Asthma Treatment
Treatment outcomes:
1. Quickly treat acute symptoms ("Rescue")
2. Prevention
Rescue Medications : Relieve or stop symptoms once they have started. May also be used prior to exercise to avoid symptoms.
Beta ? adrenergic agonists (short acting)
Albuterol (Provental);
levalbuterol (Xopenex);
pirbuterol (Maxair)
Action: Bronchodilators; relaxes smooth muscle
Special Considerations: Drug of choice to relieve acute symptoms and prevent exercise induced asthma
Anticholinergic:
Ipratropium (Atrovent)
Action: Dilates bronchioles by reducing vagal tone of the airway
Special Considerations: Does not block exercise induced bronchospasm; ensure adequate fluid intake.
Corticosteroids -systemic:
Methylprednisone (Medrol);
prednisone
Action:Anti-inflammatory; reduces swelling and mucous production
Special Considerations: May ?serum glucose; ?appetite; cause fluid retention and hypertension.
Beta ? Agonist inhaled
Salmeterol (Serevent)
Formoterol (Foradil)
Age Specific:4 years and older for salmeterol; 5 years and older for formoterol
Action:Bronchodilation; prevents exercise induced bronchoconstriction
Special Considerations: Decrease effect over time; Patient education on correct use of med dispenser. May
Anti-inflammatory -inhibits release of mediators from sensitized mast cells
Cromolyn (Intal)
Nedocromil (tilade)
Age Specific: 2 years and older
Action: Anti-inflammatory; does not cause bronchodilation; suppresses release of histamine
Special Considerations: Blocks early and late reaction to allergen. May take 4-6 weeks to see maximum benefit.
Leukotriene modifiers:
Zafirlukast (Accolate)
Montelukast (Singulair)
Age Specific: 5 years and older for zafirlukast; 12 months and older for montelukast
Action: ?inflammation; ?bronchoconstriction
Special Considerations: May cause reversible hepatitis.
5-Lipoxygenase Inhibitor:
Zileuton (Zyflo)
Age Specific: 12 year and older
Action:May be used in children 12 years and older
Special Considerations: May ?liver enzymes; may cause drowsiness.
Methylxanthine
Aminophylline;
theophylline;
caffeine
Age Specific: 4 weeks and older; age greater than 60, may require lower dose.
Action: Bronchodilator; stimulates central nervous system
Special Considerations: Use is limited by many side effects/ adverse reactions. Can cause nausea; nervousness; tachycar
Asthma Patient/family Teaching: Key Topics for self-care management
� Initially assess strengths and cultural considerations.
� Review asthma as a chronic inflammatory disease.
� Identify and provide methods to avoid triggers.
� Use of peak flow meters.
� The purpose and action of medications prescribed for acute and chro
Asthma Assessment:
� Identify possible precipitating factors or "triggers".
� Assess severity of symptoms, breath sounds, peak flow, pulse oximetry and vital signs.
� Obtain past medical health history including allergies and medications/ herbals and dietary supplements.
�
Asthma Potential Nursing Diagnoses:
� Activity intolerance related to fatigue or energy use to meet breathing requirements.
� Ineffective airway clearance related to increased secretions or bronchospasm.
� Impaired gas exchange related to air trapping.
� Ineffective breathing pattern relate
Asthma Nursing Interventions:
� Administer and monitor medications as prescribed.
� Develop a teaching plan based on patient's knowledge and treatment plan.
Asthma Evaluation:
� Patient will adhere to treatment plan as a method to improve his/her quality of life.
� Patient will be able to identify resources within the community.
� Patient will be able to identify when to seek medical attention.
Respiratory System
The respiratory circuit consists of the upper and lower airways. The upper airway includes the nose, pharynx, larynx, and epiglottis which warms, filters, and humidifies the inspired air. The lower airways consist of the trachea, bronchi, and bronchioles.
The main purpose of the respiratory system is gas exchange.
Oxygen from the atmosphere enters the body, travels through the airways to the alveoli. Oxygen and carbon dioxide are exchanged between the alveolus and the pulmonary capillary blood. The cardiovascular system then transports oxygen which is necessary for
Respiration
Respiration is gas exchange between the blood and the body cells.
