boost your asthma iq - lippincott williams &...

You’re caring for Karen Jones, a 35-year-oldAfrican American woman who was recentlyadmitted to your unit because of increasingshortness of breath and cough. She has hada long history of asthma and has been clas-sified as having severe persistent asthma byher healthcare provider. Responding to thecall bell, you realize that Karen is anxiousand pale and she’s complaining of a “tight”airway. She can only speak in short sen-tences and she’s leaning forward in a tripodposition. Her heart rate is 110 beats/minuteand her pulse oximetry value is 90%. IsKaren having an acute asthma exacerba-tion?

The U.S. government’s healthcare initia-tives for Healthy People 2010 includedecreasing hospital deaths by asthma.Therefore, it’s critical that nurses increasetheir knowledge about the disease. In thisarticle, I’ll help you boost your asthma IQand learn the latest in care and managementtechniques.

Asthma 101Commonly seen in childhood (about 50% ofpatients are younger than age 10), asthma isa chronic inflammatory disease of the air-ways. It’s estimated that over 20 million

Americans are affected by this disease, ac-counting for 500,000 hospitalizations andapproximately 5,000 deaths per year.

Asthma can be caused by either extrinsic(atopic or type 1 hypersensitivity) or intrinsicfactors. Extrinsic factors include an allergicresponse to environmental allergens, such asdust mites, pollen, molds, and animal dan-der. Intrinsic factors may be related to viralrespiratory infections; medications, such asaspirin, nonsteroidal anti-inflammatorydrugs, or beta-adrenergic antagonists; or anirritant, such as chemicals or secondhandsmoke.

So what’s going on in the airways?Asthma is a disease characterized bychronic inflammation—infiltration of lym-phocytes, eosinophils, and neutrophils. Itcauses epithelial desquamation (thickeningand disorganization of the tissues of theairway walls), smooth muscle hypertrophy,and fibroblast proliferation in the airway.Obstruction caused by these changes isusually reversible spontaneously or withmedication.

The acute or early response of asthma typ-ically occurs within 10 to 20 minutes of expo-sure to an allergen. Airborne antigens bindto mast cells coated with immunoglobulin E

42 Nursing made Incredibly Easy! January/February 2009

By gaining a better understanding of asthma, you’ll beable to respond more quickly to your adult patient’s

condition, begin appropriate intervention sooner, andhelp your patient deal with this difficult disease.

We give you the tools you need. Margaret McCormick, RN, MS

Clinical Assistant ProfessorCollege of Health Professions, Department of Nursing • Towson University • Towson, Md.

The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.

2.3ANCC/AACN

CONTACT HOURS

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(IgE) antibodies lining the airways (see Howasthma happens). Chemical mediators arereleased and cause bronchoconstriction,mucosal edema related to increased perme-ability of mucosal blood vessels, andincreased mucus secretions, which lead to adecrease in the diameter of the airways.

The hallmark signs of asthma are sudden

dyspnea, wheezing, and tightness in thechest. Other signs and symptoms include:• diminished breath sounds• coughing• thick, clear, or yellow sputum• rapid pulse• tachypnea• use of accessory muscles for breathing.

Suddenshortness of breath,

wheezing, andchest tightnessmean asthma.

How asthma happens

A case ofexposure1st exposure

Allergens may enter through the noseand mouth.1

Allergens areabsorbed into thetissues.

2

Allergens triggerimmune cells to makeimmunoglobulin (Ig) Eantibodies.

3

Ragweed

Immunecell

Allergens

IgEantibodyPollen grains

(allergens)

Ragweed


Predicting troubleAsthma involves a complex interaction ofgenetics and environmental factors. Local-ized type 1 hypersensitivity reactions ap-pear to have a genetic component, and pa-tients with asthma often have other allergicconditions, such as hay fever, hives, and

eczema. Common indoor household trig-gers for asthma include dust mites, animaldander, and fungus or mold. Alternaria, ablack- or grey-colored fungus that causesmold and is commonly found indoors onwindow sills or frames, can be the culprit.Air pollution, tobacco smoke, and occupa-

IgE antibodies attach tomast cells, which gatherin the lungs.

4

2nd exposureAllergens reenter the noseand mouth.5

Allergens attach to IgEantibodies, causing mast cells torelease mediators.

6

7

Delayedreactionoccurs hoursafter asymptom-free period.

