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Bronchial Asthma
 DEFINITION OF ASTHMA
 Asthma is a heterogenous disease usually
characterized by chronic airway inflammation. It is
defined by the history of respiratory symptoms
such as wheeze, shortness of breath, chest
tightness and cough that vary over time and in
intensity, together with variable airflow limitation

GINA 2016
Cont…
 Asthma attacks all groups but often starts in
childhood.
 Characterized by recurrent attacks s of

breathlessness and wheezing, which has

different severity and frequency in each person.
 Attack from hour to hour and day to day.

(WHO, 2013)

http://www.who.int/respiratory/asthma/definition/en
 Problem Statement
GLOBAL

287,000 (0.5% of total global deaths) deaths

151,000 men and 136,000 women (WHO, 2006)

16.7 million deaths in age 15–59 years(WHO, 2006)

As many as 300 million people of all ages, and all ethnic

backgrounds, suffer from asthma
 
Highest Asthma prevalence rates are in the:
United Kingdom (>15%) and New Zealand (15.1%)
 INDIA

Prevalence of Asthma 7.24% with SD 5.42 (2006)

277 DALYs per 100,000
-Constitutes 0.2% of all deaths and 0.5% of National
Burden of Diseases (Smith 2002)

Low prevalence rates (2%–4%) in Asian countries (especially China and India),
although reporting relatively lower rates than those in the West, account for a huge
burden in terms of absolute numbers of patients
Prevalence of Asthma India

Source: NFHS-3, 2005-06

Pathophysiology
 PATHOLOGY

Airways produce
Inflammation of mucus due to
Muscle around inflammation
inner lining of airways tighten
airways (clogged the
shrunken tubes)
 Narrowed
bronchioles

(muscles spasms)

Figure 2: Differrence between normal airway and airway in person with asthma
 SIGNS AND SYMPTOMS
Common symptoms of asthma 
1. Coughing, especially at night
2. Wheezing
3. Dyspnoea
4. Chest tightness, pain, or pressure
 Symptoms of asthma attack
Mild asthma attack
1. Cough
2. Wheezing
3. Mild difficulty breathing during normal
activities
4. Difficulty sleeping
5. Hiccups
6. Peak expiratory flow rate (PEFR) is 70 to 90%
of personal best 
Moderate asthma attack
1. Severe cough
2. Moderate wheezing
3. Shortness of breath
4. Chest tightness
Usually worsens with exercise
5. Inability to sleep
6. Nasal congestion
7. PEFR is 50 to 70% of personal best 
Severe asthma attack
1. Severe wheezing
2. Severe difficulty breathing
3. Inability to speak in complete sentences
Sentences are interrupted by breathing
4. Inability to lie down
5. Signs of severe difficulty breathing
Rib retractions: ribs are visible during each breath 
Nasal flaring: nostrils open wide during each breath 
Use of accessory muscles: neck muscles are prominent during each
breath 
6. Chest pain
Sharp, chest pain when taking a breath, coughing
7. PEFR is <50% of personal best 
8. Confusion
9. Rapid pulse
10. Fatigue
11. Rapid breathing rate
DIAGNOSIS & TESTS
 Peak Flow Testing

Peak expiratory flow rate (PEFR) Peak Flow Meter

PEFR is used to assess the severity of wheezing in
those who have asthma. PEFR measures how quickly
a person can exhale air from the lungs
Spirometry (Lung function test)
 It measures how much air you can exhale.
 FEV1(force expiratory volume) > 80% =

normal
 Confirms the presence of airway obstruction

and measure the degree of lung function

impairment.
 Monitor your response to asthma medications
 Allergy-skin Test
 A drop of liquid containing the allergen in placed
on your skin (generally forearms is used).
 A small lance with a pinpoint is poked through

the liquid into the top layer of skin (prick test).

 If you are allergic to the allergen, after about 2

minutes the skin begins to form a reaction (red,

slightly swollen, and itchy: it makes a hive).
 The size of the hive is measured and recorded.

 The larger the hive, the more likely it is that you

are allergic to the allergen tested.

