Astma Update

42 Nursing made Incredibly Easy! March/April 2010 www.NursingMadeIncrediblyEasy.com

Asthma updateFour components of care

Jim, a 23-year-old construction worker,comes to your ED with acute shortness ofbreath, complaining of chest tightness thathas progressively worsened over the pastweek while he was installing Sheetrock ata construction site. When he arrives he’sacutely dyspneic, with an oxygen saturationlevel on room air of 88%, a respiratory rateof 40 breaths/minute, and a heart rate of140 beats/minute. He’s afebrile, with aBP of 170/100 mm Hg. Jim has difficultyspeaking due to shortness of breath. Ahead, eye, ear, nose, and throat exam showsno evidence of acute infection. Circumoralcyanosis (a bluish tint to the skin aroundthe lips) and nasal flaring are present. Ex-amination of his chest shows decreased airentry bilaterally, with inspiratory and expi-ratory wheezes. Suprasternal and intercostalretractions are noted. Jim is examined andstabilized by the ED healthcare providerand admitted to the hospital for manage-ment of an acute asthma exacerbation.

A review of Jim’s past medical historyreveals intermittent asthma since age 5, withno previous hospitalizations or acute carevisits. However, his asthma symptoms haveworsened since he moved in with his broth-er, who smokes two packs of cigarettes perday and works as a pet groomer at home.Over the past 4 weeks, he has experienceddaily wheezing responsive to albuterol,

www.NursingMadeIncrediblyEasy.com March/April 2010 Nursing made Incredibly Easy! 43

Asthma is on the rise in the United States, with approximately 22million people affected by this chronic disorder. To provide optimalcare for your patients with asthma, you must be familiar with thelatest management guidelines. We spell it out.By Margaret J. McCormick, MS, RNClinical Assistant Professor, Nursing • Towson University • Towson, Md.

The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity.

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Asthma update

which he uses once every night shortly afterhe returns home. Today his symptomsbecame worse at the construction site; he’sused albuterol every 2 hours for a total ofthree doses without significant improve -ment in his symptoms.

Each year, asthma is responsible for1.8 million ED visits, 500,000 hospitaladmissions, 400 deaths, and 100 milliondays of restricted activity. In order for youto be able to help your patients with asthma,you need to become familiar with the latestrecommendations for asthma care and management as presented in the updatedNational Institutes of Health’s NationalAsthma Education and Prevention Program(NAEPP) guidelines. In this article, I’ll outlinethe key changes to the components of asthmacare, but first let’s briefly review what asthmais and how it develops.

Meet the inflamed airwaysAsthma is a chronic inflammatory disorderof the airways that’s a result of a complex in-teraction between mast cells, eosinophils, ba-sophils, Th-2 lymphocytes, neutrophils, andchemical mediators such as histamine,prostaglandin, leukotrienes, and cytokines(see Mechanisms of bronchospasm). It’s charac-terized by episodic reversible airway ob-struction, increased bronchial reactivity, andairway inflammation. In genetically suscepti-ble individuals, these interactions can lead tobreathlessness; wheezing; recurrent episodesof coughing, particularly at night or in theearly morning; and chest tightness. Theseepisodes are usually associated with variableairflow obstruction, which is often reversiblespontaneously or with treatment. The bron-chospasms that occur during an asthma attack result when the bronchial smoothmuscle contraction constricts the airways inresponse to exposure to an allergen or irri-tant (see Pathogenesis of bronchial asthma). Pa-tients with asthma often have airways thatare hyperresponsive. This means that the pa-tient has an exaggerated bronchoconstrictorresponse, causing airflow limitations.


Pathogenesis of bronchial asthma

Antigen

IgEMast cell

Increasedmucus

production

Mucus-producinggoblet cell

Cytokines

Bronchialsmoothmuscle

Bronchospasm

Epithelialcell injury

Mucus

NeutrophilBasophil

Eosinophil

Afferent and efferentvagal fibers

Bronchospasm and heightenedairway responsiveness

A: Immediate or early-phase response

B: Late-phaseresponse

Increasedvascular

permeabilityand edema


A diagnosis of asthma is considered ifa patient meets three criteria: 1. symptoms of asthma in response to a trigger (airwayhyperreactivity); 2. repeated episodes ofsymptoms (recurrence); and 3. response totreatment (reversibility). However, spirome-try is needed to confirm the diagnosis.

