Care of the Patient with Asthma

Asthma is a potentially disabling disease that is chronic and can appear at any age. There is no cure for asthma but sometimes symptoms can go away on their own, especially in children and teenagers. In most cases, however, asthma is a lifelong chronic disease. The goal is to manage the disease so that patients with asthma, at any age, can be as active as possible. Long-term management includes the patient as well as the care giver understanding the disease and having knowledge of triggers that can start an asthma attack. 

Asthma is a chronic disease that affects how a person breathes. Constriction of the airway or bronchial smooth muscle along with inflammation causes the person to wheeze, cough, have a tightening in the chest, and shortness of breath. The symptoms can be mild or life-threatening. However, the disease causes a significant impact on the lives of people who suffer from it. According to the Center for Disease Control (2014) over 22,000 individuals suffer from asthma and 6,109 of those individuals are children under the age of 18. There tends to be a higher incidence in females over all, but boys under the age of 18 seem to affect more than girls under the age of 18 (CDC, 2014). Although some races and ethnicities seem to have higher incidences, such as Puerto Rican and African-American males under the age of 18, overall Caucasians have the highest incidences of asthma diagnoses (CDC, 2014).

In the respiratory or pulmonary system, there are passageways where air travels from the nose and mouth to the lungs. The trachea runs from the back of the mouth to about the shoulder and attaches to two other passageways. One of these goes to the right and the other to the left. These are called the bronchi. The bronchi enter each lung and branch off again into more passages called bronchial trees or bronchioles. These passages are like fingers in the lungs and reach out to all parts of the lung. At the end of each finger-like extension are alveoli. Alveoli look like a cluster of grapes and hold air. The alveoli are where air gets oxygenated. The oxygenated air is delivered to the body when we inhale. A by-product that our bodies produce is carbon dioxide. One of the ways the body releases carbon dioxide is when we exhale. The act of inhaling and exhaling is a process called ventilation. Likewise, respiration is when our body moves oxygen to where it is needed in the body and then releases carbon dioxide. Although there are several types of asthma such as exercise asthma and intermittent asthma, all are characterized by chronic airway obstruction and inflammation (Grossman & Porth, 2014).

In Asthma, three processes occur. First is a hypersensitivity of the bronchial passages. Second is inflammation of the airway passages. Lastly is airway obstruction. Together, this produces an asthma attack. The patient will not be able to breathe properly.

Hypersensitivity occurs due to an exaggerated response from a variety of stimuli. This could be an allergic reaction, emotional response or a hormonal change (Grossman & Porth, 2014). Inflammatory mediators or chemical substances are released such as histamines, prostaglandins, and leukotrienes as well as neutrophils, eosinophils and lymphocytes. The result is narrowing of the bronchial passages; mucous is produced as well as inflammation in the trachea, bronchi, and the bronchioles. Additionally, the smooth muscles in the bronchial system spasm, and there is a thickening of the walls in the airway. The narrowed airway makes it difficult to breathe in air (Grossman & Porth, 2014). Receptors in the lungs trigger hyperventilation or attempts at rapid breathing. The exchange of air and oxygen in the alveoli becomes erratic. Hypoxemia or low oxygen level in the blood occurs, and carbon dioxide levels rise as it can no longer escape through exhaling. If the asthma attack continues without treatment respiratory failure can occur (Grossman & Porth, 2014).

Anyone can be subjected to an asthma attack at any age and for many reasons. Children can continue to have asthma attacks through adulthood, or it may disappear as they get older. About 50% of children who have asthma attacks will go into remission by the age of 18 (Javed et al., 2013). Adolescents who develop asthma are more likely to go into remission before entering adulthood (Edgar, 2015). In adult-onset asthma, the patient is usually over the age of 20. Adult asthma can develop in females during childbearing years and may occur during or after pregnancy. Likewise, adults with allergies or exposure to irritants can also trigger asthma. In an adult, the likelihood of remission is lower than in children (UMMC, 2013). Adults tend to have asthma for life once they develop the condition.