Allergy-skin test
 Chest X-Ray
 I
 TYPES OF ASTHMA
1. Allergic asthma (extrinsic)
2. Non-allergic asthma (intrinsic)
3. Cough variant asthma
4. Occupational asthma
5. Exercise induced asthma
6. Medication induced asthma
7. Nocturnal asthma
MANAGEMENT
 Managing Asthma: Goals

 Achieve and maintain control of symptoms

 Maintain normal activity levels, including exercise
 Maintain pulmonary function as close to normal levels as
possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma medications
 Prevent asthma mortality
 Treatment

 Step 1- Inhaled short acting b-2 agonist as required

 Step 2- PLUS inhaled steroid BDP 200-800 mcg/day (400 mcg)

 Step 3- PLUS long acting b-2 agonist(LABA)

Source: : Expert Panel Report 2: Guidellines for the diagnosis and management of asthma: National Institute of Health- National Heart,
Lung and Blood Institute 1997; NIH publication number 97-4051
Source: NFHS
 Treatment
 Step 4- Persistent poor control
Increase steroid upto 2000 mcg/day PLUS LRA, SR theophylline,
Beta-2 agonist tablet

 Step 5- Continuous or Frequent use of oral steroids

Use daily steroid tablet in lowest dose providing adequate control

*
Source : Expert Panel Report 2: Guidellines for the diagnosis and management of asthma: National Institute of Health- National Heart,
Lung and Blood Institute 1997; NIH publication number 97-4051
 Managing Acute Exacerbations
Main aim is to relieve airflow obstruction and
hypoxaemia as quickly as possible, and to plan
prevention of future relapses.

1. Oxygen inhalation 4 L/minto maintain SpO2 >90%

2. Inhaled
Salbutamol/Terbutaline preferably by nebulizer/
MDI with spacer with/without facemask
1-2 puffs every 2-4 minutes upto 10 puffs and repeat
every 20-30 minutes

Source : Expert Panel Report 2: Guidellines for the diagnosis and management of asthma: National Institute of Health- National Heart,
Lung and Blood Institute 1997; NIH publication number 97-4051
 Managing Acute Exacerbations
4. Ipratropium Bromide 250 mcg by nebulizer

5. Inj. Hydrocortisone 10mg/kg IV

6. Inj.
Magnesium sulphate 40mg/kg in 50 ml 5%
dextrose as slow infusion over 30 minutes(?)
---- NO RESPONSE?---- ABG—X-ray chest---
Serum electrolytes

Source : Expert Panel Report 2: Guidellines for the diagnosis and management of asthma: National Institute of Health- National Heart,
Lung and Blood Institute 1997; NIH publication number 97-4051
 NURSING MANAGEMENT

• SUBJECTIVE DATA
NURSING • OBJECTIVE DATA
ASSESSMENT

• GOALS
NURSING • INTERVENTIONS
DIAGNOSIS
NURSING ASSESSMENT

Subjective data
Important health information
 Past health history :allergic
 Medications:
NURSING ASSESSMENT
Subjective data
Functional health patterns
 Health recent upper respiratory infection or sinu
infection
 Activity exercise: fatigue decreased or absen
exercise tolerance ;dyspnea, cough(especially a
night)
 Sleep-rest: awakened from sleep because o
cough or breathing difficulties, insomnia
 Coping-stress tolerance: emotional distress
stress in work environment or the home.
 NURSING ASSESSMENT
OBJECTIVE DATA
General
 Restlessness or exhaustion, confusion, upright or
forward-leaning body position
Integumentary
 Diaphoresis, cyanosis (circumoral, nail bed), eczema

Cardiovascular
 Tachycardia, pulsus paradoxus, jugular venous
distention, hypertension or hypotension, premature
ventricular contractions
Respiratory
 Nasal discharge,
 nasal polyps,
 mucosal swelling;
 wheezing, crackles ,
 diminished or absent breath sounds,
 sputum (thick, white, tenacious),
 ↑ work of breathing with the use of accessory

muscles; intercostal and supraclavicular retractions;

 tachypnea with hyperventilation; prolonged
expiration
NURSING ASSESSMENT
OBJECTIVE DATA

Possible findings

 Abnormal ABC’s during attacks, ↓ O2 saturation,

serum and sputum eosinophilia, ↑ serum Ig E ,

positive skin tests for allergens, chest X-ray
demonstrating hyperinflation with attacks, abnormal
pulmonary function tests showing ↓ flow rates; FVC,

FEV1 , PEFR , and FEV1 /FVC ratio that improve

between attacks and with bronchodilators.