Immediatetightening,swelling, andincreasedmucussecretionoccurs.

Mastcell

Pollen grains(allergens)

Preformedmediators

Newlyformedmediators


tional fumes are all irritants that may aggra-vate asthma symptoms. Respiratory infec-tions, especially those caused by virusessuch as respiratory syncytial virus, rhino-virus, influenza A or B, and adenoviruses,can also precipitate an asthma attack.

Classifying severityA patient has asthma if she experiences:• symptoms of asthma in response to a trig-ger (airway hyperreactivity)• repeated episodes of symptoms (recur-rence)• response to treatment (reversibility).

Classification of severity is based on day-time and nighttime symptoms. Developedby the National Heart, Lung, and BloodInstitute, the four categories used to deter-mine appropriate treatment plans are as fol-lows:

• intermittent. The patient experiencescough and shortness of breath or wheezingon 2 days of the week or less and on lessthan 2 nights per month. • mild persistent. The patient has daytimesymptoms more than twice per week butless than once per day. In general, nighttimesymptoms occur more than twice per month.She experiences minor limitations of normalactivity due to symptoms. • moderate persistent. The patient suffersfrom asthma symptoms every day and onmore than 1 night per week. She experiencessome limitations of normal activity due tosymptoms.• severe persistent. The patient has continu-ous daytime symptoms and frequent night-time symptoms. She experiences extremelimitations of normal activity due to symp-toms.

Looking for cluesBegin the physicalexam by first per-forming a generalappraisal of yourpatient. A patientexperiencing anasthma exacerbationmay have a worriedlook, a cough, anddecreased activitytolerance. She maybe unable to com-plete a sentence ormay speak in shortphrases or incom-plete sentences.Auscultate the pa-tient’s lungs for thepresence of wheez-ing or diminished orabsent breathsounds. Rememberthat an absence ofwheezing may be asign of a worsening


Classifying asthma severityListed below are the classifications of asthma severity based on symptoms forchildren age 5 years and older and adults who are not taking medications for long-term man-agement.

Intermittent

• Symptoms twice a week or less and nighttime symptoms twice a month or less• Symptoms don’t cause interference with normal activity• Using a short-acting beta2-agonist inhaler 2 days or less a week for control of symptoms

Mild persistent

• Symptoms more than twice a week but less than once a day and nighttime symptoms three to fourtimes per month

• Minor limitation with normal activity because of symptoms• Using a short-acting beta2-agonist inhaler more than 2 days a week, but not daily for control of

symptoms

Moderate persistent

• Having daily symptoms and nighttime symptoms more than once per week, but not every night• Some limitation of normal activity because of symptoms• Using a short-acting beta2-agonist inhaler daily for control of symptoms

Severe persistent

• Having continual daytime symptoms and frequent nighttime symptoms, often seven times perweek

• Extreme limitation of normal activity because of symptoms• No control of symptoms

Source: National Heart, Lung, and Blood Institute. Expert panel report 3: guidelines for the diagnosis and manage-ment of asthma (2007). http://www.nhlbi.nih.gov/ guidelines/asthma/asthgdln.pdf.

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condition. Also note the presence of nasalflaring, sternal retractions, or use of acces-sory muscles. These may indicate an in-creased work of breathing. Some patientswith chronic asthma can develop a changein the structure of their airway as a result ofthickening of the reticular layer of the base-ment membrane, also known as airway re-modeling (see Picturing an asthmaticbronchus).

As noted earlier, our patient Karen is shortof breath, speaking in short phrases, leaningforward in a tripod position, and complain-ing of a “tight” airway. Upon auscultation,you note that Karen has a prolonged expira-tory phase and diminished breath sounds.You also hear wheezing due to bronchocon-striction. It’s obvious that Karen is experienc-ing an acute exacerbation of her asthma.

Understanding diagnosticsSpirometry, lab tests, sputum and nasal cy-tology, a bronchial methacholine challengetest, skin sensitivity tests, and chest X-raymay be used to diagnose asthma. Let’s takea closer look.

