Asthma: Care of a Patient with Asthma

The proper treatment and management of all disorders begin with proper diagnosis within the definition of the meaning of that disease, in this case asthma. Asthma is a condition of the lungs which is caused by inhaled and/or orally consumed irritants/allergens. These substances cause broncho-constriction/bronchospasm. This is the tightening of the muscles surrounding the air passages and swelling due to irritation of the mucosa. Constriction and inflammation cause narrowing of the airways which results in the classic expiatory wheezes, coughing, chest tightness, and shortness of breath. Untreated asthma can cause long-term loss of lung function.

Here, I deal with the nursing management and medical interventions for this condition. The discussion is limited because the author plans not to exceed two thousand and two hundred words. Therefore this article will not discuss diagnostic procedures but will assume that correct diagnosis has been made.

Asthma is classified according to it's severity as shown below:

Classification of the Pattern of Asthma.

1. Infrequent Episodic:

   Episode 6 to 8 weeks apart, mild attack, minimal symptoms between attacks. Normal lungs between attacks.

2. Frequent Episodic:

   Episodes 6 weeks apart, severe attacks, symptoms present between attacks, lungs abnormal between attacks

3. Persistent:

   Daytime symptoms 2 days per week, nocturnal symptoms 1 night/week, attacks 6 weeks apart. Abnormal lung function, multiple ED visits or hospital admissions.

Many asthmatics are able to lead a normal life, without attacks or symptoms between attacks. Further, the severities of all attacks are not uniform and are on a continuum. The mildest forms of asthma attacks do not require any intervention and often subside spontaneously. The most severe forms may require the patient to be paralysed and be placed on a respirator. This intervention saves lives.

Asthma attacks can be prevented by avoiding the substances which cause the breathing difficulty. However, for a patient to know which substances to avoid he/she must know the allergens. This can be done by serum sensitivity studies. The practice of doing skin tests to determine sensitivity is becoming less popular because it is less reliable. Even after knowing all the allergens it many not be possible to avoid them because the offending allergens may be present in the air or water which the patient consumes. For example, household dust is a known allergen which is difficult to avoid. Smoke and other pollutants are also known allergens which are in the air and are equally difficult to avoid unless the patient is in a closed air controlled environment where micro filters can be used to reduce the allergens in the air.

Nursing and Medical interventions must be made based on the severity of the overall disease and the severity of the episode being treated. Episodes are subdivide in four main categories as shown below:

1. Mild: Normal mental state, accessory muscles not used.
2. Moderate: Normal mental state, accessory muscles of respiration are used.
3. Severe: Agitated mental state with marked use of accessory muscles.
4. Critical: Confused/drowsy patient using accessory muscles.

The common general signs and symptoms of mild asthma are alterations in respiratory pattern, feeling tired, discomfort in chest, headache, feeling depressed, generalised weakness, mood and temperament changes, watery eyes, stuffy nose, sneezing, coughing, excessive sputum production, decreased peak flow, shortness of breath upon exertion and wheezy breathing. In very mild asthma the patient may experience an expiratory wheeze and a slight shortness of breath. Accessory muscles are not used. Oxygen administration is not needed however the patient must be observed in the ED. 6 to 12 puffs of an inhaled beta agonist (salbutamol) will help control the episode. Patient should be made comfortable, sit him upright and offer him sips of water and nutrition in small amounts.

In moderate asthma oxygen is not usually indicated. In addition to all the comfort measures used in mild asthma Beta agonists, 6 to 12 puffs are given at 20 minute intervals; three doses in one hour. The patient is reviewed after 10 minutes following the administration of the third dose. Oral prednisolone 1mg/kg/dose is usually administered to reduce inflammation. Such patients can usually be discharged after one hour. Use of accessory muscles and altered PCO2 and O2 occur during acute attacks.

In severe asthma there is extensive use of accessory muscles and the SaO2 is usually more than 92%. Oxygen administration, the use of inhaled beta agonist is indicated along with 2 to 4 puffs of ipratropium with a spacer. This is done three times/hr at 20 min intervals. Oral prednisolone 1mg/kg/dose for three days and an antiematic may be prescribed. This group of patients usually require inhospital treatment and plans for admission should be commenced as soon as possible to alleviate anxiety associated with uncertainty.

The signs and symptoms of critical asthma are shortness of breath, even when at rest, altered breathing patterns, hunched shoulders (posturing), nasal flaring (Nostril size increases with breathing), and retractions (neck area and between or below the ribs moves inward during inspirations), gray or bluish tint to skin (cyanosis), peak flow of less than 50%. The patient's life may be at risk therefore no effort is spared. O2 is commenced immediately. The patient is commenced on continuous nebulised salbutamol. 250mcg X3 doses/hr for one hour over a period of one hour, one dose is usually given. Methylprednisolone 1mg/kg/dose is given six hourly. IV salbutamol may be commenced if he response to nebulised salbutamol is poor. The patient may be referred to ICU if not responding to treatment. In the ICU it may be necessary to paralyse and ventilate the patient until the inflammation and spasm of the bronchioles is under control.