C - Asthma

Question 1

Causes & symptoms of asthma?

Answer 1

• Exact cause unknown
• genetic + environmental factors

Symptoms often initiated by environmental trigger:
- Triggering substance differs for people
- Common triggers: pollution, allergens (dust, pet dander, cockroaches, and mould)
- Medications like aspirin and beta-blockers have also been known to trigger symptoms in some individuals with asthma
- Cold dry air

Question 2

What are the anatomical difference of an INFANT’s upper airways?

Answer 2

1. BIG tongue & epiglottis -> can block airway easily -> MAKE SURE CHILDREN SIT UPRIGHT
2. SHORT neck & trachea
3. Larynx higher & anterior
4. Narrowest part of airway = cricoid cartilage
   - trauma to airway -> oedema -> narrow -> hard to breathe

Question 3

Whats the difference between mild, moderate and severe persistent asthma?

Answer 3

Mild persistent asthma
 Daytime symptoms 3-6 days/ wk
 Night time symptoms 3-4x /mth
 Lung function testing is >80% of predicted value

Moderate persistent asthma
 Daily daytime symptoms
 At least weekly night time symptoms
 Lung function testing is 60-80% of predicted value

Severe persistent asthma
 Continual daytime symptom
 Frequent night time symptom
 Lung function testing is <60% of predicted value

Question 4

Physical Assessment for asthma? (3)

Answer 4

1. Air entry
   - FEV1/FVC < 70% = airway obstruction
   - peak expiratory flow rate/PEFR = fastest and the hardest a person can exhale after a full inspiration
   - normal PEFR > 70% of the predicted peak flow for the client’s age
2. bronchodilator response
3. Signs of respiratory distress
   - increased RR, HR
   - decreased o2 saturation
   - using accessory muscles, retractions (muscles betw ribs sink inwards) & nasal flaring, grunting
   - sweaty, clammy skin
   - head bobbing: extending neck to get more air
   - STRIDOR: high-pitch, wheezing upon ascultation
   - croup cough: seal-like barking cough
   - cant speak in full sentences (if alr know how to speak
   - agitated/restless
   - cyanosis
   - conscious level:
   drowsy, hypercapnia (too much CO2 in blood)

Question 5

Nursing management for respiratory distress?

Answer 5

1. O2 therapy & humidifier
   - simple face mask put near them
2. TRIPOD POSITION!!!
   - infant lean forward with hands supporting upper body (can sit on parent’s lap) -> increase o2 inhaled
   - TO MAINTAIN AIRWAY PATENCY!!!!
3. expectorant meds to expel secretions
4. suctioning
   - last case scenario bc it can be uncomfy -> crying will worsen their breathing
   - if needed in acute situation: suction GENTLY!!
   - size 06: infants, children, neonates, size 08: children - 2/3 of nostril circumference
   - encourage spitting/swallow secretion
5. adequate fluid intake

Question 6

Nursing management for moderate exacerbation of asthma? (3)

Answer 6

1. Oxygen to maintain SaO2 >95% via nasal
   prong/mask
2. Salbutamol MDI/Nebulizer
   - relaxes the smooth muscles -> widen airways = bronchodilation -> reduce airflow obstruction
3. Oral Prednisolone:
   - suppresses severe swelling and mucus production in airways

Used for:
- Exacerbation > 48hours: there is ongoing airway inflammation that cannot be controlled with local (inhaled) treatment alone.
- Past history of severe exacerbation: airways prone to severe inflammation -> require more aggressive treatment
- Persistent asthma not responding to
increased dose of inhaled steroids

Question 7

Nursing management for acute exacerbation of Asthma? (3)

Answer 7

1. Relievers: Salbutamol/Ipratropium Bromide
   - Helps open airways quickly/short acting
2. Preventers: Corticosteroids
   - Reduces airway swelling
3. Oxygen

Question 8

Management of underlying asthma? (3)

Answer 8

• Depending on cause
   Adherence to action plan
   Environmental modification

Question 9

NOT IMPT JS READ THROUGH
ASTHMA CASE STUDY PAEDS
What are the steps to be taken for a 10-year-old patient experiencing an exacerbation of asthma?
The nurse has already applied a non-rebreather mask to administer humidified oxygen.

Answer 9

Highest priority: promote airway patency.

According to the airway, breathing, and circulation (ABC) model:

1. airway problems should always be addressed first, followed by breathing and circulation.
2. Support patient’s breathing by elevating head of the bed
3. patient and family should be reassured by the nurse by explaining procedures and answering questions.
4. once acute episode has subsided, educated on best practices to prevent future asthma exacerbations

Question 10

NOT IMPT
Pathology?

Answer 10

• Inhaling a triggering substance can initiate what is known as an asthma exacerbation or attack.
• Triggering substance travels down the airways to the bronchioles, which are composed of cartilage, smooth muscle, and a mucosal lining containing mucus-secreting goblet cells.
• Immune cells like mast cells and basophils, are stimulated to release chemical mediators such as histamine and leukotrienes that cause the smooth muscle in the bronchioles to spasm, known as a bronchospasm, and cause the goblet cells to produce an abundance of mucus.

● Bronchospasm and mucus obstruct the airway, making it difficult to breathe, and leading to symptoms such as coughing, chest tightness, dyspnea, and wheezing, which is a high-pitched whistling sound that usually happens during exhalation.

• Over time, chronic inflammation can lead to scarring and fibrosis which can permanently reduce the airway diameter.

Question 11

NOT IMPT
Risk factors

Answer 11

low birth weight, seasonal allergies, allergies to pet dander, and frequent respiratory illnesses.

Question 12

NOT IMPT
Diagnosis?

Answer 12

Asthma suspected → first step is conducting PFT
■ Forced Vital Capacity (FVC) → total volume of gas exhaled after a forced maximum expiration
■ Forced Expiratory Volume at 1 second (FEV1)
○ Both ↓ in asthma
○ FEV1/FVC ratio less than 70 percent indicates airway obstruction

Emergency situation
○ quickest way to measure airway obstruction is measuring the peak expiratory flow rate, or PEFR, which is essentially the fastest and the hardest a person can exhale after a full inspiration
○ Not as reliable as PFT (functions as a mini PFT), but very useful in an emergency setting
○ normal PEFR > 70% of the predicted peak flow for the client’s age

Question 13

NOT IMPT
Treatment?

Answer 13

● No cure, treatments manage symptoms
○ begins with avoiding or minimising contact with triggering substances
● Depending on frequency and severity of symptoms → stepwise, individualised pharmacological approach is used to control symptoms and prevent exacerbations

Medications
■ bronchodilators that cause smooth muscles in the lungs
● inhaled short-acting beta-agonists like albuterol, long-acting beta-agonists like formoterol
● anticholinergics like ipratropium
■ Corticosteroids reduce airway inflammation and mucus secretion.
● Eg. budesonide / oral prednisone
■ Leukotriene receptor antagonists, or LTRAs to block production of leukotrienes
● Eg. montelukast
■ Mast cell stabilisers → prevent release of inflammatory chemicals from mast cells
● Eg. cromolyn
■ monoclonal antibody → lowers IgE levels, then decreases the release of chemical mediators from immune cells
● Eg. omalizumab

→ Treatment for severe asthma exacerbation)
● immediately begin with a bronchodilator and supplemental oxygen titrated to an oxygen saturation above 92 percent
● Other medications will be administered until the exacerbation resolves.