Ventilation
Ventilation is the movement of air from the atmosphere into the trachea, bronchi, bronchioles, and the alveoli. Physical factors that govern the mechanics of breathing are:
� Air pressure variances
�Airway resistance
�Compliance
Air pressure variances
Air flows from an area of higher to lower pressure. When the diaphragm (the main muscle of breathing) contracts, the thoracic cavity lengthens, intrathoracic pressure decreases, allowing air to enter the lungs.
Airway resistance
Airway resistance is determined by the size and width of the airway. The smaller the radius of the tube, the higher the resistance and work of breathing.
Compliance
Compliance is the elasticity and expandability of the lung tissue. The more compliant the lung tissue, the easier it is to expand the lung.
Diffusion
Diffusion is the process where oxygen and carbon dioxide molecules are exchanged at the alveolar-capillary membrane (air and blood interface). Gases move from an area of higher concentration to a lower concentration.
Perfusion
Perfusion is the actual blood flow through the pulmonary system. Pulmonary arteries bring blood to the alveolus from the right ventricle where the oxygen and carbon dioxide exchange occurs. Oxygenated blood then returns to the left atrium through the pulm
Components of a Respiratory Health History
� Reason for seeking healthcare
� History of health care concern
� Medical history, including allergies
� Medications both prescribed and over the counter medications and herbal/dietary supplements
� Family history of respiratory diseases such as asthma,
Respiratory Signs and Symptoms
-Dyspnea
-Cough
-Sputum
-Chest Pain
-Hemoptysis
Dyspnea
is a subjective feeling of difficulty breathing or shortness of breath or breathlessness. Causes of dyspnea can be related to diseases of cardiac, neurological, muscular, respiratory, and hematological origin. Ask the patient what are the circumstances tr
Cough
is a protective mechanism that prevents accumulation of secretions or the inhalation of foreign substances. The characteristics of cough can help point to the cause of cough. Ask the patient about the frequency and characteristics of the cough.
Sputum
Ask the patient the color, quality, and quantity of sputum. Ask if there has been a recent change in the sputum characteristics.
Chest Pain
The lungs and visceral pleura lack sensory nerves. Pain arises from inflammation of the parietal pleura, intercostal muscles, ribs, or the skin. Ask the patient if the pain is made worse with inspiration.
Hemoptysis
is the expectoration of blood from the respiratory tract and usually is frothy and accompanied by sputum. The causes can be pulmonary, cardiac, or hematological in origin. Assess the color and amount of blood produced.
Respiratory Assessment
During the physical assessment of the patient with a respiratory issue, the nurse must include the following:
� Inspection of upper airway structures such as nose, mouth, and pharynx.
� Thoracic structure and respiratory excursion: Observe the chest for s
Breathing Patterns and Rates
� Eupnea: Normal and quiet respirations
� Bradypnea: Abnormally slow respiratory rate
� Tachypnea: Rapid respiratory rate
� Hyperpnea: Increased respiratory depth and rate
� Apnea: Period of cessation of breathing
� Cheyne-Stokes: Regular cycle where rate
Types of Breath Sounds
Breath sounds can be classified as:
� Crackles
� Wheezes
� Sonorous wheezes
� Pleural friction rub
Crackles
are soft, high-pitched popping sounds heard on inspiration and/or expiration and is produced by fluid in the alveoli.
Wheezes
are high-pitched whistle-like sounds heard on inspiration and expiration and are caused by air passing through narrowed or partially occluded passages.
Sonorous wheezes (rhonchi)
are deep, low-pitched sounds heard during expiration and are caused by air moving through narrowed passages.
Pleural friction
rub is a harsh grating sound like two pieces of leather being rubbed together and may be heard on inspiration and expiration. Friction rubs are related to loss of lubricating pleural fluid and secondary to inflammation.
Laboratory Studies
Some of the common diagnostic studies are: -pulmonary function tests
-arterial blood gas studies
-pulse oximetry
-radiological studies (such as, chest x-ray, lung scans, and computerized tomography).
