Pathophysiology: Asthma is a respiratory condition with chronic inflammation of the bronchioles and bronchoconstriction. This causes airway restriction. Asthma attacks are caused by triggers such as infections, allergens, exercise, and other irritants.
- Inflammatory disorder of airways
- Stimulated by triggers (infection, allergens, exercise, irritants)
- Status Asthmaticus – life-threatening condition
- Asthma unresponsive to treatment
- Narrowed airways = ↓ gas exchange
- Inflammation of airways
- Excessive mucus production
- Diminished breath sounds
- Peak Flow Rate
- Volume of expired air
- Patient should track and know baseline
- Stable = 80-100% baseline
- Caution = 50-80% baseline
- Danger = <50% baseline
- Pulmonary Function Tests
- X-ray to rule out other causes
- Peak Flow Rate
- High-fowler’s or position of comfort
- Administer O2
- Epi-Pen if allergic reaction
- Leukotriene Modulators
- Listen to lungs
- Monitor SpO2
- Administer supplemental O2
- Gas Exchange
- Monitor ABG
- Monitor for s/s CO2 toxicity
- ↓ LOC
- Keep patient calm
- Encourage position of comfort
- Identify Triggers and Avoid
- Allergy tests
- Smoke / Secondhand smoke
- SMOKING CESSATION
- Keep a journal
- Proper use of Inhaler
- Shake 10-15 times
- Large breathe, exhale completely
- Mouthpiece in mouth, seal with lips
- Tilt head back to open airway
- Depress inhaler, slow, deep breath in
- Hold breath 5-10 sec
- Breathe out slow
- Repeat if 2nd puff ordered
- Use spacer if needed
- Peak Flow Test
- Daily testing – perform 3 times and record best effort
- Track in a journal
- Report to provider if in caution or danger zone
Let’s talk about asthma. This is a really common disease you’re going to see, especially if you work in pediatrics or in the emergency room. We’re gonna hit the highlights and tell you some of the things you may see on the NCLEX and in the real world.
So Asthma is primarily an inflammatory disorder of the airways – already you can picture swollen airways means trouble breathing, right? Asthma is stimulated by triggers – this may be infections, if they get a cold or the flu, allergens like pollen, dust, cats, etc., exercise – this is something I experienced when I was in middle school – we’d be running for PE when it was cold out and suddenly I just couldn’t breathe – they called it exercise-induced asthma. And then of course any irritants like chemicals or smoke – smoking is a HUGE irritant and needs to be avoided by ANYONE with a lung disease, especially asthmatics. Now, status asthmaticus is essentially an asthma attack that won’t stop, no matter what we try. It’s a life-threatening situation because we can’t seem to get their airways to open up. It’s a really scary situation. Many times the patient needs to be intubated to prevent respiratory arrest. The sooner we recognize it, the better the outcome will be.
So let’s talk about the patho of asthma. There are three main things happening in the airways that cause it to narrow and close up. First, like we already said, is the inflammation. You can see here that compared to the normal airway, the walls of this airway are inflamed and swollen. This, by itself, can cause narrowing, but it’s not the only problem. We also see bronchoconstriction – where the smooth muscle around the airways constrict and cause even more narrowing and tightening of this airway. And then we also see excessive mucus production. So now, what used to be this beautiful big open airway, is now this tiny hole filled with mucus. Now, imagine trying to take deep breaths in and out through a soda straw. If you have one nearby, pause this video and try it! How do you think would it feel? It’s impossible to get all the air in and out like you need to. Now, you have the ability to just take the straw out and start breathing normally again, an asthmatic doesn’t have that option and it can get really scary.
So what will we see in the patient? Well we will hear wheezing and maybe crackles – remember those air passages are narrowing, that’s what causes the whistling wheeze sound. The crackles because of the mucus and fluid in the alveoli. And you might hear diminished breath sounds because they’re struggling to get enough air in to fill their lungs. And remember they’re going to be anxious, restless, even scared, and breathing really fast and shallow. It’s super important to keep them as calm as possible. A lot of times you’ll see them in the tripod position – this is when they’re leaning forward over a table or with their hands on their knees. They’re trying to force air into their lungs and open up their ribcage. And then one thing you may be able to test for is their Peak Flow Rate – asthma patients are taught to measure peak flow – they’ll know what their normal baseline is. If we can test it, we can determine how severe the attack is. They just blow hard and fast into this meter and the little red dial goes up. If their baseline is 400 mL of expired air and they’re only blowing 200, we know they’re at 50% and that’s not a good sign.
So what do we do for them – well first make sure you sit them up into high-fowler’s position or their position of comfort – I had a patient say they could breathe better on their hands and knees before. We’re going to give them O2 so that what air they CAN get in has a higher concentration of oxygen or FiO2. Then we want to give medications. If this is an allergic reaction, they can use an EpiPen to reverse that inflammatory response. Then we’ll give bronchodilators, corticosteroids, and possibly other immune modulators – again, trying to stop the immune and inflammatory response. Now, it’s SO important that you give bronchodilators FIRST before corticosteroids and here’s why. If this is your normal airway, nice and open, and this is your asthma airway – swollen and constricted. If you try to give steroids to decrease the inflammation, you can’t get them in! And if you do, the surface area you can affect is really small. So if you open the airways first, you’re making it easier to get the steroids in and help to decrease the inflammation to get it back to looking more like a normal airway. Make sense? So bronchodilators first, then corticosteroids!
Now, one thing we’ve seen on tests and on the NCLEX is the proper use of an inhaler. We need to be able to educate our patients on the proper use. I can’t tell you how many patients I’ve had who have been using one for years and are definitely not doing it right. So you shake it 10-15 times, take a deep breath and blow the whole breath out, then put the mouthpiece in your mouth and seal it. This might be directly on the inhaler or a spacer that we use to help the patient get more of the medication – especially for little ones that struggle. Then tilt your head back slightly to open the airways and press the inhaler button. Take a slow, deep breath in and hold it for 5-10 seconds. THIS is the big part I see patients missing and I see on tests. They have to hold it in. Once they’ve held it, they can breathe out slowly and repeat if they are supposed to do more than 1 puff. One more important note is that inhalers with corticosteroids can cause mouth ulcers so they need to rinse their mouth out afterwards.
So you can check out the care plan for patients with asthma for more details, but I’m sure you can imagine our priorities here. Oxygenation and gas exchange, of course – monitor their SpO2, give oxygen, give those bronchodilators, then the steroids – and make sure they’re using their inhaler correctly. Advocate for your patient and make sure the respiratory therapist knows about them! Then comfort is important because they’re going to be very uncomfortable and restless and anxious – as nurses we can play a huge role in keeping them calm and getting them through it.
Okay, let’s recap really quick. Remember that asthma is inflammation triggered by things like pollen, dust, smoke, or allergies. Three things happen, causing narrowed airways – inflammation, bronchoconstriction, and excess mucus production. We give bronchodilators BEFORE we give corticosteroids to make sure the meds can actually get in the lungs. We need to make sure patients know their triggers and avoid them, they need to use their inhalers correctly, and we can teach them how to track their peak flow rates. And finally our priorities are oxygenation, gas exchange, and keeping them comfortable and calm during this scary time.
Like we said before, asthma is super common, so we hope this helps you to understand what it is and how to help these patients. Now, go out and be your best selves today. And, as always, happy nursing!