There is research that asthma tends to be genetic (Barnes, 2014). Additionally, asthma can be triggered by the environment, such as inhaled substances, air pollution, smoking, air fresheners, or paint fumes. Other allergies to animals or plants may also trigger an attack. Exercised induces asthma occurs after strenuous activity. Researchers are not sure of the exact mechanism but believe that loss of water, excess heat, and dry mucus membranes contribute to an attack (Mayo Clinic, 2014). Occupational asthma is caused by inhaling fumes, gases, or dust while at work. A person with allergies is more likely to develop this type of asthma. Nocturnal or nighttime asthma can also occur. This type of asthma is worse at night and can be caused by positioning while sleeping, hormones or circadian rhythms, cooler night air or air conditioning, gastroesophageal reflux disorder, or allergy exposure. Other issues that can impact the development of asthma include obesity and co morbid disorders such as chronic obstructive pulmonary disease or COPD (Grossman & Porth, 2014).

Asthma symptoms can be very different from person to person and from the type of asthma. Some symptoms may only be irritating while other symptoms can be life threatening. It is important to keep in mind that symptoms should be treated as soon as they appear. Symptoms most seen are coughing, wheezing, and dyspnea. A cough can be either dry or have mucus production. A chronic cough should be reported to the nurse for possible asthma assessment. Wheezing, on the other hand, is caused by the constriction of the bronchioles. Wheezes are sometimes heard with or without a stethoscope. Dyspnea is shortness of breath. The patient may also complain of chest tightness and anxiety from not being able to breath properly.

Asthma is classified according to severity (“Asthma Care Quick Reference: Diagnosing and Managing Asthma,” 2012). In adults and children, the classifications include intermittent, mild, moderate, and severe. The classifications range from two attacks per week to several times a day. This includes nighttime awakenings, interference with daily activities and use of medications. The classifications should direct care and help in developing a long-term management plan.

Sleep disturbances can also be an issue with a patient who has asthma (Mayo Clinic, 2014). There is some research that indicates those with asthma can contribute to the development of sleep apnea. Remember that although these symptoms are part of asthma, they may also be present in other disease states. It is important to collect subjective and objective data to report to the nurse.

In an infant, the parent or caregiver may notice that the baby is a slow feeder or has shortness of breath during feedings. In a toddler or older child, the parent or caregiver may notice that the child does not play as much or gets breathless easily. The child may become tired easily and cough more when playing or early in the morning. Ty may have problems in school, and present with a high pitched almost musical wheeze upon exhaling air (Mayo Clinic, 2014). Illness such as colds can not only trigger an asthma attack, but the underlying illness may last longer as well.

Several things can trigger an asthma attack. It is important to note what the trigger may be so a plan can be developed to eliminate or control the triggers. Triggers can include infections, inhaled substances, foods, medicine, temperatures, storms, exercise, or emotions. Other triggers can be smoking, hobbies, or pets as well. It is important to observe for any types of triggers that could lead to an asthma attack.

The main goal is to prevent asthma attacks and minimize risks. Identify any environmental triggers such as dust, pollen or insects. Molds, pets, and even foods can also trigger an attack. Once triggers have been identified, a plan can be developed with the patient to avoid the triggers and how to handle an attack when it occurs. A plan should include teaching the patient to recognize signs and symptoms of an attack, how to use the medication provided, what triggers to avoid and when to seek medical attention (Mayo Clinic 2014; Sawiki & Haver, 2016). It is also a good idea to ask the patient to keep a journal of when their attacks occur and what medications worked best. This will help with the treatment plan.

One of the goals of patient care is teaching the patient to recognize early symptoms or worsening symptoms (“Asthma Care Quick Reference: Diagnosing and Managing Asthma,” 2012). The care giver should also make sure that the patient understands how to properly use all medications including inhalers and oxygen. Typically, the patient will have a long-term medication such as an inhaler to reduce inflammation which is taken daily. However, they can also have quick-relief medication that is used during asthma attacks. The quick-relief medication relaxes the muscle of the airway, relieving symptoms. The patient should also know when to contact emergency services for help when needed.