Pulmonary function tests
are used to assess lung function and evaluate response to therapies. A series of tests measure lung volumes, ventilatory function, and the mechanics of breathing.
Arterial Blood Gases
Arterial blood gases are tested to measure the arterial blood acidity (p H) and oxygen and carbon dioxide levels. The tests measure the following:
�p H
�P a O2
�P a C O2
�H C O3
�O2 saturation
p H
is a measure of hydrogen ions in the blood. The normal human blood value is slightly basic with a p H between 7.35 and 7.45. The cellular enzymatic activities depend on a p H within a 7.35 to 7.45 level. Acidemia is when the blood p H is below 7.35. Alkal
P a O2
This is a measure of the partial pressure of oxygen dissolved in the blood. It reflects how well oxygen can move from the airspace in the lungs into the blood.
P a C O2
This is a measure of the partial pressure of carbon dioxide dissolved in the blood. The value reflects the ability of the body to eliminate the byproducts of carbohydrate metabolism.
H C O3
Bicarbonate is a buffer that maintains a normal p H.
O2 saturation
This measures how much of the hemoglobin is carrying oxygen.
Normal blood gas values at sea level and breathing room air are
-p H: 7.40 (7.35 to 7.45)
-P a O2: 80-100 m m H g
-P a C O2: 35-45 m m H g
-H C O3: 22-26 m E q per L
-S a O2: Greater than or equal to 95%
Note: High altitudes have a lower oxygen tension and the P a O2 and S a O2 will be slightly less.
Acid/Base Abnormalities
Value: P a C O2 greater than 45
Term: Respiratory acidosis
Cause: Hypoventilation
Examples: Chronic obstructive pulmonary disease (C O P D), sleep apnea, over sedation, head trauma, neuromuscular disorders, pneumothorax
Acid/Base Abnormalities
Value: P a C O2 less than 35
Term: Respiratory alkalosis
Cause: Hyperventilation
Examples: Hypoxemia, sepsis, pregnancy, brainstem tumors, anxiety
Acid/Base Abnormalities
Value: H C O3 greater than 26
Term: Metabolic alkalosis
Cause: Loss of acid; Increase of H C O3
Examples: Vomiting, diuretics, potassium deficiency, bicarbonate ingestion
Acid/Base Abnormalities
Value: H C O3 less than 22
Term: Metabolic acidosis
Cause: Gain of an acid that the kidney is unable to excrete or H C O3 lost and kidney is unable to regenerate
Examples: Diarrhea, drainage of pancreatic juices, lactic acidosis, uremia, ketoacidosis, drugs�methanol, paraldehyde, s
Compensation
Compensation is the body's response to maintain near normal p H. Compensation can be of two types:
� Respiratory disturbances (P a C O2) - results in kidney compensation. This may take days.
� Metabolic disturbances (H C O3) - results in pulmonary compens
Nasal Cannula Flow Rates
Flow Rate; Approximate Amount Delivered (F i O2):
� 1 L / min = 24%
� 2 L / min = 28%
� 3 L / min = 32%
� 4 L / min= 36%
� 5 L / min= 40%
Nasal Cannula
Advantages, Disadvantages, & Nursing Implications
Advantages
Lightweight, inexpensive, fairly comfortable to use with activity and meals
Disadvantages
� The amount of F i O2 varies with respiratory depth and rate.
� Nasal mucosal drying
Nursing Implications
Check skin around tubing for redness.
Simple Mask Flow Rate
Flow Rate; Approximate Amount Delivered (F i O2):
� 6 to 10 L / min = 40 to 60%
� Oxygen flow must be at 6 L / min or greater
Simple Mask Advantages, Disadvantages, & Nursing Implications
Advantages
� Simple to use
� Inexpensive
Disadvantages
Must remove to eat, variable F i O2, "fit" of mask can be obtrusive, uncomfortable, and confining. Coughing difficult.