Asthma severity is classified as follows:• intermittent—symptoms twice a week or less andnighttime symptoms twice a month or less—symptoms don’t cause interference withnormal activity—using a short-acting beta2-agonist (SABA)inhaler 2 days or less a week for control ofsymptoms• mild persistent—symptoms more than twice aweek but less than once a dayand nighttime symptoms threeto four times per month—minor limitation with normalactivity because of symptoms—using a SABA inhaler morethan 2 days a week, but notdaily for control of symptoms• moderate persistent—having daily symptoms andnighttime symptoms morethan once a week, but notevery night—some limitation of normalactivity because of symptoms—using a SABA inhaler dailyfor control of symptoms• severe persistent—having continual daytimesymptoms and frequent night-time symptoms, often seventimes per week—extreme limitation of normalactivity because of symptoms—no control of symptoms.

More than one causeThe development of asthma isthought to be multifactoral,involving environment

and genetics. One hypothesis, called the hygiene hypothesis, is based on observa-tions that asthma is more common in urban rather than rural communities.The hygiene hypothesis states that if envi-ronmental exposures occur at a criticaltime in the development of the immunesystem, it can lead to a change in the bal-ance between Th-1 and Th-2 type cytokineresponses. For example, if a child is ex-posed to respiratory infections early in lifethrough exposure to day care or older sib-lings and lives in a rural community, he’slikely to have a Th-1 response and a lowerincidence of asthma. The absence of these

Mechanisms of bronchospasm

Edema Epithelial injury

Impaired mucociliary function

Airflowlimitation

Bronchospasm

Increased airwayresponsivenessAirway inflammation

Allergen

Mast cells

Early Phase

Late Phase

Release histamine, leukotrienes,interleukins, and prostaglandins

Infiltration of inflammatory cells

Release cytokines, interleukins,and other inflammatory mediators

factors is associated with a persistent Th-2response and a higher rate of asthma.

Recent studies have found that there’sa genetic component to asthma. Genetic differences may alter susceptibility toasthma, as well as responsiveness to med-ications. Different phenotypes, varying

intensity ofinflammation,cellular mediatorpatterns, andtherapeuticresponses to asth-ma exist.Research in thearea of geneticsmay lead to newtreatmentapproaches

targeted at specific patient phenotypesand genotypes.

Signs and symptoms, pleaseSigns and symptoms of asthma may in-clude sudden shortness of breath, chesttightness, wheezing, cough, and sputumproduction. Not every patient has all ofthese symptoms; some may experience onlya cough. During a patient’s acute asthma attack, you may observe an elevated respi-ratory rate due to an increased work ofbreathing. This patient may have a de-creased activity tolerance and may not beable to complete a full sentence whenspeaking to you. When auscultating the patient’s lungs, you may hear wheezing,crackles, or rhonchi. The air movement orair entry will be diminished or absent andmay have a prolonged expiratory phase.

Remember that the absence of wheezingisn’t always a good sign. It may mean thatthe obstruction is so severe that it’s limitingthe passage of air within the airways. Othersigns of respiratory distress may includenasal flaring and suprasternal or intercostalretractions. The patient will have a pale orcyanotic color to his skin, lips, or mucousmembranes and bluish nasal turbinates.

Chronic asthma sufferers may have allergicshiners (bluish rings under their eyes), transverse nasal creases (a line across thebridge of their nose) from chronic sinusitis,and a barrel chest or clubbing of the fingersfrom chronic hypoxia.

Ask the right questionsWhen conducting an initial history andphysical exam on a patient with asthma it’simportant to ask not only about signs andsymptoms, but also about their pattern. Besure to ask when the symptoms occur. Dothey occur during the fall, winter, spring, orsummer? What are the onset, duration, andfrequency of the symptoms? Make sureto ask about the number of days andnights per week or month that he experi-ences signs and symptoms. Ask him ifhe experiences symptoms at night or earlyin the morning.

