Ventilation Disorders

The focus of the nursing guidelines is on ...

promoting asthma control

The goal of the guidelines is to achieve asthma control with ...

minimum pharmacotherapy

The cornerstone of asthma management

education

Emphasis should be placed on...

evaluating outcomes in asthma control

components that enable successful asthma management

(a) establishment of a confirmed diagnosis through the use of objective measures;
(b) development of a partnership between health care providers and the patients and families affected by asthma;
(c) limited exposure to triggers;
(d) education of patients;
(e) appropriate pharmacotherapy;
ent and monitoring of asthma control and severity;
(g) implementation of a written action plan; and
(h) ensuring regular follow-up.

In Canada, asthma treatment is based on the

Asthma Management Continuum

the primary goal of asthma management

Controlling the disease to prevent complications, morbidity, and mortality

The continuum accounts for the fact that

the level of control and severity of asthma change over time and that constant assessment and adjustment of therapy is necessary to achieve and maintain control.

All individuals with asthma need to have access to

a rescue med (salbutamol)

In rare cases, a select subgroup of individuals with moderately severe asthma but poor control and prone to exacerbations are already receiving...

a fixed maintenance of a FABA; this may consist of a combination of an inhaled corticosteroid (ICS) and a long-acting β2 agonist (LABA)

If symptoms are infrequent and lung function measurements are normal....

a SABA used on an as-needed basis to relieve symptoms is all that is required.

in addition to a SABA

an ICS is also required if one or more indicators of poor control are identified

Most patients with asthma, unless it is very mild and manifests infrequently, require...

an ICS in addition to a SABA

If symptoms persist and are outside the limits of acceptable asthma control, the next step recommended on the Asthma Management Continuum in children 6 to 11 years old is advancement to...

a moderate dosage ICS

In children 12 years of age and older and in adults the best second line therapy is...

the addition of a LABA in the form of a combination inhaler;

the third-line therapy is an increase to a moderate-dosage ICS or addition of leukotriene receptor antagonists (LTRAs)

In a minority of patients, symptoms persist despite the use of these therapies. If the FEV1 is below 60% of predicted levels or of their best value, treatment with an...

oral cortico (prednisone)

Long-term prednisone use may be indicated and effective for asthma that is difficult to control, but...

it should be avoided, if at all possible, because of its adverse effects

An anti-IgE antagonist, omalizumab (Xolair), may be considered in patients 12 years of age and older with

atopic asthma that is poorly controlled despite high-dosage ICS and additional therapies, either with or without prednisone

The Asthma Management Continuum also stresses the importance of...

assessing symptom control, lung function, inhaler technique, adherence to therapy, avoidance of exposure to asthma triggers, the presence of comorbid conditions, and examination of sputum eosinophils (where available) on a regular basis and before therapy is advanced

emergency room

The examiner can assess the degree of severity by measuring FEV1 or PEFR, by identifying the degree of change in objective measurements, and by evaluating the baseline pulse oximetry value

emerg

Inhaled SABA (e.g., salbutamol) should be administered immediately and supplemental oxygen provided to keep arterial oxygen saturation (SaO2) above 92%

In more severe cases, ABG measurements may be used to monitor SaO2.

Inhaled β2-adrenergic agonists

- are preferably administered through a metered-dose inhaler (MDI) with a spacer at a frequency of four to eight puffs every 15 to 20 minutes, usually repeated three times.
- If the FEV1 or PEFR is below 40% of predicted, one puff every 30 to 60 seconds (up to 20 puffs) may be administered, depending on the patient's response to and tolerance of treatment
- Ipratropium bromide (four to eight puffs inhaled every 15 to 20 minutes, repeated three times) may be added to salbutamol during moderate and severe acute asthma episodes.

oral cortico

- are indicated for treatment of an acute exacerbation that necessitates a visit to the emergency department.
- Intravenous corticosteroids are generally administered to patients who have difficulty with swallowing.
- Therapy should be continued until the patient is breathing comfortably, wheezing has disappeared, and pulmonary function measurements are near baseline values.

