Asthma Nursing Management and Emergency Interventions

Overview

Asthma is a common chronic disease worldwide and affects approximately 26 million persons in the United States. It is the most common chronic disease in childhood, affecting an estimated 7 million children, and it is a common cause of hospitalization for children in the United States.

Asthma is a chronic disease with acute exacerbations characterized by intermittent airway obstruction in response to various stimuli. The epithelial lining in the airway responds by becoming inflamed and edematous. Bronchospasm occurs in the smooth muscle of the bronchi and bronchioles; secretion increases in viscosity and elastic recoil decreases. These changes result in a reduction of the diameter of the airways, making breathing more difficult. With continued exposure to inflammation, it can lead to irreversible remodeling of the airway, making the management of asthma symptoms and disease control increasingly difficult.

Causes

The fundamental causes of asthma are not completely understood. The strongest risk factors for developing asthma are a combination of genetic predisposition with environmental exposure to inhaled substances and particles that may provoke allergic reactions or irritate the airways, such as:

• indoor allergens (for example, house dust mites in bedding, carpets and stuffed furniture, pollution, and pet dander)
• outdoor allergens (such as pollens and molds)
• tobacco smoke
• chemical irritants in the workplace
• air pollution

Other triggers include cold air, extreme emotional arousals such as anger or fear, and physical exercise. Even certain medications can trigger asthma: aspirin and other non-steroid anti-inflammatory drugs, and beta-blockers (which are used to treat high blood pressure, heart conditions, and migraine). Gastroesophageal reflux (GERD) can also cause asthma. The presence of acid in the distal esophagus, mediated via vagal or other neural reflexes, can significantly increase airway resistance and reactivity. Exercise-induced asthma (EIA), or exercise-induced bronchoconstriction (EIB), is an asthma variant defined as a condition in which exercise or vigorous physical activity triggers acute bronchoconstriction in persons with heightened airway reactivity.

Incidence/Classification

Asthma is a common pathology, affecting around 15% to 20% of people in developed countries and around 2% to 4% in less developed countries. It is significantly more common in children.

In childhood, asthma is more common in boys with a male-to-female ratio of 2:1 until puberty when the ratio becomes 1:1. After puberty, the prevalence of asthma is greater in females. About 60% are diagnosed before the age of 18 years. Asthma prevalence is increased in extremes of age due to airway responsiveness and lower levels of lung function.

Treatment

For all but the most severely affected clients, the ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity.

• Calm the client during the asthma attack.
• Remove the client from the source of the allergen.
• Provide environmental control.
• Promote weight reduction.

Pathophysiology

Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant or an allergen, which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration. If not corrected rapidly, asthma may become more difficult to treat, as the mucus production prevents the inhaled medication from reaching the mucosa.

Epidemiology of Asthma

Asthma affects an estimated 300 million individuals worldwide. Annually, the World Health Organization (WHO) has estimated that 15 million disability-adjusted life-years are lost and 250,000 asthma deaths are reported worldwide. Asthma is common in industrialized countries such as Canada, England, Australia, Germany, and New Zealand, where much of the asthma data have been collected. The prevalence rate of severe asthma in industrialized countries ranges from 2 to 10%. Factors that have been implicated include urbanization, air pollution, passive smoking, and change in exposure to environmental allergens.

The overall prevalence rate of exercise-induced bronchospasm is 3 to 10% of the general population if persons who do not have asthma or allergy are excluded, but the rate increases to 12 to 15% of the general population if clients with underlying asthma are included.

In the United States, asthma prevalence, especially morbidity, and mortality, is higher in Blacks than in Whites. Larger asthma-associated lung function deficits are reported in Hispanics, especially females.

Signs and Symptoms

People with asthma have different signs and symptoms-they can change over time or depend on the situation.

Common signs and symptoms

• Cough may be the only symptom of asthma, especially in cases of exercise-induced or nocturnal asthma. Usually, the cough is nonproductive and non-paroxysmal. Children with nocturnal asthma tend to cough after midnight and during the early hours of the morning.
• Wheezing (whistling sound when breathing). Wheezing, a musical, high-pitched, whistling sound produced by airflow turbulence, is one of the most common symptoms. In the mildest form, wheezing is only end-expiratory. As severity increases, the wheeze lasts throughout expiration.
• Chest tightness. Chest tightness or a history of chest tightness or pain in the chest may be present with or without other symptoms of asthma, especially in exercise-induced or nocturnal asthma.
• Shortness of breath. During a mild episode, the client may be breathless after physical activity such as walking; they can talk in sentences and lie down; and they may be agitated. The respiratory rate is also increased.
• Increased mucus. Chronic mucous plug formation consists of exudate of serum proteins and cell debris that may take weeks to resolve. This excessive mucous production may cause airway obstruction.

