Pathology Discussion Diagnosis: ASTHMA How long patient has had this diagnosis? Other co-morbidities? 1.

What is the etiology of this diagnosis? Environmental allergens (house dust mites, animal allergens, especially cat and dog, cockroach allergens, and fungi), viral respiratory tract infections, exercise, hyperventilation, gastroesophageal reflux disease, chronic sinusitis or rhinitis, aspirin or nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity, sulfite sensitivity, use of beta-adrenergic receptor blockers (including ophthalmic preparations), obesity, environmental pollutants, tobacco smoke, occupational exposure, irritants (eg, household sprays, paint fumes), high- and low-molecular-weight compounds (eg, insects, plants, latex, gums, diisocyanates, anhydrides, wood dust, and fluxes; associated with occupational asthma), emotional factors or stress, perinatal factors (prematurity and increased maternal age; maternal smoking and prenatal exposure to tobacco smoke; breastfeeding has not been definitely shown to be protective). 2. What clinical manifestations are present? 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. In a more severe asthmatic episode, wheezing is also present during inspiration. During a most severe episode, wheezing may be absent because of the severe limitation of airflow associated with airway narrowing and respiratory muscle fatigue. Asthma can occur without wheezing when obstruction involves predominantly the small airways. Thus, wheezing is not necessary for the diagnosis of asthma. Furthermore, wheezing can be associated with other causes of airway obstruction, such as cystic fibrosis and heart failure. Patients with vocal cord dysfunction have a predominantly inspiratory monophonic wheeze (different from the polyphonic wheeze in asthma), which is heard best over the laryngeal area in the neck. Patients with bronchomalacia and tracheomalacia also have a monophonic wheeze. In exercise-induced asthma, wheezing may be present after exercise, and in nocturnal asthma, wheezing is present during the night. Cough may be the only symptom of asthma, especially in cases of exercise-induced or nocturnal asthma. Usually, the cough is nonproductive and nonparoxysmal. Children with nocturnal asthma tend to cough after midnight and during the early hours of morning. Chest tightness or a history of tightness or pain in the chest may be present with or without other symptoms of asthma, especially in exercise-induced or nocturnal asthma. Other nonspecific symptoms in infants or young children may be a history of recurrent bronchitis, bronchiolitis, or pneumonia; a persistent cough with colds; and/or recurrent croup or chest rattling. Most children with chronic or recurrent bronchitis have asthma. Asthma is also the most common underlying diagnosis in children with recurrent pneumonia; older children may have a history of chest tightness and/or recurrent chest congestion.

3. What is the usual treatment for this diagnosis? What treatments is your patient receiving? Medical care 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, inhaled cromolyn or nedocromil, long-acting bronchodilators, theophylline, leukotriene modifiers, and more recent strategies such as the use of antiimmunoglobulin E (IgE) antibodies (omalizumab). Relief medications include short-acting bronchodilators, systemic corticosteroids, and ipratropium. For all but the most severely affected patients, the ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity to provide a healthy lifestyle appropriate to the age of child. 4. What medications is your patient receiving for this diagnosis? How do these medications work in relation to this diagnosis? Quick relief medications are used to relieve acute asthma exacerbations and to prevent exerciseinduced asthma (EIA) or exercise-induced bronchospasm (EIB) symptoms. These medications include short-acting beta agonists (SABAs), anticholinergics (used only for severe exacerbations), and systemic corticosteroids, which speed recovery from acute exacerbations. Long-term control medications include inhaled corticosteroids (ICSs), cromolyn sodium, nedocromil, long-acting beta agonists (LABAs), combination inhaled corticosteroids and long-acting beta agonists, methylxanthines, and leukotriene antagonists. Inhaled corticosteroids are considered the primary drug of choice for control of chronic asthma, but unfortunately the response to this treatment is characterized by wide variability among patients 5. Which assessments are important prior to administering these medications? During a mild episode, patients may be breathless after physical activity such as walking; they can talk in sentences and lie down; and they may be agitated. Patients with mild acute asthma are able to lie flat. In a mild episode, the respiratory rate is increased, and accessory muscles of respiration are not used. The heart rate is less than 100 bpm, and pulsus paradoxus (an exaggerated fall in systolic blood pressure during inspiration) is not present. Auscultation of the chest reveals moderate wheezing, which is often end expiratory. Rapid forced expiration 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 also is increased. Typically, accessory muscles of respiration are used. In children, also look for supraclavicular and intercostal retractions and nasal flaring, as well as abdominal breathing. The heart rate is 100-120 bpm. Loud expiratory wheezing can be heard, and pulsus paradoxus may be present (10-20 mm Hg). Oxyhemoglobin saturation with room air is 91-95%. Patients experiencing a moderately severe episode are breathless while talking, and infants have feeding difficulties and a softer, shorter cry. In more severe cases, the patient assumes a sitting position.