What are the precipitating or aggravat -ing factors? Does he experience increasedepisodes of shortness of breath when he has aviral respiratory infection? Does he experi-ence increased symptoms when exposed toindoor allergens (such as mold or mildew,dust mites, and animal dander) or outdoorallergens? Does pollen, pollution, exposureto occupational chemicals or allergens, or anirritant such as tobacco smoke or smoke froma wood burning stove bother him? Has henoticed that emotions (such as fear, anger, orcrying), stress, or changes in the weather trigger symptoms? Does his asthma getworse when he takes certain medications suchas aspirin or nonsteroidal anti-inflammatorydrugs? Do certain foods or food additivessuch as sulfites aggravate his symptoms?

Ask the patient about when he first devel-oped asthma, the progression of the disease,and his present treatment and care duringexacerbations. Ask him how often he uses ashort-acting inhaler and whether he has beenprescribed oral corticosteroids or inhaledcorticosteroids. If so, how often does heuse them? A family history of asthma, aller-gies, sinusitis, eczema, or nasal polyps is


What would we do without

you?

significant in the development of asthma,according to the latest research. A social his-tory should include characteristics about hiswork setting (or day care or school settingfor a child or adolescent) that may interferewith adherence to treatment. Ask about hissocial support network and level of educa-tion and employment. If your patient is awoman, does menstruation, pregnancy, orthyroid disease influence her symptoms?

If the patient is in acute distress, shortenthe history and wait until he feels better toask more detailed questions such as a profileof typical exacerbation. Other questions thatare important to record, but not during anacute episode, include: What impact doesasthma have on the patient and his family?Does he go to the ED for unscheduled careor hospitalization? How many days of workor school does he miss? Does asthma limithis activity, especially playing sports orstrenuous work? Does he wake up at night?What effect has asthma had on his growth,development, and behavior or school perfor-mance? What’s the impact on his family’sroutines, activities, or dynamics? Does thefamily have financial concerns about copingwith or treating his asthma?

During a physical exam of the patient,perform a general appraisal by observinghis color, posture, and respiratory rate andnote increased work of breathing and signsof decreased activity tolerance. Auscultatehis lungs for adventitious breath sounds anddecreased air movement or use of accessorymuscles. Also note whether he’s able to finish a complete sentence.

Medications coming right upPrescribed therapy for patients with asthmaincludes long-term control medications andshort-term, quick relief medications for anacute attack.

Long-term control medications include:• inhaled corticosteroids—these agents, suchas beclomethasone, budesonide, budesonidewith formoterol, fluticasone, fluticasone with salmeterol, mometasone, and triamcinolone,

block late phase reaction to allergens, reduce airway hyperresponsiveness, and inhibit in-flammatory cell migration and activation; themost effective medications for the long-termtreatment of asthma• cromolyn sodium and nedocromil—stabi-lize mast cells and interfere with chloridechannel function• immunomodulators—omalizumab is amonoclonal antibody that prevents thebinding of immunoglobulin E to the high-affinity receptors on basophils and mastcells; note the blackbox warning to beprepared to treatanaphylaxis• leukotriene modi-fiers—leukotrienereceptor antagonists,such as montelukastand zafirlukast, arean alternative butnot preferred treat-ment for mild per-sistent asthma, andthe 5-lipoxygenaseinhibitor zileuton isan alternative butnot preferred ad-junct therapy inadults; liver func-tion must be moni-tored with zileuton• long-acting beta2-agonists (LABAs)— salmeterol and for-moterol arebronchodilators,with action lastingup to 12 hours, thatmay be used incombination withinhaled corticos-teroids (theyshouldn’t be used asmonotherapy); notethe new black boxwarning about


Key changes tothe NAEPPasthma guidelinesFour components of effectiveasthma care

Component 1: Assessment and monitoring• Asthma severity• Daytime symptoms• Nighttime symptoms• Lung function (peak flow measurements,pulmonary function tests)• Asthma control• Current degree of impairment• Risk of future impairment

Component 2: Education • Should occur at every point of care• Importance of partnering for effective care• Assess and teach self-monitoring skills• Develop an asthma action plan for every patient

