BIOL 2305 Pathophysiology

1. Disease: Acute Severe Asthma with severe dyspnea

Definition: Acute Severe Asthma is a chronic disease of the lungs, which can be controlled but not cured. It results in excessive lung function variations by limiting airflow supply compared to healthy people (Papiris, Manali, Kolilekas, Triantafillidou & Tsangaris, 2009).

Aetiology

Variation of the lung function, which restricts breathing resulting from:

• Virus induced such as Rhinovirus (RV), Respiratory syncytial virus (RSV), Influenza virus and Human metapneumovirus (HMV)
• Bacteria induced
  • Mycoplasma pneumonia
  • Chlamydia pneumonia
• Occupational
  • Chemical exposure
  • Animal exposure
• Irritants
  • Airway pollutants
• Allergen
  • Tree, weed and grass pollen
  • Indoor allergens
  • Fungi (Hedlin, Bush, Carlsen, Wennergren, De Benedictis, Melén, Paton, Wilson & Carlsen, 2010)

 Pathogenesis

• Immunopathogenesis includes cold symptoms which decrease in peak flow with RV infections.    
• In allergen based asthma exacerbations include increase eosinophil recruitment and degranulation.
• Development of acute severe asthma leads to blocking of the passageway of breathing leading to shortness of breath and decreased activities and functionalities.  

Asthma is a common chronic disease, pathophysiology of asthma is rather complex includes airway inflammation, bronchial hyper responsiveness and intermittent airflow obstruction (Murphy & O’Byrne, 2010).  

Clinical Manifestation: 

• Chest tightness or pain
• Short ness of breath
• Trouble sleeping from shortness of breath, wheezing and coughing
• Whistling or wheezing sound when exhaling
• Coughing or wheezing worsened by means of respiratory virus of flu or the cold

Diagnosis

• History
• Physical examination
• Considering other diagnosis
• Documenting variable airflow limitation (Lemanske Jr & Busse, 2010)

Treatment

Acute Severe Asthma attack is triggered by flu, allergens or from other potential triggers, treatment for which includes;

• Using proper asthma medications, including quick relief medicines along with long term control medicines.
• Immunotherapy such as allergy shots can be a potential treatment. Long-term control medications include antileukotrienes, inhaled corticosteroids, oral corticosteroids and several other medications (Bacharier, Boner, Carlsen, Eigenmann, Frischer, Götz & Platts?Mills, 2008).

Course of Disease 

• With diagnosis of the disease and assessing asthma control, initial treatment appropriate has to be started.  
• Reviewing and adjusting of drug treatment periodically will enable adequate control of the disease.
• Assisting in self-management by providing information, skills and necessary tools such as training in inhalers, maximise adherence, writing down an asthma plan and avoiding potential triggers.
• Management of flare-ups is essential whenever it occurs
• Most important is managing of comorbid conditions which further triggers asthma or contribute in respiratory symptoms.
• Providing advice related to smoking, physical activities, immunisation, healthy eating and healthy weight maintaining.    

Prognosis

• Prognosis of asthma is not well described and defined in chronic obstructive pulmonary disease.
• Complete remission rates are low and possible which remains limited to milder cases.
• In some cases permanent lung function impairment might develop and patients are admitted to intensive care units with high risk of severe asthma complications (Lugogo & MacIntyre, 2008).  

Prevention 

Prevention of acute severe asthma includes the following;

• Reduced exposure to allergens
• Reduced physical exertion
• Reducing exposure to smoking areas
• Maintaining healthy diet
• Maintaining appropriate body mass

2. High priority nursing strategies to manage Jackson’s condition includes treating him with immunization shots (Gupta, Sjoukes, Richards, Banya, Hawrylowicz, Bush & Saglani, 2011). His oxygen levels need to be monitored and oxygen needs to be given to him so that levels of oxygen in his body does not deplete. Monitoring of blood pressure has to be undertaken to understand any abnormalities. A pulse measurer has to be connected as well to monitor rate of heart beat and activity levels. Taking steps to relieve from respiratory rates of 32 breaths/minute to 15 breaths/ minute. All necessary steps have to be taken to reduce such high rates of breaths. SpO2 90% on room air has to be monitored and supplement oxygen has to be given. BP rate of 150/85 mmHg has to be reduced to 120/80 mm/Hg levels. The pulse rate of the patient is also very high at 130 beats/minute, which has to be reduced to 92 beats/minute. Auscultation of lung reflects diminished breath south and widespread of wheeze from Chest X-ray. Such wheezing has to be reduced by regular monitoring of appropriate drug dosage. X-Rays has to conduct on regular basis to track any signs of improvement. To ease his breathlessness immediate shots of nebulization has to be initiated of Ipratropium bromide (4/24). To ease his nerves and reduce possibilities of cardiac arrest oral solution of corticosteroid as per body weight has to be administered through injection, to relieve inflammation. The solution will immediately help ease allergic conditions and is to be continued for minimum of 3 days till symptoms eases.    

