Pathogenesis And Nursing Management Strategies For Acute Severe Asthma: A Case Study

Explanations of Asthma Pathogenesis and Clinical Manifestations

1. This case scenario reveals the fact that Jackson Smith has possibly suffered from an asthmatic attack. The normal clinical manifestation of asthma is chest tightness, cough, and respiratory distress. Some of the important symptoms of asthma that is common to most of the patients with asthma are, airway obstruction due to airway inflammation, formation of mucus plug and wide spread wheezing. The pathogenesis of the airway obstruction is due to a variety of changes taking place in the airways, such as the bronchoconstriction (Bonini & Usmani, 2015). This is caused due to the contraction of the bronchial smooth muscles in response to the exposure to a variety of stimuli including the allergens and the irritants. Bronchoconstriction is again caused due to the release of the IgE dependant mediators like tryptase, histamine and prostaglandins. In addition to this airway oedema formed due to the inflammation of the airways also restricts the passage of airway causing widespread wheezing. Wheezing is the musical sound that is produced when air is passed through a limited area through the airways. A wide spread wheezing can be noticed in this patient which is the most important symptoms of asthma. Other stimuli such as exposure to cold, dust and other irritants can also trigger asthmatic attacks (Bonini & Usmani, 2015).

Airway hyper responsiveness is an important manifestation that is mainly caused due to airway inflammation. Permanent or partial structural changes may occur in the airways causing a gross loss in the lung function that cannot be recovered by any current therapy. Airway remodelling also involves the activation of a number of cells, that can increase the airway obstruction and airway responsiveness, which normally renders the patients less responsive to any kind of therapies.

The case study reveals that the patient suffered from acute dyspnoea. It has to be remembered that dyspnoea is the primary symptom of asthma. The exertional dyspnoea in case of asthma is due to some complex pathological mechanisms like dynamic hyperinflation, an increased ventilatory demand, impaired capacity, hypercapnia, hypoxemia and the neuro-mechanical dissociation. A large number of inflammatory cells are responsible for the inflammation of the airways. Activation of the mucosal mast cells releases bronchoconstriction mediators. Increased number if eosinophil have been observed in patients suffering from asthma.

It is also evident from the case study that smith was having a low oxygen saturation level than the normal value, which is above 95 %. Low oxygen saturation is common during an asthma attack. This is due to the fact that low amount of oxygen reaches the blood. The respiratory rate in the patient was found to be much higher than the standard value ( Papazian et al., 2016). This can be explained simply by the fact that the amount of air entering the lungs in each of the breath is reduced and hence the person needs to take more breaths to cope up with the normal oxygen demands of the body ( Papazian et al., 2016). Diminished breath sound is another symptoms of asthma. Decreased sound signifies air or fluid round the lungs or the increased thickness of the chest walls or reduced flow of air in to the lungs. Serum lactate level has been found to increase during asthmatic attack. According to a study, high serum lactate levels has been observed in patients taking IV or nebulised salbutamol (Rodrigo, 2014). The aggressive attack of the Beta agonists during asthmatic attack have been found to be responsible for the increased lactate concentration. When a chest x-ray was performed a hyper-inflated lungs was noticed. Hyper inflated lungs can be caused due to the blockages in the air passage that interferes with the expulsion of air from the lungs. Normally mild inflation of the lungs takes place at the time of asthma exacerbation. However hyperinflation of the lungs are more common in patients with chronic obstructive pulmonary disease (COPD). The recorded pulse rate of Jackson Smith is greater than the standard value. Rapid pulse during an asthmatic attack is probably due to the fact that the heart pumps   more rapidly to send blood to different parts of the body. Rapid pulse during an asthmatic attack can also be due to psychological reasons. Panic attack due to breathlessness can be the cause of an elevated pulse rate.

• One of the clinical nursing priority to manage asthma in Jackson Smith is to maintain an optimal breathing pattern in the patient. This can be evidenced by relaxed breathing in the patient, normal respiratory pattern and absence of dyspnoea in the patient. Optimal breathing pattern in the patient is facilitated by administering medicines like short acting beta-2-adrenergic agonist like Albuterol, Terbutaline (Murphy et al., 2013). Optimal breathing is also facilitated by encouraging the patient to use a pursed lip breathing for the inhalation. Management of effective breathing pattern also involves proper monitoring of the oxygen saturation level and assessing the presence of the paradoxical pulse of greater than 12mm Hg (Lalloo et al., 2013).

Two High Priority Nursing Strategies for Managing Acute Severe Asthma

Rationale: Short acting beta agonist acts as bronchodilators. They tend to relax the inner muscular lining of the airways. The inhaled corticosteroids helps in the reduction of the inflammation of the airways that carry air to the lungs (Cates, Welsh & Rowe, 2013). Pursed lip breathing can help in improving the breathing pattern by moving the used air out of the lungs and oxygen to enter the lungs. Paradoxical pulses should be assessed because paradoxical pulse occurs when there is an abnormal decrease in the systolic pressure at the time of inspiration.