NURSING DIAGNOSIS
 Ineffective airways clearance related to
bronchospasm, excessive mucus production,
tenacious secretions and fatigue as evidenced
by ineffective cough, inability to raise
secretions, adventitious breath sounds.
 NURSING DIAGNOSIS
INTERVENTIONS AND RATIONALES
Asthma management
 Determine baseline respiratory status

 Monitor rate, rhythm, depth, and effort of respiration

 Observe chest movement, including symmetry, use

of accessory muscles and supraclavicular and

intercostals muscle retractions to evaluate
respiratory status.
 Auscultate breath sounds

 Administer medication

 Teach breathing /relaxation technique to improve

respiratory rhythm and rate.

 Offer warm fluids to drink to liquefy secretions and
promote bronchodialtion.
NURSING DIAGNOSIS
 Anxiety related to difficulty breathing ,
perceived or actual loss of control and fear of
suffocation as evidenced by restlessness,
elevated pulse , respiratory rate and blood
pressure.
NURSING DIAGNOSIS
INTERVENTION AND RATIONALES
ANXIETY REDUCTION
 Identify when level of anxiety and possible
precipitating factors.
 Use calm, reassuring approach to provide
reassurance.
 Stay with patient to promote safety and reduce fear.
 Encourage verbalization of feelings, perceptions

and fear to identify problem areas so appropriate

planning can take place.
 Instruct patient in the use of pursed lip breathing

and relaxation techniques to relieve tension and to

promote ease of respirations.
NURSING DIAGNOSIS
 Deficient knowledge related to lack of
information and education about asthma and
its treatment as evidenced by frequent
questioning regarding all aspects of long
term management.
 NURSING DIAGNOSIS
INTERVENTIONS AND RATIONALES
Asthma management
 Determine patient/family understanding
 Teach patient to identify and avoids triggers
 Encourage verbalization of feelings about diagnosis, treatment

and impact on lifestyle to offer support and increase compliance

with treatment.
 Educate patient about the use of the peak expiratory flow rate

(PEFR) meter at home to promote self management of symptoms.

 Instruct patient/family on anti inflammatory and bronchodilator

medications and their appropriate use to promote understanding

of effects.
 Teach proper technique for using, medication and equipment

(e.g. inhaler, nebulizer, peak flow meter) to promote self care.

 Establish a written plan with the patient for managing
exacerbations to plan adequate treatment of future exacerbations.
 PATIENT EDUCATION
 ACTIVITY PACING
 OXYGEN THERAPY
 ASTHMA TRIGGERS
 COUGHING TECHNIQUE
 PURSED LIP BREATHING
 TENSION RELAXATION EXERCISE
 USE OF INHALERS
 NUTRITIONAL THERAPY
Bronchodilators

LABA
 Asthma nebulizer

Changes asthma medications

from a liquid to a mist, so that
they can be more easily inhaled
into the lungs.
Surgical Treatment
Bronchial thermoplasty

 Invasive procedure for severe asthma

 Is not painful (no nerves inside airways)
 Risks : mainly lung collapse, bleeding and additional

breathing problems, mostly related to the bronchoscope.

 Precaution: Pt. must be at least 18 y/o to have the

procedure.
 Pt. still need to use their asthma-maintenance

medications after the procedure

 Benefits: Pt. may use rescue inhalers less often and are

able to engage strenuous physical activity than before

(Beck, n.d)
 PROGNOSIS
 In mild-to-moderate cases, asthma can
improve over time, and many adults even
become symptom free.
 For severe cases, improvement depending on

the degree of obstruction in the lungs and the

timeliness and effectiveness of treatment.

(Simon, 2009)
Cont…
 72% of men and 86% of women with asthma
had symptoms 15 years after an initial
diagnosis. Only 19% of these people, however,
were still seeing a doctor, and only 32% used
any maintenance medication.
 Death from asthma is a relatively uncommon

event, and most asthma deaths are

preventable.

(Simon, 2009)
THANK YOU