3. a The three drugs that were given to Jackson included nebulized Salbutamol and nebulised Ipratropium bromide (4/24) and IV Hydrocortisone 100mg (6/24). The underlying pathogenesis of an Acute Severe Asthma with mechanism of action of these drugs includes broadening of the passageway through which oxygen enters the body (Lötvall, Akdis, Bacharier, Bjermer,  Casale, Custovic & Greenberger, 2011). In clinical setting for acute asthma nebulized bronchodilators are in common use in nebulized form. They are known to relieve symptoms of lung disorder functionality. They enable regulation of lung function by allowing extended passageway which allows more oxygen to enter the lungs and blood stream. In long term they help prevent asthmatic conditions by reducing manifestation of asthmatic triggers. They provide immediate relief by reducing calming down pulse rate and reducing heart rate, overall having calmer effects on the lungs. The drugs are known to allow diffusion of more oxygen into blood levels so as to reduce risks from possible cardiac arrests. Nurses are expected to conduct continuous monitoring and evaluation of the patient’s vital signs till the patient is able to stabilize. Further risks from reappearance of the symptoms have to be prevented as well by providing training for self-medications and control procedures of asthmatic conditions. In long term period nebulized dosage does not have to be monitored rather normal shots can be given to keep a check on the symptoms.       

b. Nursing implications is tremendous while administering of drugs to patient with an Acute Severe Asthma. Nurses need to continuously monitor for vitals that includes pulse rates, pressure monitoring for fluctuations and levels of oxygen in the blood. The patient diagnosed with acute severe asthmatic symptoms have to be monitored continuously to check for any signals of deterioration. Moreover, the dosage of nebulized Salbutamol has to be administered with specific gaps in between. The dosage will continue till the patient is able to regain normal pulse rate and pressure rates. Nursing monitoring will include regular blood monitoring as at current levels blood pH level was at 7.35 PaO2 at 60 mmHg, HCO3 will be at 25 mEq/L, Lactation at 1 and SaO2 at 90%. It will also include regular X-Ray monitoring, Blood oxygen levels, pulse rate and heart beat levels. Every possibility of rising adverse effects has to be reducing to further reduce potential impacts from escalating the situation into severe acute asthmatic conditions.   

Reference:

Bacharier, L. B., Boner, A., Carlsen, K. H., Eigenmann, P. A., Frischer, T., Götz, M., … & Platts?Mills, T. (2008). Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy, 63(1), 5-34. Retrieved on 26^th September 2018, from  https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1398-9995.2007.01586.x

Gupta, A., Sjoukes, A., Richards, D., Banya, W., Hawrylowicz, C., Bush, A., & Saglani, S. (2011). Relationship between serum vitamin D, disease severity, and airway remodeling in children with asthma. American journal of respiratory and critical care medicine, 184(12), 1342-1349. Retrieved on 16^th September 2018, from  https://www.atsjournals.org/doi/abs/10.1164/rccm.201107-1239oc

Hedlin, G., Bush, A., Carlsen, K.L., Wennergren, G., De Benedictis, F.M., Melén, E., Paton, J., Wilson, N. and Carlsen, K.H., (2010). Problematic severe asthma in children, not one problem but many: a GA2LEN initiative. Retrieved on 15^th September 2018, from https://erj.ersjournals.com/content/36/1/196.short

Lemanske Jr, R. F., & Busse, W. W. (2010). Asthma: clinical expression and molecular mechanisms. Journal of Allergy and Clinical Immunology, 125(2), S95-S102. Retrieved on 17^th September 2018, from https://www.sciencedirect.com/science/article/pii/S0091674909016133

Lötvall, J., Akdis, C. A., Bacharier, L. B., Bjermer, L., Casale, T. B., Custovic, A., … & Greenberger, P. A. (2011). Asthma endotypes: a new approach to classification of disease entities within the asthma syndrome. Journal of Allergy and Clinical Immunology, 127(2), 355-360. Retrieved on 10^th September 2018, from https://www.sciencedirect.com/science/article/pii/S0091674910018580

Lugogo, N. L., & MacIntyre, N. R. (2008). Life-threatening asthma: pathophysiology and management. Respiratory Care, 53(6), 726-739. Retrieved on 20^th September 2018, from https://rc.rcjournal.com/content/53/6/726.short

Murphy, D. M., & O’Byrne, P. M. (2010). Recent advances in the pathophysiology of asthma. Chest, 137(6), 1417-1426. Retrieved on 25^th September 2018, from https://www.sciencedirect.com/science/article/pii/S0012369210602978

Papiris, S. A., Manali, E. D., Kolilekas, L., Triantafillidou, C., & Tsangaris, I. (2009). Acute severe asthma. Drugs, 69(17), 2363-2391. Retrieved on 30^th September 2018, from https://link.springer.com/article/10.2165/11319930-000000000-00000