On occasion, an asthma attack is so severe and unresponsive to treatment that the patient requires...

mechanical ventilation

Indications for mechanical ventilation are ...

persistent or progressive carbon dioxide retention and respiratory acidosis, clinical deterioration (indicated by fatigue, hypersomnolence), metabolic acidosis, and cardiopulmonary arrest

In life-threatening asthma exacerbation, the goals of initiating mechanical ventilation are to ...

achieve a partial pressure of arterial oxygen (PaO2) of 60 mm Hg or higher, an SaO2 of 90% or higher, and a normal pH.

Audible wheezing may occur in the airways, which indicates a...

response to therapy as airflow increases

As the patient begins to respond to therapy and symptoms begin to subside, it is important to remember that ...

- despite the reversibility of most of the bronchospasm, the edema and cellular infiltration of the airway mucosa and the viscous mucous plugs are still present, and improvement may take several days

- Thus intensive therapy includes corticosteroids and must be continued even after clinical improvement has occurred

In addition, discharge instructions should include an action plan detailing

the use of the medications and the criteria for returning to the emergency department for immediate medical assistance

Medications used to treat asthma are divided into 2 categories

(a) Relievers (b) Controllers

which route is preferred?

Inhlaed route is preferred because the drug is delivered directly to the lungs, which minimizes systemic absorption and thus the number and intensity of adverse effects

Relievers, used to ease asthma symptoms, are also known as

"rescue medication" and are used intermittently as required

Controllers are

maintenance therapy used on a daily basis, typically twice a day

Relievers

bronchodialtors, anticholinergics

controllers

cortico, leuko, anti IGE, LABA, methylxan....

Because inflammation is considered an early and persistent component of asthma, drug therapy is directed toward...

long-term suppression of inflammation

Short-Acting β2-Adrenergic Agonists

salbutamol, terbutaline

Selectively stimulates β2 receptors on airway smooth muscle, causing relaxation and producing bronchodilation

Tremor, tachycardia, headache, nervousness, palpitations,

Rapid onset of action: 1-3 min
Duration of action: 4-7 hr

Long-Acting β2-Adrenergic Agonists

Formoterol, Salmetrol

Selectively stimulates β2 receptors on airway smooth muscle, causing relaxation and producing bronchodilation

Tremor, tachycardia, headache, nervousness, palpitations, insomnia

rapid onset 1-3 mins
Duration of protection: 8-12 hr

Anticholinergics

Ipratropium bromide

Blocks action of acetylcholine, resulting in bronchodilation; competitive inhibitor of muscarinic receptors

Dry mouth, cough, bad taste in mouth, nausea, headache

Onset: 5-15 min

Duration: 4-6 hr

CAUTION WITH glaucoma, prostatic hyperplasia, or bladder neck obstruction

Anti inflammatory

all the "sones"

ex. prednisone, hydrocortisone, etc.

most are ORAL and IV

- Potent anti-inflammatory and immuno-suppressive effects; interferes with inflammatory cascade; decreases edema in bronchial airways; increases number and affinity of β2 receptors; abolishes and prevents tolerance induced with chronic use of inhaled β2 agonists; decreases mucus secretion; effective in late-phase reaction of asthma

- recall all the problems with corticosteroids (ex, weight gain, increased appetite, Cushingoid appearance, menstrual changes)

Onset: Some effects within 2-4 hr

In acute severe asthma, 4-12 hr may be required before clinical response noted

(too much on chart :( )

Antileukotrienes

ex. orilstat

(oral)

- Blocks the action of leukotrienes released by inflammatory cell membranes; has bronchodilator and anti-inflammatory effects

- Headache, indigestion, nausea, vomiting, diarrhea, fatigue,

- good for exercise-induced asthma

anti IGE

ex, Omalizumab

- subcut
-Binds free IgE and therefore prevents IgE from binding to receptors on its effector cells, primarily mast cells and basophils, which, in turn, prevents allergens from triggering acute allergic reactions
-Reaction at injection site (pain, bruising, redness, warmth)
-Only for moderate to severe persistent allergic asthma not inadequately controlled by ICS

Methylxanthines

oral and IV

- Relieves bronchoconstriction and its accompanying symptoms by dilating the muscles around the bronchi

- Tachycardia, blood pressure changes, dysrhythmias, ....