Nursing Implications
Monitoring of correct placement of mask, may need to use nas
Partial Rebreather Mask
Flow Rate
Flow Rate; Approximate Amount Delivered (F i O2):
6 to 10 L / min = 70 to 80%
Partial Rebreather Mask Advantages, Disadvantages, & Nursing Implications
Advantages
Delivers concentrated oxygen
Disadvantages
Must remove to eat; feels warm; must be tightly sealed on the face. Risk of C O2 retention
Nursing Implications
Keep reservoir bag free of kinks; reservoir bag should remain 2/3 full during inspiration
Nonrebreather Mask
Flow Rate
Flow Rate; Approximate Amount Delivered (F i O2):
12 L / min = 80 to 100%
Nonrebreather Mask Advantages, Disadvantages, & Nursing Implications
Advantages
Delivers high concentration of oxygen
Disadvantages
Difficult to keep in place; may cause skin breakdown behind ears; not for long term use.
Nursing Implications
Reservoir bag is to collapse slightly during inspiration; monitor oxygen saturatio
Venturi Mask
Flow Rate
Flow Rate; Approximate Amount Delivered (F i O2):
4 to 8 L / min = 24, 28, 31, 35 and / or 40%
Venturi Mask Advantages, Disadvantages, & Nursing Implications
Advantages
Delivers precise concentration of oxygen by mixing oxygen and room air. Used when concern for C O2 retention.
Disadvantages
Must remove to eat.
Nursing Implications
Ensure air intake valves are open (not blocked by clothing/linen)
High-flow Nasal Oxygen
Flow Rate;
Flow Rate; Approximate Amount Delivered (F i O2):
10 to 40 L / min
High-flow Nasal Oxygen Advantages, Disadvantages, & Nursing Implications
Advantages
Delivers high concentration of humidified oxygen, facilitates secretion clearance; comfortable; decreases work of breathing
Disadvantages
High resource use (oxygen source and health care personnel)
Nursing Implications
Close monitoring of patie
Oxygen Hood
Flow Rate
Flow Rate; Approximate Amount Delivered (F i O2):
10 to 15 L / min up to 80 to 90%
Oxygen Hood Advantages, Disadvantages, & Nursing Implications
Advantages
For infants. Easy access to chest and lower body
Disadvantages
Need to remove for infant feeding
Nursing Implications
Should be humidified
Oxygen Tent
Flow Rate
Flow Rate; Approximate Amount Delivered (F i O2):
Up to 50%
Oxygen Tent Advantages, Disadvantages, & Nursing Implications
Advantages
Provides high humidity.
Disadvantages
May interfere with visualization of child; oxygen level drops when tent opened; child may become fearful.
Nursing Implications
Edges of tent need to be tucked or secured. Frequent linen change required as l
Airway Adjuncts
Artificial airways are used to maintain a patent airway and to facilitate ventilation.
Oropharyngeal
An oropharyngeal airway is inserted through the mouth to keep the tongue from occluding the upper airway. It is used in the unconscious patient who breathes spontaneously. Potential complications include vomiting and aspiration with an intact gag reflex a
Nasopharyngeal
A nasopharyngeal airway is inserted through the nare and ends in the back of the pharynx. It is used in the conscious or unconscious patient who requires frequent nasotracheal suctioning or in facial and jaw fractures. Potential complications include nasa
Endotracheal Tube
An endotracheal tube is inserted through the nose or mouth into the trachea. It is used to protect the airway. It requires expertise for insertion and maintenance. Some of the potential complications include aspiration, dysrhythmias, patient discomfort, a
Tracheostomy
Tracheostomy is a temporary or permanent surgically inserted tube in the trachea. It is used to maintain an airway by bypassing an upper airway obstruction, removing secretions, and permits long term use of mechanical ventilation.
Patient care considerations when a patient has an artificial airway include the following activities:
� Auscultate breath sounds.
� Monitor oxygen saturation.
� Ensure inspired oxygen is warmed and humidified.
� Maintain skin integrity.
� Promote nutrition and hydration.
� Assess for signs/symptoms of infection.
� Suction as needed per assessment findings
Non-Invasive Ventilation
Non-invasive ventilation is a ventilation modality for preterm infants, children, and adults that supports breathing without using an invasive artificial airway. It is used to support ventilation in the spontaneously breathing person. It helps to keep the
Non-Invasive Ventilation Patient Care Considerations
Acute Use (Continuous, Short Term Use)
� Mask require proper fit.