Prevention

All clients with asthma should be advised to avoid exposure to allergens to which they are sensitive, especially in the setting of occupational asthma. Control of factors contributing to asthma severity is an essential component in asthma treatment.

• Encourage the client to change lifestyle and control environmental trigger factors.
• Promote the maintenance of healthy body weight as evidence reveals that the disorder is more difficult to control in overweight individuals.
• Educate the client to avoid tobacco and the use of beta-blockers, aspirin, and sulfites as much as possible.
• Perform a skin test to be used to assess sensitivity to perennial indoor allergens, and any positive results should be evaluated in the context of the client’s medical history.

Medical Management

Medical management includes treatment of acute asthmatic episodes and control of chronic symptoms, including nocturnal and exercise-induced asthmatic symptoms. Pharmacologic management includes the use of control agents such as inhaled corticosteroids, long-acting bronchodilators, theophylline, leukotriene modifiers, and more recent strategies.

• Environmental control. Environmental exposures and irritants can play a strong role in symptom exacerbations. Allergen avoidance takes different forms, depending on the specific allergen size and characteristics. Improvement in symptoms after avoidance of the allergen should result rather rapidly, though the allergen itself may linger in the environment for months after the primary removal of the source.
• Allergen immunotherapy. Repeated injections of small doses of allergen have been used for more than almost 100 years to treat allergic rhinitis. This treatment is clearly effective, and positive effects may persist even years after treatment is stopped. Allergen immunotherapy should be considered if specific allergens have a proven relationship to symptoms and a vaccine to the allergen is available; the individual is sensitized; the allergen cannot be avoided and is present year-round; or symptoms are poorly controlled with medical therapy.
• Monoclonal antibody therapy. Omalizumab is indicated for adults and children aged 6 years or older with moderate-to-severe persistent asthma who have a positive skin test result or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. The treatment can lower IgE levels, which in turn decreases histamine production.
• Bronchial thermoplasty. This is a novel intervention for asthma in which controlled thermal energy is delivered to the airway wall during a series of bronchoscopy procedures.
• Nebulizer therapy. Continuous nebulization may be superior to the MDI/holding chamber method in a client with severe exacerbations. The dose of albuterol is 10 to 15 mg in 70 ml of isotonic saline. However, an MDI/spacer may be more cost-effective and a better alternative to nebulizer therapy for some individuals.
• Intravenous or oral steroids. Although the use of systemic corticosteroids is recommended early in the course of acute exacerbations in clients with an incomplete response to beta-agonists, oral administration is equivalent in efficacy to intravenous administration. Corticosteroids speed the resolution of airway obstruction and prevent a late-phase response.
• Heliox. Heliox is a helium-oxygen mixture that may provide dramatic benefits for emergency department clients with severe exacerbations. Helium travels more easily down married passages, making it valuable for clients at risk of intubation by quickly decreasing the work of breathing and by better delivery of the inhaled bronchodilator.
• Antireflux therapy. Aggressive antireflux therapy may improve asthma symptoms and pulmonary function in selected clients with GERD. Treatment with proton pump inhibitors, antacids, or H2 blockers may improve asthma symptoms or unexplained chronic cough.

Assessment and Diagnosis

Updated guidelines from the National Asthma Education and Prevention Program (NAEPP) highlight the importance of correctly diagnosing asthma, by establishing episodic symptoms of airflow obstruction are present; if airflow obstruction or symptoms are at least partially reversible; and if there is the exclusion of alternative diagnoses.

Physical Assessment

A focused respiratory assessment includes inspection of the client’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope.

• Inspection. Inspection during a focused respiratory assessment includes observation of the level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion.
• Palpation. Palpation should be performed to investigate for areas of abnormality related to the disease. Confirm symmetric chest expansion by placing both hands on the anterior or posterior chest at the same level, with thumbs over the sternum anteriorly or the spine posteriorly. As the client inhales, the thumbs should move apart symmetrically.
• Auscultation. Using the diaphragm of a stethoscope, the nurse listens to the movement of air through the airways during inspiration and expiration. Instruct the client to take deep breaths through their mouth. The nurse should listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration.

Findings

Findings during the physical assessment for a client diagnosed with pneumonia include the following:

• During an acute exacerbation, there may be a fine tremor in the hands due to salbutamol use, and mild tachycardia. Clients will show some respiratory distress, often sitting forward to splint open their airways. Children with imminent arrest may appear drowsy, unresponsive, cyanotic, and confused.
• Rapid force expiration during a mild episode may elicit wheezing that is otherwise inaudible, and oxyhemoglobin saturation with room air is greater than 95%.
• In a moderately severe episode, the respiratory rate is also increased. Typically, accessory muscles of respiration are used. In children, look for supraclavicular and intercostal retractions and nasal flaring, as well as abdominal breathing.
• On auscultation, a bilateral, expiratory wheeze will be heard. In life-threatening asthma, the chest may be silent, as air cannot enter or leave the lungs, and there may be signs of systemic hypoxia.

