 37 breaths per minute (Mims, 2015; Chawes, 2011).
Cough can be of two types productive cough and non-productive cough. Productive cough expels phlegm and it act as defense mechanism. Non-productive cough is dry cough and it occurs due to irritation of the inflamed airways and constricted airways. In asthma patients, non-productive cough occurs. If cough is accompanied by other signs and symptoms like chest tightness, wheezing, fatigue, long duration infection and breathing difficulties, it is considered as cough due to asthma. In asthma children, there are more incidences of cough in the night (Patadia et al., 2014). In case of Zachy also, cough is more in the night time. Wheezing is the whistling like sound of exhaled air. By force passage of air through narrow and constricted airways produces wheezing sound in the Zachy. Wheezing can be of two types like transient and persistent wheezing. If wheezing stops at age of 3 years, it is called as transient wheezing. If wheezing continues after age of 5 years, it is called as persistent wheezing. In case of Zachy, there is persistent wheezing (West et al., 2013; Krishnan et al., 2012).
Conclusion:
Asthma is a multifactorial disease with diverse etiological factors. Asthma is a very common disease in children and associated with nocturnal cough. Pathophysiological changes associated with asthma are inflammation of airways, bronchospasm and airway remodeling. Zachy exhibited symptoms of asthma like rapid respiratory rate, coughing, wheezing and low oxygen saturation level with respect to the pathological changes. Multiple mechanisms are involved in the pathogenesis of asthma and these different mechanisms exhibit respective symptoms. For the management of symptoms of asthma nurse should have sound knowledge of relevant pathophysiological mechanisms.
Asthma is a complex disease involving different mechanisms like immune, allergic and inflammatory. Due to these different mechanisms, different types of receptors, enzymes and cytokines are responsible for the different symptoms and pathological changes in asthma. Asthma patients should be treated with different drugs acting on different targets for the management of different symptoms. Asthma is a chronic disease, hence different types of drugs or different types of treatments should be planned at different stages of the disease. In acute stage of the asthma treatment should be planned for the management of symptoms while in chronic stages treatment should be planned to reverse pathological changes. In addition to the medication treatment, asthma patients should also be managed by incorporation of the non-medication treatment. In this essay, Zachy’s medication and non-medication treatments are discussed.
Ipratropium is an anticholinergic and muscarinic receptor antagonist drug, which acts on the airway smooth muscle. Inhibition of muscarinic acetylcholine receptors results in the degradation of cyclic guanosine monophosphate (cGMP). As a result, there is reduced action of cGMP on intracellular calcium which lead to reduced contractibility of smooth muscle of airways and inhibition of bronchoconstriction. It results in the smooth muscle relaxation and consequently bronchodilation. Nurse should educate Zachy and her parents about the use of ipratropium inhaler. Zachy should be encouraged to use mouthpiece instead of face mask. Nurse should monitor asthma symptoms in Zachy, prior to and after administration of ipratropium inhalation (Aaron, 2001).
Prednisolone is glucocorticosteroidal anti-inflammatory drug which also exhibits immunosuppressant action. It produces effect on the feedback mechanism of immune system to produce immunosuppressant and anti-inflammatory effect. It exhibits its effect by binding to the glucocorticoid receptor which results in the activation of the glucocorticoid receptors. Activation of glucocorticoid receptors lead to transactivation and transrepression. These two mechanisms exhibits anti-inflmmatory effect. Transactivation comprises of upregulation of the anti-inflammatory genes like lipocortin I, p11/calpactin binding protein, secretory leukoprotease inhibitor 1 (SLPI), and mitogen-activated protein kinase phosphatase (MAPK phosphatase). Repression of expression of proinflammatory proteins in cytosol occurs in transrepression. As a result, translocation of transcription factors like NF-κB from cytosol to nucleus gets inhibited. Hence, transcription of inflammatory genes like NF-κB gets prevented. Nurse should monitor electrolyte balance and occurrence of infection in Zachy because consumption of prednisolone may disturb electrolyte balance in Zachy and increase susceptibility to infection (Olin and Wechsler, 2014; Zhang et al., 2014).
Salbutamol through inhalation route is useful as bronchodilator in the asthma patients. Salbutamol is a short acting β2 adrenergic receptor agonist. Bronchial smooth muscle of the lung contains abundant amount of β2 adrenergic receptors. Adenyl cyclase enzyme gets activated due to activation β2 adrenergic receptors. Adenyl cyclase acts as catalyst for the conversion of adenosine-tri-phosphate (ATP) to adenosine-mono-phosphate (cyclic AMP). This increase in the cyclic AMP results in the relaxation of the airway smooth muscle and decrease in the airway resistance due to decrease in the amount of intracellular calcium ions. This increased level of cyclic AMP prevents release of mediators such as leukotreine and histamine which are responsible for bronchoconstriction (van Buul and Taube, 2015; Neininger et al., 2015).