During an asthma attack, the patient should sit down, preferably in a semi-fowler position to help with breathing (Wilson, 2015). The patient should try to relax as much as possible and breathe from their diaphragm. Remember that hypoxia can occur easily. Any signs of lips or nails turning blue means that they need medical attention. If the patient has an inhaler, they should use it to try to gain respiratory control. Remember the goal is to relieve hypoxia and airway obstruction or inflammation as soon as possible.

Help the patient to remain calm and reassure them that you are staying until the episode subsides. Explain to the patient that the anxiety and agitation will subside if they can try to relax their breathing. If possible, monitor vital signs. Breathing heavily during an attack can drain energy from the patient and cause dehydration. Once the attack has passed, the patient may be dehydrated. Offer fluids to help maintain their fluid balance.

A patient with asthma may have a limited quality of life. Several factors contribute to poor quality of life. First is the patient’s inability to sleep. Lack of sleep can be an issue for a child who has to get up and go to school or the persons who has to be to work on time. Physical activity can be limited as well putting the patient at a greater risk for developing medical issues including obesity and depression (Sundbom et al., 2015).

Recognize when the asthma attack is getting worse. Signs include (Gibbons, 2013):

• Increased difficulty in breathing
• More or louder wheezing
• The medications are not controlling the attacks as well as before
• The patient is waking up more at night
• Missing normal activities, school, or work
• Not able to speak complete sentences

A child may report that their chest hurts or they can’t catch their breath (Mayo Clinic, 2014). These signs should be discussed with the nurse. If you observe the patient showing signs of inability to breath, cyanosis, drowsiness, or confusion, this can signify a medical emergency and should be reported immediately (Lalloo et al., 2013).

Any signs or symptoms of worsening or inadequate breathing during an attack should also be immediately reported to the nurse. These signs and symptoms may include (Hegner, Acello, & Caldwell, 2010):

• Little or no movement of the chest
• Breathing movement is in the abdomen, not the chest
• Slow or rapid respiratory rate
• Gasping for air or shallow breaths
• Difficulty breathing (Dyspnea)
• Coughs up secretions
• Blue or gray coloring in nails, mucus membranes, ear lobes, tongue, lips, or skin
• Noisy breathing
• Nasal flaring
• Muscles above rib cage are retracted

Allie is an 8-year-old that has been brought to the clinic today by her mother. Allie’s mother states that she has a dry cough and has a hard time catching her breath after playing or running. Allie also complains that her chest hurts during recess most days. You observe that she sits down and is breathing slightly labored. She has no signs of cyanosis, but her breathing is somewhat labored. Her mother tells you the coughing and difficulty catching her breath has been going for about 2 months and has been getting slowly worse. She tells you that Allie has not had allergies in the past, but everyone in the family has allergies. No one that the mother is aware of in the family has asthma. Allie appears to be otherwise healthy and when she speaks she can talk in complete sentences without getting breathless.

Mr. Thompson is a 65-year-old male and was recently discharged from the hospital with a diagnosis of pneumonia. He lives with his wife. You are assigned as his home health nurse through his recovery. His wife is concerned because his breathing seems difficult. When talking to him, you notice he coughs several times and has trouble catching his breath. You also notice his finger nails have a slight blue tint to them. You also notice at times he has an almost musical sound when he breathes out. His wife tells you he is not sleeping well and has been complaining of his chest hurting him. You further notice that he appears anxious and upset.

Asthma can be a scary when the patient is not able to breath correctly. Remember that asthma is a serious condition that needs to be controlled and treated. Helping patients to identify triggers and developing a plan of action is a good way for a patient to maintain control over this disease. The patient may have to be taught to recognize their own symptoms and use their inhalers. The patient’s quality of life is disrupted with this disease. It can affect work, school, and social activities. The patient needs to be active but also understand that they need more breaks than the average person to regain their breathe. Other issues that may need to be addressed are respiratory illnesses. Pneumonia, pneumothorax, and bronchitis can develop from excessive attacks or environmental triggers such as smoke. There is also an increase risk of asthma attacks during an episode of influenza. Children and adults can develop asthma from various other diseases and triggers as well. It is important for health care providers to understand the impact asthma has on their patients and how to help patients control the disease.

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