Diagnostic Testing

• This test measures the movement of air in and out of the lung after the client takes the deepest breath. Spirometry should be performed prior to initiating treatment in order to establish the presence and determine the severity of baseline airway obstruction.
• Chest X-rays. Chest radiography shows areas with hyperinflation with local atelectasis and flattened diaphragm. Chest radiography is usually more useful in the initial diagnosis of bronchial asthma than in the detection of exacerbations, although it is valuable in excluding complications such as pneumonia and asthma mimics, even during exacerbations.
• Complete blood count. This reveals the increase in eosinophil count. Blood eosinophilia greater than 4% or 300 to 400/µL supports the diagnosis of asthma, but an absence of this finding is not exclusionary.
• Pulse oximetry. This test shows decreased oxygen saturation. Oxygenation decreases 4 to 10 mm Hg with beta-agonist inhalant therapy due to increases in V/Q mismatch. Therefore, all clients with acute asthma should have oxygen saturation measured by pulse oximetry.
• Serum IgE level. Levels may increase from an allergic reaction. Total serum immunoglobulin E levels greater than 100 IU are frequently observed in clients experiencing allergic reactions, but this finding is not specific to asthma and may be observed in clients with other conditions. A normal total serum immunoglobulin E level does not exclude the diagnosis of asthma.
• Skin testing. Allergy skin testing may identify specific allergens. Results help guide indoor allergen mitigation or help diagnose allergic rhinitis symptoms.
• Arterial blood gas(ABG). Analysis may detect hypoxemia. This test may reveal dangerous levels of hypoxemia or hypercarbia secondary to hypoventilation and, hence, respiratory acidosis.
• Pulmonary function test. This reveals airway obstruction and decreases the peak expiration flow rate. Single-breath counting (SBC) is a novel technique for measuring pulmonary function in children. SBC is the measurement of how far an individual can count using a normal speaking voice after one maximal effort inhalation.

Diagnosis

Laboratory assessments and studies are not routinely indicated for the diagnosis of asthma, but they may be used to exclude other diagnoses. Spirometry is the diagnostic method of choice and will show an obstructive pattern that is partially or completely resolved by salbutamol.

Complications

Asthma is not a benign illness and accounts for 1 death per 100,000 people in some countries. The mortality is related to lung function and is exacerbated by smoking. Clients with poorly controlled asthma develop long-term changes over time, such as with airway remodeling. This can lead to chronic symptoms and a significant irreversible component of their disease. Asthma complications may also include:

• Signs and symptoms that interfere with sleep, work, and other activities
• Sick days from work or school during asthma flare-ups
• A permanent narrowing of the tubes that carry air to and from the lungs, affects breathing
• Emergency department visits and admissions for severe asthma attacks
• Side effects from long-term use of some medications used to stabilize severe asthma.

Nursing Management

Many guidelines have been published for the diagnosis and management of asthma, but the most critical feature is client education. The nurses are the last professionals to see the client before discharge from the emergency department or the wards. Nurses also play a vital role in school-based asthma education programs that can help improve self-esteem, knowledge, and self-management behaviors.

Nursing Assessment

A detailed assessment of the medical history should address whether symptoms are attributable to asthma, whether findings support the likelihood of asthma, asthma severity, and the identification of possible precipitating factors.

Subjective Cues

• Fatigue, exhaustion, malaise
• Inability to perform basic activities of daily living
• Inability to sleep, need to sleep sitting up
• Dyspnea at rest
• Changes in lifestyle
• Inability to eat because of respiratory distress
• Seasonal or episodic occurrence of breathlessness, a sensation of chest tightness, inability to breathe

Objective Cues

• Hypertension
• Tachycardia
• Pale or bluish (cyanotic) skin color and mucous membranes
• Anxious, fearful
• Diaphoresis
• Poor skin turgor
• Rapid, shallow respirations
• Use of accessory muscles for respiration
• Nasal flaring
• Rhonchi, wheezing throughout lung fields on expiration
• flushing

Nursing Diagnosis

Nursing diagnoses applicable for a client diagnosed with asthma include:

• Ineffective airway clearance related to bronchospasm, increased production of secretions
• Impaired gas exchange related to obstruction of airways
• Imbalance nutrition: less than body requirements related to dyspnea and sputum production
• Deficient knowledge related to lack of information, unfamiliarity with information resources, or information misinterpretation
• Self-care deficit related to intolerance to activity
• Ineffective home maintenance related to an inadequate support system, insufficient finances, or unfamiliarity with community resources
• Risk for infection related to increased environmental exposure

Nursing Care Planning and Goals

The goals appropriate for the care of a client with asthma are:

• The client will maintain airway patency.
• The client will participate in measures to facilitate gas exchange.
• The client will consume adequate nutritional requirements.
• The client will prevent complications and have a slow progression of the condition.
• The client will understand information about the disease process, prognosis, and treatment regimen.