Amoxicillin is administered to Zachy through per oral route for the prevention of bacterial infection. Amoxicillin antibiotic comes under penicillin class. Amoxicillin produce bactericidal action against the bacteria at the stage of active multiplication. It produces bactericidal action by inhibiting cell wall biosynthesis. It inhibits cell wall biosynthesis by inhibiting cross-linkage of linear peptidoglycan polymer chains. Nurse should perform hypersensitivity tests for amoxicillin in Zachy prior to its administration. Zachy should consume amoxicillin along with food because it can produce GI upset on empty stomach. Parents of Zachy should be educated about discontinuation of amoxicillin. Amoxicillin should not be discontinued and should be consumed for scheduled course, even if infection disappeared (Ghoshal et al., 2012; Francis et al., 2015).
Paracetamol is administered in Zachy for treating pain. Exact mechanism of action of paracetamol has not been established. However, few mechanisms are proposed for mechanism of paracetamol for pain. These mechanisms include inhibition of COX activities, modulation of endogenous cannabinoid system in the brain and activation of transient receptor potential cation channel subfamily V member 1 (TRPV1). Nurse should monitor hypersensitivity to paracetamol in Zachy (Karakaya and Kalyoncu, 2003)
Treatment should be initiated with quick relief medication like salbutamol inhalation. It should be initiated with 2 puffs each time and it should be repeated every four hours. It should not be given earlier than four hours without consultation of the doctor. Zachy and her parents should be educated to use inhaler in the initial period. By this, they can use it in absence of hospital staff and it would avoid medication discontinuation. Zachy should not be given any cough suppressant. Inhaler should be use with spacer because it would increase amount of drug reaching to lungs. Zachy should be encouraged to consume lot of fluid because it would be helpful in keeping Zachy in hydrated condition and facilitate thinning of phlegm. Humidifier should be provided in the room, if there is more dry air in the room. Dry air can exaggerate cough in Zachy. Zachy should be advised to maintain hygienic condition by using face mask. Also, hospital staff and visitors should be advised use all personal protective equipments (PPEs) before entering in the room. Due to asthma, Zachy is more susceptible to infection. As oxygen saturation level is low in Zachy, supplemental oxygen should be immediately started in Zachy to achieve oxygen saturation level above 95 %. Corticosteroid like prednisolone should be administered in Zachy within first hour of admission to the hospital. Nurse should assess breathing pattern and cough in Zachy every hour. If these symptoms are not responding to the given treatment, nurse should consult doctor for change in medications or changing frequency of medications. Nurse should monitor Zachy for approximately one hour after the resolution of the breathing difficulty (Howcroft et al., 2016; Heffner, 2011).
Nurse should assess breathing pattern in Zachy by hearing sounds and measuring breathing rate. Along with medication administration, nurse should provide non-medical interventions for Zachy to improve breathing pattern. Zachy should sit in upright position with proper body alignment, as it is helpful in chest expansion. Zachy should take deep and diaphragmatic breathing because it reduces air trapping in the lung, relaxes muscle and increase oxygen saturation level. Nurse should advise Zachy to perform suitable exercise because it increases working capability of respiratory muscle. Zachy should take frequent meals with small quantities because it would keep stomach empty and ventilation would be improved. Nurse should record body weight and nutritional requirements of Zachy prior to initiation of the treatment because asthma patients tend to consume less food. Nurse should also record physical and vital signs of Zachy. Nurse should provide Zachy with good environment and parents company while taking meals. Zachy should consume high protein containing liquids because it provide high calorie. Zachy should not consume caffeinated and carbonated liquids because it gives false feeling of satiety and reduces hunger (Chow et al., 2015; Janssen et al., 2012).
Irrespective of the age of the patient and severity of the disease, patient and family members education should be the integral part of asthma management. It is evident from the literature that patient and family members education can reduce hospitalization and improve quality of life in children. Several guidelines indicated education about pathophysiology of asthma, use of inhaler and medication adherence as the components of education programme in asthma patients. Zachy and her parents should be informed openly about the possible side effects of medications. Action plan for nursing intervention should be given in written format for Zachy’s parents. This action plan should also comprise of signs and symptoms and extent of its worsening (Klok et al., 2015).
Zachy should cough for 2-3 times in sequence and should change position on regular basis during coughing. Zachy should keep himself away from dust and allergens because these can exaggerate asthma condition in Zachy. Different professionals like pharmacist, clinical laboratory scientist, dieticians and physical trainers should be incorporated in the management of Zachy. Pharamcist should take care of the medication management in Zachy. Clinical laboratory scientist should perform required tests for the assessment of Zachy’s condition. Dietician should plan proper diet in Zachy, so that consumption would be increased and would provide high calorie to Zachy. Physical trainer should teach Zachy about suitable exercise to improve breathing pattern (VanGarsse et al., 2015; Young, 2011).
Conclusion:
For the treatment of asthma in Zachy different drugs like anti-inflammatory prednisolone, bronchodilator salbutamol and ipratropium, antibiotic amoxicillin and paracetamol for pain relief are incorporated. These drugs are useful in the management of different symptoms and pathological changes. Non-medication management provided for Zachy in the form of education about the disease, medication management, diet, infection prevention, exercise and nebulization use. Different professionals like pharmacist, clinical laboratory scientist, dieticians and physical trainers are incorporated in the management of asthma in case of Zachy. In summary, targeted treatment would definitely be useful in improvement of asthma signs and symptoms of Zachy.
References:
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