Phosphodiesterase 4 Inhibitor

- Selective phosphodiesterase 4 inhibitor

- Nonsteroidal anti-inflammatory drug that targets systemic and pulmonary inflammation associated with COPD

- Indicated for use in severe COPD as an "add on med"

Corticosteroids

- are anti-inflammatory medications that reduce bronchial hyper-responsiveness by blocking the late-phase reaction and that inhibit migration of inflammatory cells
- more effective than any other long-term drug in improving asthma control.
- are the mainstay therapy for the long-term control of asthma
- must be given on a fixed schedule and it takes 1-2 weeks (some take 24 hrs tho) until max therapeutic results observed

In children and adults presenting with an asthma exacerbation necessitating a short-term regimen of systemic corticosteroids...

a daily low- to moderate-dosage ICS should be initiated as maintenance therapy

In children 6+, if low-dosage ICS is not adequate in achieving or maintaining control, then...

increase to moderate

To minimize the intensity of adverse effects, however, add-on therapy should be considered in patients

12 years of age and older before ICS therapy is increased to moderate dosages and certainly before high dosages are prescribed

ICSs administered at the highest dosage levels have been associated with

- adverse events such as easy bruising and accelerated bone loss
- Oropharyngeal candidiasis, hoarseness, and dry cough are local adverse effects caused by ICS

Occurrence of these oropharyngeal adverse events can be reduced by

mouth rinsing and gargling after every inhalation treatment

If an MDI is used, absorption can be improved, and the intensity of adverse events is reduced with the use of a spacer

OCortico

long-term use should be avoided in all age groups if possible, especially children, because of adverse effects

t or f - In acute asthma exacerbations, short courses of orally administered corticosteroids are indicated for gaining prompt control

t

If long-term use is indicated...

a single dose in the morning, to coincide with endogenous cortisol production, and alternate-day dosing should be considered; these schedules are associated with fewer adverse effects

Adults using maintenance oral corticosteroids or high dosages of ICS (\>500 mcg of fluticasone and beclomethasone; \>800 mcg of budesonide), or both, should be monitoredn 4

- osteoporosis with bone densitometry
-Patients should take adequate amounts of calcium and vitamin D and participate in regular weight-bearing exercise

Anti-leukotrienes

The anti-inflammatory action of antileukotrienes is not as potent as that of ICS, and thus they are not recommended as a single drug in the treatment of persistent asthma

This is add-on (adjuvant) therapy

Antileukotrienes may be considered as an alternative to increasing dosages of ICS.

anti ige

- a monoclonal antibody to IgE that decreases circulating free IgE levels
- prevents IgE from attaching to mast cells, which thus prevents the release of chemical mediators.
For moderate or severe
-subcut 2-4 wks
- This medication is expensive and therefore should be reserved for specific patients: those with asthma that is difficult to control despite adherence to a regimen of high-dosage ICS and at least one additional controller therapy; those who have objectively confirmed asthma; those who have documented allergic perennial asthma; and those whose serum IgE level is 30 to 700 IU/mL

Bronchodilators

β2-adrenergic agonists, anticholinergic drugs, and methylxanthines.