Nursing Interventions for Asthma

• Obtain a history of previous attacks.
• Assess the client’s vital signs routinely.
• Evaluate wheezes for location, duration, and phase of respiration when they occur.
• Monitor pulse oximetry and ABG for oxygenation and acid-base balance.
• Identify medications the client is currently taking.
• Assess dietary habits, recent food intake, and current weight.
• Place the client in a high Fowler position.
• Administer medications as prescribed and monitor the response of the client to those medications.
• Administer fluids if the client is dehydrated.
• Provide reassurance to relieve anxiety.
• Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to the individual situation.
• Encourage and assist with abdominal or pursed-lip breathing exercises to provide a means for coping.
• Encourage expectoration of sputum to improve airway patency.
• Encourage a rest period of 1 hour before and after meals and provide frequent feedings.
• Explain and reinforce explanations of the individual disease process.
• Discuss the importance of regular medical follow-up care, when to notify healthcare professionals of changes in the condition, and periodic spirometry testing.

Emergency Interventions

• Alert the healthcare provider immediately.
• Observe the client closely for respiratory arrest. Monitor the respiratory rate continuously and other vital signs every 5 minutes. Never leave the client alone.
• Make sure the client receives oxygen and bronchodilator and nebulizer therapies as ordered.
• Have emergency equipment brought to the bedside and prepare to assist with intubation and mechanical ventilation if respiratory arrest occurs.
• Obtain a request for ABG for immediate blood gas analysis.
• Administer corticosteroids, epinephrine, sympathomimetic aerosol agents, and IV aminophylline as ordered.
• Prepare to transfer the client to the intensive care unit.

Nursing Evaluation

After the implementation of nursing interventions, the nurse evaluates if the desired goals and outcomes were achieved. The nurse needs to ensure that:

• The client’s ventilation/oxygenation is adequate to meet self-care needs.
• The client’s nutritional intake meets caloric needs.
• The client’s infection is treated or prevented.
• The client understood the disease process, prognosis, and therapeutic regimen.
• The client has a plan in place to meet needs after discharge.

Discharge and Home Care Guidelines

For clients discharged to their homes, monitoring should be performed on a continual basis based on the following parameters, which help in the overall management of the disease.

• Clients should be taught to recognize inadequate asthma control, and providers should assess control at each visit.
• To monitor pulmonary function, the client should regularly perform spirometry and peak-flow monitoring.
• Inquire about missed work or school days from the client, reduction in activities, sleep disturbances, or change in caregiver activities.
• Determine whether the clients are monitoring themselves to detect asthma exacerbations and if these exacerbations are self-treated or treated by healthcare providers.
• Ensure the client’s adherence to medications and usage of short-acting beta agonists.
• Monitor client-provider communication and client satisfaction.

Nursing Documentation

The focus of documentation on a client diagnosed with asthma should include the following:

• Related factors for individual client
• Breath sounds, presence/character of secretions, use of accessory muscles for breathing
• The character of cough/sputum
• Plan of care and who is involved in planning
• Teaching plan
• Response to interventions, teachings, and actions performed
• Attainment or progress toward desired outcomes
• Modifications to the plan of care
• Long-term needs
• Specific referrals made

References

1. Chippewa Valley Technical College. (2020). Nursing Skills. Pressbooks. https://wtcs.pressbooks.pub/nursingskills/front-matter/introduction/
2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
3. Hashmi, M. F., Tariq, M., & Cataletto, M. E. (2023, February 19). Asthma – StatPearls. NCBI. Retrieved April 9, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK430901/
4. Hashmi, M. F., Tariq, M., Cataletto, M. E., & Hoover, E. L. (2023, February 19). Asthma (Nursing) – StatPearls. NCBI. Retrieved April 16, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK568760/
5. Mayo Clinic. (2022, March 5). Asthma – Symptoms and causes. Mayo Clinic. Retrieved April 15, 2023, from https://www.mayoclinic.org/diseases-conditions/asthma/symptoms-causes/syc-20369653
6. Morris, M. J., & Mosenifar, Z. (2023). Asthma: Practice Essentials, Background, Anatomy. Medscape Reference. Retrieved April 9, 2023, from https://emedicine.medscape.com/article/296301-overview