Component 3: Control of environmentalfactors• Identify allergic sensitivities/triggers • Incorporate measures to reduce indoor andoutdoor allergens/irritants• Manage comorbidities

Component 4: Medication therapy• Step-wise approach to treatment based onachieving good asthma control• Long-term controller medication (corticos-teroids, LABAs, mast cell stabilizers,immunomodulators, leukotriene modifiers,methylxanthines)• Short-term rescue medication (anticholiner-gics, SABAs, systemic corticosteroids)

sheet

cheat

asthma-related deaths on all preparationscontaining a LABA• methylxanthines—sustained-release theo-phylline is a mild-to-moderate bronchodila-tor that’s used as an alternative, but notpreferred, therapy; it’s essential to monitorserum theophylline levels because of thedrug’s narrow therapeutic range.

Quick relief medications include:• anticholinergics—these agents, such asipratropium, ipratropium with albuterol,and tiotropium, inhibit muscarinic choliner-gic receptors and reduce intrinsic vagal toneof the airways• inhaled SABAs—bronchodilators that re-lax smooth muscle include albuterol tablets,metered-dose inhaler, and solution for neb-ulization; levalbuterol metered-dose inhaler;and pirbuterol autohaler (metered-dose in-haler); in December 2008 the majority ofchlorofluorocarbon inhalers were removedfrom the marketplace because of the threatto the ozone layer• systemic corticosteroids—oral steroids,such as methylprednisolone and pred-nisone, may be used concomitantly with aSABA for treatment of moderate-to-severeasthma exacerbations to quicken recoverytime.

Asthma guidelines updateThe NAEPP Expert Panel Report 3 (EPR-3)was built on the comprehensive guidelinesissued in 1991, 1997, and an update in2002. Its purpose is to provide updatedrecommendations for selecting care andtreatment based on the individual needsof patients with asthma. These new guide-lines include an expanded section onchildhood asthma with an additional agegroup (ages 5 to 11), new guidelines onmedications, recommendations on patienteducation in settings beyond the health-care provider’s office, and advice for controlling environmental factors that cancause asthma symptoms. Information fordeveloping these guidelines was based ondata from the scientific literature and evi-

dence-based practice in the field. The fo-cus of the guidelines is to help patientswith asthma gain better control of theircondition so that they can “be active allday and sleep well at night.”

Key changes to the four components ofcare are as follows:• assessment and monitoring of asthmaseverity. Severity is described as the intrin-sic intensity of the disease process. It can be measured in a patient who isn’t receiv-ing long-term control therapy, after asthmacontrol is achieved, or by the amount ofmedication required to maintain control.Control is obtained when asthma symp-toms are minimized by therapeutic inter-ventions and the therapeutic goals areachieved. Some patients are unable to de-termine their level of airway obstructionand, despite their best intentions, may notgive an accurate portrayal of their level ofasthma control. Specific questions aboutsleep, level of activity, and use of an in-haler rather than just asking about howthe patient’s asthma is doing can givemore information about the real level ofhis asthma control. Asthma responsivenessis considered to be the ease with whichasthma control is achieved by the pre-scribed therapy. New features in the EPR-3include the use of multiple measurementsto assess the patient’s level of current im-pairment and future risk.

According to the NAEPP guidelines, theseverity and control of a patient’s asthmacan determine his level of impairment andfuture risk. Impairment is defined as the fre-quency and intensity of symptoms, low lungfunction, and current or recent limitations ofdaily activities. Future risk is identified asthe patient’s risk of exacerbations, progres-sive loss of lung function, or adverse reac-tions from medications. The new guidelinesstate that patients can still be at high risk forfrequent exacerbations even if they experi-ence minimal day-to-day effects of asthma.A detailed history is the first step to assess-ing and monitoring asthma severity and


did youknow?There are new areasof specialization inasthma care. Nursescan join the Associ-ation of Asthma Educators or take acertification exam tobecome certified asan asthma educator,or AE-C. More infor-mation about asthmaspecialization canbe found at the Na-tional Asthma Edu-cator CertificationBoard website athttp://www.naecb.org.

control. It can also help determine the pres-ence of impairment and possible future risks.• education for partnership in care. Team-work can improve quality of care. For ex-ample, the pharmacist might be the first torecognize that a patient is experiencing poorasthma control because he’s requesting mul-tiple refills of albuterol inhalers in a shortperiod. Cultural and ethnic factors andhealth literacy of the patient and his familyare important to consider when tailoringtreatment goals. Open lines of communica-tion and agreement on the treatment plancan improve patient adherence to treatment.