Fast-acting β2-adrenergic agonists are the

drug of choice for relief of acute symptoms of asthma and are used as rescue or reliever medication for quick relief of symptoms; therefore, they should be carried by the patient at all times

They are also used to prevent bronchospasm precipitated by exercise, with administration 10 to 15 minutes before exercise
The duration of effect varies according to the drug, but airflow rates remain significantly elevated for 2 to 6 hours after inhalation

mild tremor and tachycardia, which diminish with repeated use without loss of bronchodilator effect

The frequency of use of reliever medications is a good indicator of

a patient's level of asthma control

LABAs provide

sustained bronchodilation (approximately 12 hr) and include formoterol and salmeterol

LABAs should be considered as add-on therapy in adults who have persistent symptoms despite low-dosage ICS and in children 6 to 11 years of age who have persistent symptoms despite use of moderate-dosage ICS

LABAs are to be used not as monotherapy but rather in combination with an ICS

Salmeterol and formoterol cannot be considered interchangeable

formoterol has a greater bronchopulmonary protective effect and is rapid acting; thus it can be used as rescue therapy for prompt relief of symptoms when taken in combination with only an ICS

Salmeterol has a narrower therapeutic window, and dosage should stay within the recommended range.

Anticholinergic Drugs

Anticholinergic bronchodilators are not recommended as first-line therapy in asthma, primarily because their action does not peak until 30 minutes to 1 hour after ingestion; therefore, they are inferior to SABAs as rescue or reliever inhalers.

The most common adverse effect of anticholinergic drugs is dry mouth

related to the PNS (decrease secretions and relax smooth muscle)

Mathylxanthines

Methylxanthines are bronchodilators with mild anti-inflammatory effects.

Sustained-release methylxanthine (theophylline) preparations should be used only as controller medication for asthma that is difficult to control, after ICS, LABA, and LTRAs.

Education

- Information about medications with which the patient should be familiar includes name, dosage, method of administration, frequency of use, indications, adverse effects, consequences of improper use, and the importance of adherence
- patients need to be taught about the different roles and indications for using relievers and controllers
- it is essential that the nurse assess a patient's ability to use inhaler devices accurately and provide coaching in the proper use of the device

Wet nebulizers

Used primarily to deliver large bronchodilator doses during acute asthma attacks in emergency department and other hospital settings. In the home, they are used as a last resort for patients unable to use other inhalation devices.

the use of wet nebulization has decreased in emergency departments and hospitals because when wet nebulization is used, aerosol is released into the environment, not just to a patient's airways; thus everyone in the room is breathing in the aerosol.

MDIs with spacers are as effective as

nebulizers in delivering large doses of bronchodilators during acute asthma attacks because the amount of drug delivered to the lungs is enhanced with the spacer.

In addition, spacers

enhance the delivery of medication to the airways and decrease the intensity of adverse events from ICS because less medication is delivered to the mouth

MDIs with spacers can be considered for all

ages

A spacer with a face mask is recommended for

old ppl and young children

How to Use an MDI Correctly ?

1. Firmly place the metal container into the mouthpiece. Remove the cap, and shake the inhaler vigorously.
2. Breathe out only to the end of a normal breath (not a forced breath).
3. Position the mouthpiece end of the inhaler approximately 4 cm (1.5 inches) from your mouth.
4. Open your mouth widely, and tilt your head back slightly. (Another way of doing this is to close your lips around the mouthpiece, keeping teeth apart and tongue flat so the medication can flow freely into the lungs.)
5. At the same time that you start to breathe in slowly, depress the metal container into the mouthpiece to release one puff of medication.
6. Continue breathing in slowly until your lungs are full (approximately 5 seconds).

MDI tips

• Once you have breathed in fully, hold your breath for 10 seconds (or as long as comfortable).
• If you need a second puff, wait 30-60 seconds before repeating the preceding steps.

Some people, no matter how hard they try, still have trouble coordinating an MDI.

Fortunately, spacers (holding chambers), which hold the medication for a few seconds after it has been released from the inhaler, are available

Spacers may also reduce occurrence of adverse drug events such as hoarseness or sore throat if the patient is taking higher dosages of IC

Is the Inhaler Full?

The only reliable method, if the MDI does not have a counter, is to count each puff.

Alternatively, the patient can plan the length of use on the basis of prescribed puffs per day: for example, if the patient uses two puffs, twice-a-day use means that the inhaler must be replaced in 50 days.

Most canisters contain 200 doses. It is a good practice to keep a spare inhaler on hand.