� Patient requires frequent monitoring of response to therapy.
� Mask needs to be removed if patient nauseated (risk for aspiration).
� Skin assessment around mask.
� Need to address nutritional needs.
Non-Invasive Ventilation Patient Care Considerations Chronic Use (Night Time for Sleep Apnea)
� Mask require proper fit.
� Ongoing follow-up care for reassessment/ readjustment of settings.
� Effective in relieving symptoms and reversing some complications of sleep apnea.
� Patient/ partner education.
� Can be expensive (insurance coverage).
Invasive Mechanical Ventilation
Invasive mechanical ventilation is a method using machines to deliver a controlled flow of oxygen into the patient's airways. This life support system is designed to replace or support normal lung function. The support may be short or long term treatment.
Upper Airway Problems
The upper airway includes the nose, sinuses, pharynx, larynx, trachea, and bronchi. Disorders that involve the upper airways can be minor or can be life-threatening. The nurse needs expert assessment skills and an understanding of the causes and treatment
Asthma Pathophysiology:
Reversible and diffuse airway inflammation that leads to airway narrowing. The inflammation causes bronchoconstriction, airway edema, airway hyper responsiveness, and airway remodeling.
Asthma Risk factors:
Common triggers are pet dander, dust, changes in air quality, cold air, chemicals, strong odors, tobacco smoke, exercise, pollen, respiratory infections, nonsteroidal anti-inflammatory medications.
Asthma Causes:
Acute bronchoconstriction, airway edema, and mucus hypersecretion occur in response to chemicals released in response to the allergen.
Asthma Signs/symptoms:
Cough, shortness of breath that worsens with activity, wheezing.
Asthma Diagnostic tests:
Allergy testing, peak flow measurements.
Asthma Treatment:
� Prevention
� Medications for acute episodes
� Medications to prevent acute episodes
Asthma Potential complications:
Status asthmaticus, respiratory failure, pneumonia, death.
Rhinitis Pathophysiology:
Inflammation and irritation of the mucous membranes of the nose.
Rhinitis Risk factors:
Prolonged use of decongestant nasal drops or sprays, females (hormonal changes), exposure to fumes in the workplace, chronic illness.
Rhinitis Causes:
Allergies (more likely in patients under the age of 20), environmental irritants (smog, second hand smoke, strong perfumes), weather changes, infections (viral or common cold), foods, medications (nonsteroidal anti-inflammatory, beta blockers, antidepress
Rhinitis Signs/symptoms:
Stuffy and runny nose, post-nasal drip.
Rhinitis Diagnostic tests & Treatment
�Diagnostic tests: Assess for underlying allergy or sinus condition.
�Treatment: Avoid triggers, symptom relief.
Rhinitis Potential complications & Patient education
�Potential complications: Nasal polyps, chronic sinusitis, middle ear infections.
�Patient education: Reduce exposure to allergens and irritants, hand hygiene, cough etiquette, yearly influenza vaccination for persons six months and older.
Rhinosinusitis Pathophysiology
Rhinosinusitis is inflammation of the paranasal sinuses and nasal cavity.
�Pathophysiology: Bacterial or viral infection that usually follows a viral upper respiratory infection or cold. When the nasal passages are congested or obstructed sinus cavity can
Rhinosinusitis Risk factors:
Allergies/hay fever, nasal polyps, deviated nasal septum, tooth infection, enlarged adenoids (children), cystic fibrosis, gastroestophageal reflux disease (G E R D).
Rhinosinusitis Causes:
Viral, bacterial, or fungal infection.
Rhinosinusitis Signs/symptoms:
Difficulty breathing through nose, drainage of thick purulent mucus from nose or back of throat, pain/pressure around sinuses, cough that is worse at night.
Rhinosinusitis Diagnostic tests & Treatment
�Diagnostic tests: Physical exam, possible allergy testing.
�Treatment: Symptom relief - saline nasal sprays, nasal corticosteroids, decongestions. Antibiotics are generally not needed to treat acute symptoms.
Rhinosinusitis Potential complications:
Asthma attack, chronic sinusitis, meningitis, vision problems, ear infection.