Spirometry measures forced vital capacity(FVC), forced expiratory volume in 1 second(FEV1), and FEV1/FVC values. The FVCvalue indicates the degree of lung and chestexpansion. It measures the total amount ofair that can be blown out as rapidly andforcefully as possible. The FEV1 value indi-cates the patency of large airways and mea-sures the amount of air forcefully exhaledduring the first second of the effort. It givessome indication of large and small airways.The ratio of FEV1/FVC indicates how muchof the FVC is blown out during the first sec-ond. A reduced FEV1/FVC ratio (less than80%) may indicate airway obstruction. Spi-rometry also allows the healthcare providerto evaluate the progression of the disease.

Lab tests for asthma include a radioaller-gosorbent test for an elevation of allergen-specific IgE and a complete blood cell countfor an elevated eosinophil count, both ofwhich may indicate the patient is experienc-

ing asthma due to an allergic response.Sputum and nasal cytology may be used todetermine if nasal eosinophils and sputummast cells are elevated, typically seen in air-way hyperresponsiveness.

A bronchial methacholine challenge test isperformed by giving the patient a nebulizedinhalation of methacholine in increasingdoses in an attempt to produce at least a 20%drop in FEV1. In a skin sensitivity test,small amounts of suspected allergy-causing substances are placed on apricked or scratched area of thepatient’s skin or injected todetermine allergic reaction.

It’s often routine for thehealthcare provider toorder a chest X-ray for apatient with suspectedasthma; however, hyperin-flation of the lungs may beobserved in acute exacerba-tions.

A stepwise approach to treatmentTreatment for asthma is based on classifica-tion and severity of symptoms. As previ-ously described, there are four classifica-tions of asthma: intermittent, mildpersistent, moderate persistent, and severepersistent. The National Institutes of Health(NIH) Expert Panel Report recommendsthat a newly diagnosed patient’s asthmashould be classified using the most severecategory when prescribing medication, thenreevaluated after 4 to 6 weeks. If a patient’scondition is stable or under good control,then the amount of medication can be re-duced, as well as visits to the healthcareprovider.

Stepping up or stepping down a patient’sclassification is useful when determining theproper treatment. The four steps are as fol-lows:• step 1. If a patient is diagnosed as havingintermittent asthma, a short-acting beta2-agonist may be used to control symptoms.


Think step upand step

down when itcomes to

treatment.


Note the mucusbuildup and inflamed

tissue.

Normal bronchus Trapped air in alveoli

Asthmatic bronchus

Surfaceepithelium

Smoothmuscle

Cartilage

Cartilage

Mucousgland

Mucusplug

Mucousgland

Bronchospasm

Artery

Vein

Inflamedbronchialtissue

Enlargedsmoothmuscle

Enlargedbasementmembrane

Inflamedsurfaceepithelium

Mucusbuildup

Elasticfibers

Picturing an asthmatic bronchus

• step 2. If a patient has mild persistentasthma, treatment should include a low- tomedium-dose inhaled corticosteroid. • step 3. If a patient has moderate persis-tent asthma, treatment should include alow- to medium-dose inhaled corticosteroidand a long-acting inhaled beta2-agonist. Aleukotriene modifier may be added if thepatient is unable to tolerate a beta2-agonistor if she doesn’t respond to treatment.• step 4. At this stage, the patient may begiven recombinant humanized monoclonalanti-IgE antibody if she meets the criteria ofhospitalizations and exacerbations in 1 year.A patient at this stage should be referred tospecialty care.

Quick relief vs. long-termcontrolRemember that inhaled short-acting beta2-agonists are used during an asthma attackto relieve acute symptoms. The current rec-ommendation to relieve an acute exacerba-tion is albuterol via nebulizer, 2.5 to 5 mg,or metered-dose inhaler (MDI) with aspacer, four puffs every 20 minutes up tothree times. Albuterol has a rapid onset ofaction (10 to 15 minutes) and its effects last4 to 6 hours. Adverse reactions include ner-vousness, tremors, anxiety, headache, anddizziness. It may also cause nausea, vomit-ing, and tachycardia. If a patient needs touse her rescue inhaler more than two timesper week, awakens at night with symptomsmore than two times per month, or refillsher prescription more than two times peryear, she should seek professional help toreevaluate her current treatment regimen. Ifyour patient doesn’t respond to treatmentwithin 15 minutes, her symptoms aren’t im-proving, or she experiences an adverse reac-tion, notify the healthcare provider immedi-ately.

Long-term-control medication is used tocontrol the airway inflammation caused byasthma but isn’t used for relief of acutesymptoms. Combination therapy with aninhaled steroid and a long-acting beta2-

agonist may be prescribed for long-term con-trol. An IgE-blocker or immunotherapy canbe used for patients over age 12 whosesymptoms aren’t adequately controlled byinhaled corticosteroids.