Special Instructions

Most children younger than 9 years cannot use an MDI properly.

For these children, a spacer should be used with the MDI.

Regardless of the child's age, spacers are recommended when a steroid inhaler is used, to reduce the risk of developing a yeast infection in the mouth or the throat and to enhance the distribution of the medication to the small airways.

How to Use a Spacer with an MDI

1. Remove the plastic cap from the inhaler mouthpiece and the spacer mouthpiece.
2. Insert the inhaler mouthpiece into the large opening of the spacer.
3. Hold the spacer and inhaler together and shake well.
4. Forcibly exhale.
5. Put the mouthpiece of the spacer into your mouth, close your lips around it; do not cover the small slots.
6. Press the metal canister down into the inhaler to spray the medication into the spacer. Then, breathe in slowly and deeply through your mouth (for approximately 5 seconds).
7. Hold your breath for as long as you comfortably can (approximately 10 seconds).
8. Breathe out slowly through your mouth or nose.
9. If more puffs are prescribed, wait 1 minute and then repeat these steps, starting from step 3.

Caring for the Spacer

- Spacers must be cleaned weekly because powder collects on the walls of a spacer with repeated use.
- To clean, agitate the spacer device carefully in warm tap water mixed with dish soap.
- Shake off excess water, do not rinse, and allow it to air dry overnight; do not dry with a towel. - The soap residue left on the chamber, as well as not using a towel to dry, will prevent static cling and therefore prevent medication from clinging to the inside of the chamber.

DPI (dry powder inhaler)

The DPI contains dry, powdered medication and is breath-activated

No propellant is used; instead, an aerosol is created when the patient inhales quickly and forcefully through a reservoir containing a dose of powder.

Patients find DPIs easier to use than MDIs with no spacer

There are several advantages to using DPIs:

(a) less manual dexterity is required;
(b) the patient does not need to coordinate depressing the canister with inhaling;
(c) an easily visible colour or number system indicates the number of doses left in the device; and
(d) no spacer is necessary

The biggest problem with DPIs is that...

the medication may clump if exposed to humidity, and so they should be stored in a dry place

The care of DPIs involves

wiping off the mouthpiece with a dry tissue.

Water or other liquids should never be used to clean the device, which could cause clumping of the medication and cause the device to work improperly.

conclusion

It is important to explain to patients the importance and purpose of taking controller therapy regularly, emphasizing that maximum improvement may take more than 1 week

assesment data

General - Restlessness or exhaustion, confusion, upright or forward-leaning body position

Integumentary - Eczema, diaphoresis, cyanosis (circumoral, nail beds)

Respiratory - Wheezing, crackles, diminishment or absence of breath sounds on auscultation; hyper-resonance on percussion; sputum character and quantity; increased work of breathing, demonstrated by use of accessory muscle, intercostal and supraclavicular retractions; tachypnea; prolonged expiration

Cardiovascular - Tachycardia, pulsus paradoxus, jugular venous distension, hypertension or hypotension, premature ventricular contractions

self-management asthma education programs can

reduce the number of emergency department visits, hospitalizations, urgent care visits, nocturnal awakenings related to asthma, and days of interrupted activity and can improve quality of life

environmental control

Triggers can be divided into two groups: allergens and irritants

common triggers

-house dust mites (control strategies focus on the bedroom and include keeping the relative humidity below 50%; encasing the mattress, box springs, and pillows in covers that are impermeable to mites and mite allergens; laundering bed linen in hot water and hot (55°C) air to dry it; and possibly removing carpet_

- pet dander (the removal of the pet is the best idea lol, other strategies include excluding the pet and its dander from the bedroom by keeping the door and heating register closed; frequent vacuuming (including furniture) with a high-efficiency particulate air (HEPA)-filtered vacuum; removing carpets; and washing the pet at least twice a week)

- tobacco smoke (MOST harmful) (tell parents to stop smoking they r killing their kids)

- exercise and cold air

ashtma is not an excuse for

not exercising

Occupational asthma

defined as asthma symptoms induced by exposure to a specific irritant in the workplace, is the most common occupational lung disease.