• Effective airway clearance is another clinical priority of Jackson Smith suffering from asthmatic attack. It is necessary to clear the secretions or obstructions from the respiratory tracts for maintaining a clear airway. Ineffective airway clearance is mainly evidenced by abnormal arterial blood gases, adventitious wheezes and changes in the respiratory rate and rhythm (Cates, Welsh & Rowe, 2013). The nursing intervention for an effective airway clearance includes auscultation of the lungs for the adventitious breath sounds, encourage the increased fluid intake, administration of oxygen, encouraging the patient in effective coughing (Lalloo et al., 2013).
• Rationale: effective coughing can be natural way to clear the secretion from the throat. Wheezes heard at the time of lung auscultation may suggest partial blockage of the lungs. Increasing fluid intake might help in minimising the mucosal drying and increases the ciliary action for removing the secretions (Lalloo et al., 2013).

3. Nebulised Salbutamol- Salbutamol acts at the β₂-adrenoreceptors present on the smooth muscles enveloping the bronchi. By binding, it stabilizes the receptor at the active state. The receptor stays at the active state for more time and as a result generates more cAMP. The development of the cAMP triggers the intercellular cascade to reduce the intracellular Ca2+. This prevents the smooth muscles to contract (Sue Jordan, 2011).  This cause the smooth muscles in the airway to relax and allows the airways to open making it easier for the patient to breathe. This is how Salbutamol can cease the smooth muscle contraction of the airways in Jackson Smith during asthma exacerbations.

Nebulised Ipratropium-Ipratropium is an anticholinergic agent that blocks the muscarinic receptors of acetyl choline and also appear to inhibit the vagally mediated reflexes by the antagonisation of the action of the acetyl choline released from the vagus nerves. It is the cholinergic nerves that stimulates the smooth muscles cells in the airways to contract. The anticholinergic effect of the ipratropium stops the effects of the cholinergic nerves (Cates, Welsh & Rowe, 2013).

Hydrocortisone- It helps in reducing the mucus secretion in the airways by the inhibition of the release of secretagogue from the macrophages. They inhibit the late phase reaction by the inhibition of the inflammatory response (Alangari, 2014). The intravenous application of hydrocortisone Jackson Smith was given to decrease the bronchoconstriction.

Nurses should conduct a careful monitoring of the blood pressure and pulse rate after the administration of the salbutamol. It can cause several changes like hypokalaemia and might increase the blood glucose level. It is necessary to monitor for tachycardia and cardiac dysrhythmias in the patient. Nebulised salbutamol solution more than 5mg should not be given.

While administering the dosage, the dilution of the solution should be adjusted as per the equipment and the length of the administration. A mouthpiece should be used rather than a facemask. Nurses should check for any history of hypersensitivity before the application and side effects like nausea, dizziness after the application. The heart rate, depth, rhythm and the lung sounds should be assessed.

Nursing Implications when Administering Three Specific Drugs for Asthma

Before the initiation of the treatment with hydrocortisone, the contraindications and the cautions have to be kept in mind. Hydrocortisones can exacerbate several long term complications like peptic ulcer disease, hypertension (This, 2012). It is necessary to establish the baseline and the continuing data on the vital signs. It is necessary to report for any changes in the mood and the behaviour of the patient (Alangari, 2014).

References

Alangari, A. A. (2014). Corticosteroids in the treatment of acute asthma. Annals of Thoracic Medicine, 9(4), 187–192. https://doi.org/10.4103/1817-1737.140120

Bonini, M., & Usmani, O. S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Therapeutic advances in respiratory disease, 9(6), 281-293. https://doi.org/10.1177/1753465815588064

Cates, C. J., Welsh, E. J., & Rowe, B. H. (2013). Holding chambers (spacers) versus nebulisers for beta?agonist treatment of acute asthma. The Cochrane Library.

Lalloo, U. G., Ainslie, G. M., Abdool-Gaffar, M. S., Awotedu, A. A., Feldman, C., Greenblatt, M., … & Otto, W. (2013). Guideline for the management of acute asthma in adults: 2013 update-Part 2: March 2013. SAMJ: South African Medical Journal, 103(3), 189-200. Retrieved September 17, 2018, from https://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742013000300031&lng=en&tlng=en..

Murphy, K. R., Meltzer, E. O., Blaiss, M. S., Nathan, R. A., Stoloff, S. W., & Doherty, D. E. (2012, January). Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey. In Allergy & Asthma Proceedings (Vol. 33, No. 1). https://doi.org/10.1016/j.rmed.2015.11.002

Papazian, L., Corley, A., Hess, D., Fraser, J. F., Frat, J. P., Guitton, C., … & Ricard, J. D. (2016). Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review. Intensive care medicine, 42(9), 1336-1349. https://doi.org/10.1007/s00134-016-4277-8

Rodrigo, G. J. (2014). Serum lactate increase during acute asthma treatment: a new piece of the puzzle. Chest, 145(1), 6-7. DOI: https://doi.org/10.1378/chest.13-2042

Sue Jordan, M. B. (2011). Bronchodilators: implications for nursing practice. DOI 10.7748/ns2011.03.15.27.45.c2999

This, B. N. I. (2012). Corticosteroids: implications for nursing practice. DOI: 10.7748/ns2012.12.17.12.43.c3312

                                                           

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Lange, P., Çolak, Y., Ingebrigtsen, T. S., Vestbo, J., & Marott, J. L. (2016). Long-term prognosis of asthma, chronic obstructive pulmonary disease, and asthma-chronic obstructive pulmonary disease overlap in the Copenhagen City Heart study: a prospective population-based analysis. The Lancet Respiratory Medicine, 4(6), 454-462.https://doi.org/10.1016/S2213-2600(16)00098-9

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