Take actionPatient teaching should include an asthmaaction plan, making sure your patientknows how to determine when she shoulduse her inhaler and when to seek emer-gency medical intervention. The actionplan should be a collaboration of the pa-tient, the healthcare provider, and thehealthcare team, focusing on teaching the patient to control her asthma. Self-management is the name of the game be-


Asthma medicationsAsthma medications may be divided into two cate-gories: quick relief medications and long-term control medica-tions.

Quick relief medications

Used to treat acute symptoms and exacerbations of asthma.• Inhaled short-acting beta2-agonist—treatment of choice for acute

symptoms.• Anticholinergics—used in the emergency care setting and may be ben-

eficial when administered concomitantly with an inhaled short-actingbeta2-agonist.

• Systemic corticosteroids—used for moderate and severe asthma exac-erbations.

Long-term control medications

Used to achieve and maintain control of persistent asthma symptoms.• Inhaled corticosteroids (ICSs)—most effective medications for long-

term control of asthma.• Long-acting beta2-agonists—may be used as combined therapy with

ICSs for control of moderate or severe persistent symptoms.• Cromolyn sodium or neocromil—not considered preferred treatment,

but may be used as an alternative treatment for mild persistent asthmasymptoms.

• Leukotriene modifiers—not considered preferred therapy, but may beused as an alternative treatment for moderate persistent symptoms.

• Immunotherapy—used as an alternative therapy for patients 12 years ofage and older with severe persistent symptoms. Requires referral to aspecialist.

Source: National Heart, Lung, and Blood Institute. Expert panel report 3: guidelinesfor the diagnosis and management of asthma (2007). http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

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cause asthma is a chronic illness.Remember that an asthma action plan

should be culturally sensitive. Ask yourpatient about what type of home remedies, ifany, she uses to treat her asthma. Find out ifshe has any cultural beliefs about asthma ormedication use. Creating an open environ-ment will allow patients to share their beliefswith you. Each hospitalization should beused as a teachable moment because the

goal of therapy is to help your patientregain control of her disease and its effect

on her life.Teach your patient the following:• the nature of asthma as a chronic

inflammatory disease• the definition of inflammation

and bronchoconstriction• the purpose and action of each med-ication

• triggers to avoid, including informationabout types of indoor and outdoor allergensthat can aggravate her asthma, and how todo so.

Environmental control measures that limitallergens and irritants are imperative. Teachyour patient how to control dust mites,pollen and mold, animal dander, and otherirritants. To control dust mites:• Don’t use feather or down pillows andcomforters; only use synthetic polyester fill.Encase pillows, mattresses, and box springsin zippered dust mite-proof covers.• Wash sheets and blankets once a week invery hot water to kill dust mites.• Dust and vacuum weekly. If possible, usea vacuum cleaner with a high-efficiencyparticulate air filter to collect and trap dustmites; use washable throw rugs and washthem in hot water weekly.• Reduce the number of dust-collectinghouseplants, books, and nonwashableknickknacks.

To control pollens and molds:• Avoid the use of humidifiers because hu-midity promotes mold growth. If you mustuse one, change the water every day andclean the inside two to three times per week

to prevent mold growth. Humidity in theair should stay below 50%.• Ventilate bathrooms, basements, andother dark, moist places that commonlygrow mold. Consider using a dehumidifierin basements to remove air moisture.• Air conditioning removes excess air mois-ture, filters out pollens from the outside,and circulates air throughout your home.Filters should be changed once a month.• Use a weak bleach solution to clean bath-rooms, which are notorious for moldgrowth.• Keep windows and doors shut duringpollen season.

To control animal dander:• If allergic to a pet, it might be advisableto find a new home for the animal.• It may help to wash the animal at leastonce a week to remove excess dander.

To control irritants:• Don’t smoke or allow others to smoke inthe house.• Don’t burn wood fires in fireplaces orwood stoves.• Avoid strong odors from paint, chemicalcleaners, disinfectants, perfume, and glues.

Walking papersBefore discharge, review proper inhalertechnique with your patient. For tips onteaching her how to use an MDI, see“Breathe Easier: A Step-By-Step Guide toMDIs” from our November/December2006 issue. Also teach her how to use apeak flow meter (see Picturing peak flowmonitoring).