Pharyngitis Pathophysiology
Pharyngitis is inflammation of the pharynx and/or tonsils.
�Pathophysiology: Usually infectious with most being viral in origin. The virus or bacteria invade the pharyngeal mucosa causing a local inflammatory response.
Pharyngitis Risk factors:
Occurs with greater frequency in children aged four to seven years.
Pharyngitis Cause & Signs/Symptoms
� Causes: 80% to 90% are viral.
� Signs/symptoms: Fever, sore throat, anorexia.
Pharyngitis Diagnostic test & Treatment
� Diagnostic test: Rule out streptococcal infections.
� Treatment: Usually self-limited and resolves in three to four days. Promote rest, comfort (warm saline gargles), reduce body temperature (acetaminophen or ibuprofen), promote hydration (do not force
Pharyngitis Potential complications:
Tonsillitis in children
Laryngitis
Laryngitis is an inflammation of the larynx.
� Pathophysiology: Vocal cords become inflamed and irritated. The swelling distorts sounds produced as air passes through the vocal cords.
Laryngitis Risk factors:
Patients who are malnourished, immunosuppressed, or smokers. Occurs more frequently in winter months.
Laryngitis Causes:
Usually triggered by viral infection or vocal strain. May also be caused by allergies, gastroesophageal reflux disease (G E R D), and croup.
Laryngitis Signs/symptoms:
Hoarseness or voice loss, sore throat, "tickle" in the throat, and dry cough.
Laryngitis Diagnostic tests & Treatment
�Diagnostic tests: May need referral to a specialist if condition is ongoing.
�Treatment: Rest, vocal rest, inhalation of cool steam.
Laryngitis Potential complications:
May be more severe with very young or the elderly. Rarely severe respiratory distress may develop.
Sleep Apnea Pathophysiology:
Intermittent compressed upper airway during sleep that causes intermittent apnea.
Sleep Apnea Risk factors:
Middle and older adults, obesity, male gender, smoking, use of alcohol, sedatives or tranquilizers, family history of sleep apnea, children with enlarged tonsils.
Sleep Apnea Causes:
The muscle tone is reduced during sleep. The upper airway collapses when a small amount of negative pressure is generated during inspiration. With repetitive apnea episodes, hypoxia and hypercapnia then triggers the sympathetic nervous system.
Sleep Apnea Signs/symptoms:
Loud snoring, excessive daytime sleepiness, morning headache, witnessed episode of apnea during sleep, memory or learning problems, personality changes.
Sleep Apnea Diagnostic tests & Treatment
�Diagnostic tests: Polysomnographic (overnight sleep studies).
�Treatment: Weight loss, avoidance of alcohol and hypnotics, sleep on side, smoking cessation, continuous positive airway pressure (C P A P), or bilevel positive airway pressure (Bi P A P).
Sleep Apnea Potential complications:
Diabetes mellitus type 2, hypertension, increased risk of heart failure, stroke and cardiac dysrhythmias, sleeping partner problems.
Upper Airway Obstruction Pathophysiology:
A foreign body can settle in the larynx, trachea or bronchus. The larger objects tend to be lodged in the larynx. In adults bronchial foreign bodies tend to lodge in the right main stem bronchus; and in children can be either right or left bronchus. A sev
Upper Airway Obstruction Risk factors:
Not completely chewing food; running when eating; alcohol.
Upper Airway Obstruction Causes:
Most foreign body aspirations occur in children younger than 15 years.
Upper Airway Obstruction Signs/symptoms:
Initially will see choking, coughing, or airway obstruction. Use of accessory muscles to maximize airflow signals high risk of respiratory collapse. The patient may become asymptomatic as the reflexes relax. Foreign bodies in the lower airways can produce
Upper Airway Obstruction Diagnostic tests:
X-ray for lower airway obstruction.
Upper Airway Obstruction Treatment:
Acute airway obstruction�if the person is unable to speak and has a complete obstruction, Heimlich maneuver can be life saving. An immediate tracheotomy would be required for complete airway obstruction. For severe allergic reactions, the treatment includ
Upper Airway Obstruction Potential complications:
Brain damage, death.