Everyone with asthma should have an

action plan

action plan

An action plan is a written plan developed to provide the patient with a framework for monitoring and determining his or her level of asthma control and making treatment changes to achieve and maintain control

zones

The green zone represents a time when a patient's asthma is under good control; peak flow rates are usually 80% or more of predicted or of the patient's personal best
If asthma status has been in the green zone for a couple of months, an attempt to reduce medication dosages may be warranted

The yellow zone represents a time of uncontrolled asthma, as demonstrated by symptom occurrence, the need for an inhaled short-acting bronchodilator (reliever), and, if measured, PEFR between 50% (some authorities use 60%) and 79% of predicted or personal best. In response to worsening asthma, some patients are advised to see their primary asthma care providers, whereas others are advised to increase dosages of anti-inflammatory medication

The red zone represents a time of severe asthma and the need for immediate medical assistance. Indications of the red zone are difficulty completing a sentence without needing another breath; incomplete relief from reliever inhaler or use more frequently than every 2 hours; or, if the patient is using a peak flowmeter, a PEFR between less than 50% and 60% of predicted or personal best value

Often, action plans are designed according to a ...

traffic-light analogy: green, yellow, and red "zones."

traffic light

Green \= go with current therapy, yellow \= a time of worsening or uncontrolled asthma and signals "caution" and the need for enhanced anti-inflammatory therapy, red zone\= a time of danger during which the asthma is severe enough to necessitate urgent medical attention; it signals "stop" current activities in order to address this need.

what is a more sensitive measure

Asthma symptoms are a more sensitive measure and change earlier in the course of an exacerbation than does PEFR.

The choice of whether an action plan is based on PEFR or symptom monitoring may be made according to a patient's ability to perceive symptoms and airflow limitation, the availability of peak flowmeters, and, of most importance, the patient's preferences

COPD complications : COR pulmonae

- hypertrophy of the right side of the heart, with or without heart failure, that results from pulmonary hypertension
- pulmonary hypertension is caused primarily by constriction of the pulmonary vessels in response to alveolar hypoxia; acidosis further potentiates the vasoconstriction
- Cor pulmonale is a late manifestation of COPD with a poor prognosis.
- When pulmonary hypertension develops, the pressures on the right side of the heart must increase to push blood into the lungs. Eventually, right-sided heart failure develops.
The clinical manifestations of cor pulmonale are related to dilation and failure of the right ventricle with subsequent intravascular volume expansion and systemic venous congestion.
- Management of cor pulmonale includes continuous administration of low-flow oxygen and diuretics

the most frequent cause of medical visits, hospitalizations, and death among people with COPD

AECOPD

An acute exacerbation of COPD (AECOPD) is defined as

a sustained worsening of respiratory symptoms, such as dyspnea, cough, or sputum production that leads to an increased use of maintenance medications or supplementation with additional medications

The term sustained implies a change from baseline that lasts 48 hours or longer.

Exacerbations should be characterized as purulent or nonpurulent (do we need antibiotics)

Pneumonia

is a frequent complication of COPD. The most common causative pathogens are S. pneumoniae, H. influenzae,and viruses.

The most common manifestation is purulent sputum

acute respiratory failure

An acute exacerbation leads to increased decline in overall lung function, deterioration in health status, and risk of death

patients with COPD wait too long to contact their health care provider when they develop fever, increased cough and dyspnea, or other symptoms suggestive of AECOP

Causes include discontinuing medication, using a beta blocker, sedatives, surgery, painful illness and opiods

copd emotions

People with COPD experience higher rates of depression, anxiety, and panic

Approximately 40% of patients with COPD report clinically significant anxiety or depression

Tobacco consumption should be quantified and is typically expressed in

pack years

Pack-years are calculated by multiplying the number of cigarette packs smoked daily by the number of years smoked

The severity of breathlessness is determined by...

- identifying the magnitude of the task (often an ADL) necessary to cause discomfort in breathing.