According to the Health Belief Model,before the patient is adherent to the treat-ment plan, he and his family need to recog-nize that there’s a problem, acknowledgethat it can be serious, and believe that some-thing can be done about it. The patient alsoneeds to know what to do and believe thatit’s worth doing. He must be able to correctlycomplete the action and be reinforced for hisaccomplishments. Self-monitoring skills arealso needed to ensure that the patient willknow how to manage his asthma. By using awritten asthma action plan, instructions areoutlined to allow the patient to learn how torecognize and handle worsening asthma.• control of environmental factors and otherconditions that can affect asthma. Factorsthat precipitate asthma or cause symptomsto persist include indoor or outdoor aller-gens, weather changes, tobacco smoke, andsmog. Indoor allergens can be controlled byencasing pillows and mattresses in allergen-proof covers, dusting and vacuumingweekly, washing bedding weekly with waterhotter than 130° F (54.4° C), reducing clutterthat can collect dust, avoiding upholsteredfurniture, and reducing indoor humidity toless than 50%. Control measures for polleninclude drying clothes in the dryer, shower-ing after spending time outside, and stayinginside with air conditioning on days withhigh pollen counts.

The EPR-3 recommends that severalapproaches be used to control environmen-

tal factors. If there’s a clear relationshipbetween exposures to an allergen to whichthe patient is sensitive, subcutaneousimmunotherapy may be used for patientswith mild or moderate persistent asthma.However, the healthcare provider must beprepared to treat anaphylaxis if it occurs.Asthma patients may have several comorbidconditions that may add to breathing prob-lems, such as obesity, gastroesophagealreflux disease, sleep apnea, and sinusitis.And psychiatric diagnosis such as depres-sion may decrease a patient’s medicationcompliance. Therefore, the new guidelinesalso recommend treating chronic problemsto help improve asthma control.• medications. The NAEPP guidelines stilluse a step-wise approach to treatment. Med ications are stepped up or down whenneeded to achieve control. Charts were revised and expanded to include three agegroups: ages 0 to 4, ages 5 to 11, and ages12 and older. This was due to emerging evidence that children may respond to med-ication differently than adults. The old guide -lines grouped 5- to 11-year-olds with adults.EPR-3 found that inhaled corticosteroids arestill the most potent and effective long-termcontrol medications across all age groups.

Under your influenceLet’s check in with our patient. Accordingto the new guidelines, Jim’s baseline classification is moderate persistent andpoorly controlled. He has daily symptomsand requires rescue therapy once a day.At the present time, he’s having an acuteexacerbation, so his control classification ischanged to very poorly controlled. Thetreatment strategies for managing acuteasthma exacerbations include the adminis-tration of oxygen, albuterol, and systemiccorticosteroids. After the acute episode isover, he’ll need to return to his healthcareprovider for follow-up care and long-termmedication. Pulmonary function testingand evaluation and treatment of asthmatriggers and comorbidities, as well as the


Stress theimportance of

an asthmaaction plan.

development of an asthma action plan,will be important factors in helping himachieve future control.

Before beginning patient teaching, youshould assess the patient’s and his family’sperception of the disease. How much doeshe really know about asthma? Does he knowwhat happens to the airways during an asth-

ma attack? Ask him about his healthbeliefs regarding the chronic natureof asthma and the effectiveness oftreatment. What’s his belief aboutthe long- and short-term effects ofmedication? Does he know howto use an inhaler, spacer, andnebulizer? Does he know howto perform daily monitoring todetect early airflow changes that

may require treatment?Inquire about the levelof support within the

patient’s family and hiscapacity to recognize the severity of

an exacerbation.Demonstrate the proper use of an

inhaler and describe how to recognize whenthe canister is empty. Teach the patient howto use a peak flow meter so that he can per-form self- monitoring of his asthma symp-toms and understand what to do in case ofworsening symptoms. Encourage him to

avoid smoking andperform regular aer-obic exercises toimprove cardiopul-monary and muscu-loskeletal condition-ing. Also encouragehim to maintainadequate fluidintake to help thinbron chial mucusand balanced nutri-tion. It’s highly rec-ommended thatasthma patientsreceive influenzaand pneumococcal

vaccinations, if not contraindicated. Teachthe patient about the importance of follow-up visits with his healthcare provider.Referral to an allergy specialist, respiratoryspecialist, or pulmonologist may be needed.