Peak flow monitoring is a simple, inex-pensive, and objective way to measurelarge airway lung functions. Patients areencouraged to perform daily monitoring todetect early airflow changes that mayrequire treatment. Patients can also usepeak flow monitoring to evaluate theirresponse to treatment. Short-term monitor-ing should be done over a 2- to 3-weekperiod when the patient’s asthma is undergood control. Readings should be taken at


Teach yourpatient to

controlallergens and

irritants.


Picturing peak flow monitoringPeak flow meters measure the highest volume of airflow during forced expiration. Volume is measured in color-coded zones: Thegreen zone signifies 80% to 100% of personal best; yellow, 60% to 80%; and red, less than 60%. If peak flow falls below the redzone, the patient should take the appropriate actions prescribed by her healthcare provider.

the same time each day so the patient candetermine her personal best value. Thisvalue can help her identify a relationshipbetween suspected triggers. Keeping adaily diary to track peak flow readings,along with symptom scoring, allows thepatient to better manage her disease.

Encourage your patient to avoid smokingand to perform regular aerobic exercises toimprove cardiopulmonary and musculo-skeletal conditioning. The use of an inhaledshort-acting beta2-agonist or cromolyn sodi-um 15 minutes before exercise is recom-mended if attacks are triggered by exercise.Encourage her to maintain adequate fluidintake and balanced nutrition. Fluids andantioxidants thin bronchial mucus while vit-amin B5 (pantothenic acid) helps to formantibodies. Because patients with lung dis-ease may feel more short of breath when

their stomachs are full, smaller, more fre-quent meals may be helpful. It’s highly rec-ommended that influenza and pneumococ-cal vaccines be given to asthma patients aswell. Stress management and relaxationtechniques might be useful to improve well-being and prevent asthma attacks triggeredby stress.

Teach your patient the importance ofmaintaining regular follow-up visits withher healthcare practitioner. Referral to anallergy specialist is recommended for sensi-tivity testing and monitoring. In more severecases, referral to a respiratory specialist orpulmonologist should be considered.

A case of exposureAsthma is a serious and growing problemin the United States, especially for thoseliving in urban areas exposed to multiple

allergens and environmental pollutants.Looking ahead, more research needs to bedone in the area of patient outcomes toreduce the number of hospital admissionsand ED visits by patients with asthma. Byfollowing the step-up and step-down ap-proach to treatment, as outlined by theNIH, you’ll have a useful tool that will al-low you to improve the care and manage-ment of your patient’s asthma. When apatient like Karen appears in your unit,you’ll be better prepared to effectivelyand efficiently assess her symptoms, mak-ing sure she gets appropriate treatmentand teaching her self-management tech-niques to help her control her asthmasymptoms at home to prevent futureexacerbations. n

Learn more about itGern J, Busse W. Contemporary Diagnosis and Managementof Allergic Diseases and Asthma. 4th ed. Newtown, PA:Handbooks in Health Care; 2007:38-48.

Healthy People 2010. Respiratory diseases. http://www.healthypeople.gov/Document/HTML/Volume2/24Respiratory.htm. Munoz C, Luckmann J. Transcultural Communication inNursing. 2nd ed. New York, NY: Delmar Learning;2007:60-69. National Heart, Lung, and Blood Institute. Expert panelreport 3: guidelines for the diagnosis and management ofasthma (2007). http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. National Institute of Allergy and Infectious Diseases.Asthma. http://www3.niaid.nih.gov/topics/asthma. Olubummo C. Asthma epidemic: tighten your treatmentoptions. Nurse Pract. 2008;38(8):12-18.Porth C. Pathophysiology: Concepts of Altered Health States.7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2005:694-701. Smeltzer SC, et al. Brunner and Suddarth’s Textbook ofMedical-Surgical Nursing. 11th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:709-717.


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DISCOUNTS and CUSTOMER SERVICE• Send two or more tests in any nursing journal published by Lippincott Williams& Wilkins together and deduct $0.95 from the price of each test.• We also offer CE accounts for hospitals and other health care facilities on nursingcenter.com. Call 1-800-787-8985 for details.

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Lippincott Williams & Wilkins is accredited as a provider of continuing nurs-ing education by the American Nurses Credentialing Center’s Commission onAccreditation.

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