In a severe episode, patients are breathless during rest, are not interested in eating, sit upright, talk in words rather than sentences, and are usually agitated. In a severe episode, the respiratory rate is often greater than 30 per minute. Accessory muscles of respiration are usually used, and suprasternal retractions are commonly present. The heart rate is more than 120 bpm. Loud biphasic (expiratory and inspiratory) wheezing can be heard, and pulsus paradoxus is often present (20-40 mm Hg). Oxyhemoglobin saturation with room air is less than 91%. As the severity increases, the patient increasingly assumes a hunched-over sitting position with the hands supporting the torso, termed the tripod position. When children are in imminent respiratory arrest, in addition to the aforementioned symptoms, they are drowsy and confused, but adolescents may not have these symptoms until they are in frank respiratory failure. In status asthmaticus with imminent respiratory arrest, paradoxical thoracoabdominal movement occurs. Wheezing may be absent (associated with most severe airway obstruction), and severe hypoxemia may manifest as bradycardia. Pulsus paradoxus noted earlier may be absent; this finding suggests respiratory muscle fatigue. As the episode becomes more severe, profuse diaphoresis occurs, with the diaphoresis presenting concomitantly with a rise in PCO2 and hypoventilation. In the most severe form of acute asthma, patients may struggle for air, act confused and agitated, and pull off their oxygen, stating, "I cant breathe." These are signs of life-threatening hypoxia. With advanced hypercarbia, bradypneic, somnolence, and profuse diaphoresis may be present; almost no breath sounds may be heard; and the patient is willing to lie recumbent. 6. What lab values support the patients diagnosis? Laboratory assessments and studies are not routinely indicated for the diagnosis of asthma, but they may be used to exclude other diagnoses. Eosinophilia and elevated serum IgE levels may help guide therapy in some cases. Arterial blood gases and pulse oximetry are valuable for assessing severity of exacerbations and following response to treatment. 7. What is the prognosis? International asthma mortality is reported as high as 0.86 deaths per 100,000 persons in some countries. US asthma mortality rates in 2006 were reported at 1.2 deaths per 100,000 persons. Mortality is primarily related to lung function, with an 8-fold increase in patients in the lowest quartile, but mortality has also been linked with asthma management failure, especially in young persons. Other factors that impact mortality include age older than 40 years, cigarette smoking more than 20-pack years, blood eosinophilia, and forced expiratory volume in one second (FEV1) of 40-69% predicted. Nearly one half of children diagnosed with asthma have a decrease in symptoms and require less treatment by late adolescence or early adulthood. In a study of 900 children with asthma, 6% required no treatment after 1 year, and 39% only required intermittent treatment.

Patients with poorly controlled asthma develop long-term changes over time (ie, with airway remodeling). This can lead to chronic symptoms and a significant irreversible component to their disease. Many patients who develop asthma at an older age also tend to have chronic symptoms. 8. What is the primary nursing concern? What nursing interventions would address this concern? How would you know if your plan was working? Administer oxygen therapy as prescribed, place client in high fowler's position to facilitate air exchange, monitor cardiac rate and rhythm for changes during an acute attack, initiate and maintain IV access, give medication as prescribed (bronchodilators, anti-inflammatories), and remain calm. 9. What are 3 things you would teach your patient/family member about this diagnosis? Recognize triggers (smoke, dust, mold, weather changes), encourage regular exercise, promote good nutrition and proper hand hygiene.