Partnering for effective careAsthma education should occur at everypoint of care (see The PACE curriculum). Itshould begin in the ED, during the patient’shospitalization, at the follow-up appoint-ment with his healthcare provider, and evenwith his pharmacist when he’s refilling hisprescriptions. The patient should be familiarwith his asthma action plan. Patients withpersistent asthma, like our patient Jim,should have two plans: one for rescue andone for control. If the patient is refillinghis rescue inhalers frequently or getting several at a time, his asthma may be poorly controlled and he needs to be reevaluatedby his healthcare provider. Family membersshould also be able to recognize airway oractivity limitations, be supportive, and en-courage the patient to be compliant with histreatment. Nurses in both inpatient and of-fice settings can be instrumental in facilitat-ing an asthma management partnership toimprove adherence, compliance, avoidanceof triggers and, ultimately, control. ■

Learn more about itKelly W, Oppenheimer J, Argyros G. Allergic and envi-ronmental asthma. http://www.emedicine.medscape.com/article/137501-overview.

McCormick M. Boost your asthma IQ. Nursing made Incredibly Easy! 2009;7(1):42-52.

National Asthma Education and Prevention Program Expert Panel Report 3. Education for a Partnership inAsthma Care. Bethesda, Md: National Heart, Lung, andBlood Institute; 2007:93-164.

National Asthma Education and Prevention Program ExpertPanel Report 3. Measures of Asthma Assessment and Monitoring.Bethesda, Md: National Heart, Lung, and Blood Institute;2007:36-92.

National Asthma Education and Prevention Program Expert Panel Report 3. Medications. Bethesda, Md: National Heart, Lung, and Blood Institute; 2007:213-276.

National Heart, Lung, and Blood Institute. Guidelines forthe diagnosis and management of asthma (EPR-3). http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.


The PACE curriculumNurses can help improve outcomes and qualityof life for patients with asthma by partneringwith other healthcare professionals. TheNational Heart, Lung, and Blood Institute’sphysician asthma care education, or PACE,curriculum is available for health educatorsat http://www.nhlbi.nih.gov/health/prof/lung/asthma/pace/curriculum.htm. This programdiscusses the clinical aspects of asthma, com-munication strategies, patient education infor-mation, clinical case studies, and informationon documentation. It includes a slide presenta-tion and discussion for healthcare professionalsto learn more about asthma.

Make sure yourpatient knows

how to use one of these.

National Heart, Lung, and Blood Institute. The PACE curriculum. http://www.nhlbi.nih.gov/health/prof/lung/asthma/pace/curriculum.htm.

Otto N, O’Hollaren MT. Recently updated National Insti-tutes of Health asthma treatment guidelines: important clinical applications, part 1. http://www.medscape.com/viewarticle/580163.

Otto N. Recently updated National Institutes of Health asthma treatment

guidelines: important clinical applications, part 2. http://www.medscape.com/viewarticle/581937.

Porth CM. Essentials of Pathophysiology: Concepts of AlteredHealth States. 2nd ed. Philadelphia, PA: Lippincott Williams& Wilkins; 2007:497-498.

Wu F, Takaro TK. Childhood asthma and environmen-tal interventions. Environ Health Perspect. 2007;115(6):971-975.


On the WebThese online resources may be helpful to your patients and their families:• Asthma and Allergy Foundation of America: http://www.aafa.org• CDC: http://www.cdc.gov/ASTHMA• MedlinePlus: http://www.nlm.nih.gov/medlineplus/asthma.html• National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/

Asthma_WhatIs.html• U.S. Environmental Protection Agency: http://www.epa.gov/asthma.

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