Chapter 4: Management of Patients with Chronic Pulmonary Disease (Part 2)

Asthma

- chronic inflammatory disease of the airways causes airway hyperresponsiveness, mucosal edema, and mucus production

- ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea

Pathophysiology of Asthma

Mast cells, macrophages T lymphocytes, eosinophils, neutrophils

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Activated (during inflammation)

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Release of mediators

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histamine, bradykinin, prostanoids, cytokines, leukotrienes

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Perpetuates the inflammatory response

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Increase blood flow, vasoconstriction, mucus secretion,

bronchoconstriction

Largely reversible

- distinctive characteristic of Asthma from other obstructive lung disease

- can happen either spontaneously or with treatment

Allergy

strongest predisposing factor for asthma

Prevention of Asthma

avoid the causative agents whenever possible

Complications of Asthma

- status asthmaticus

- respiratory failure

- pneumonia

- atelectasis

Pharmacologic Therapy for Asthma

- Quick relief medications

- Long acting medications

Quick relief medications

- for immediate treatment of asthma symptoms and exacerbations

- SABAs (albuterol, levalbuterol)

- Muscarinic antagonists/anticholinergics (ipratropium)

Long acting medications

- to achieve and maintain control of persistent asthma

- corticosteroids (budesonide, fluticasone)

- LABAs (Salmeterol and formoterol)

- Leukotriene modifiers (inhibitors), or antileukotrienes (montelukast, zafirlukast)

- Phosphodiesterase inhibitors (theophylline)

- Immunomodulators

SABAs

- medications of choice for relief of acute symptoms and prevention of exercise-induced asthma

- used to relax smooth muscle

Muscarinic antagonists/anticholinergics

may be used in patients who do not tolerate short-acting beta-2- adrenergic agonists.

Corticosteroids

- broadly effective in alleviating symptoms, improving airway function

- gargle and spit every after puff: to prevent mouth ulcer

LABAs

- effective in the prevention of exercise-induced asthma

- not indicated for immediate relief--have duration of bronchodilation of at least 12 hours

Leukotriene modifiers (inhibitors), antileukotrienes

act either by interfering with leukotriene synthesis or by blocking the receptors where leukotrienes exert their action.

Phosphodiesterase inhibitors

- cause bronchodilation and act as mild antiinflammatory agents by influencing epinephrine release

- should be used with reservation because it has the potential to cause many drug interactions and its higher risk of side effects

Immunomodulators

- prevent binding of IgE to the high-affinity receptors of basophils and mast cells

- omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab

Peak Flow Monitoring

- measure the highest airflow during a forced expiration

- Green Zone, Yellow Zone, Red Zone

Green Zone

- 80-100% of usual or "normal" peak flow rate

- signals all clear

- asthma is under reasonably good control

- continue management

Yellow Zone

- 50-80% of usual or "normal" peak flow rate

- signals caution

- may require extra treatment

- symptoms can get better or worse

- contact HCP for changes in medications or management plan

Red Zone

-

Status Asthmaticus

- used to describe rapid onset, severe, and persistent asthma that does not respond to conventional therapy

- medical emergency

Contributors to Status Asthamticus

- Infection,

- anxiety

- inhaler abuse

- dehydration

- increased adrenergic blockage

- nonspecific irritants

severe bronchospasm with mucus plugging leading to asphyxia

The most common scenario that results to status asthmaticus

disappearance of wheezing

sign of impending respiratory failure

SABA followed by corticosteroids

initial treatment for status asthmaticus

Management for Status Asthmaticus

- bronchodilators via nebulization

- O2 (high flow) and IV fluids for hydration

- MgSO4

MgSO4

-may be given to induce smooth muscle relaxation in status asthmaticus

- single 2gram infusion over 20 minutes

- AE: facial warmth, flushing, tingling, nausea, central nervous system depression, respiratory depression, and hypotension

Cystic Fibrosis

- the most common fatal autosomal recessive disease among Caucasians

- less frequently found among Hispanic, Asian, and African Americans

- results in a mutation of a gene that impairs chloride transport and sodium absorption, resulting in thickened secretions (dehydrated secretions) that blocks major ducts in the body

mutations, dysfunction in the protein cystic fibrosis transmembrane conductance regulator (CFTR)

- causes cystic fibrosis

- normally transports chloride ions across epithelial cell membranes

Classic Symptoms of Cystic Fibrosis

- Salty tasting Skin

- Persistent Cough

- Foul Smelling Oily Poos

- Bowel Blockages

- Failure to Thrive

Foul smelling fatty (steatorrhea)

- due to pancreatic insufficiency

- mucus plugs in the pancreas obstruct the release of pancreatic enzymes, leading to malabsorption of nutrients (CHO, protein, fats) and fat-soluble vitamins (ADEK)

Bowel obstruction (meconium ileus)

- often the first sign of CF in NB

- inability to pass stool in 24 hrs

- due to tenacious mucus preventing passage in the colon

Failure to thrive

due to malabsorption and an increased metabolic rate associated with frequent infection, children with CF have difficulty maintaining adequate weight & growth

Infertility

- due to congenital absence of vas deferens in males, resulting in low sperm levels and infertility

- female clients have thick cervical secretion that can obstruct sperm entry

Salty Skin

- diagnosed through sweat chloride test (SC) in the skin

- >60 mEq/L = CF

Persistent Cough

- due to recurrent sinus and pulmonary infections

- thickened mucus inhibits normal ciliary action and cough clearance

- the resulting airway obstruction can lead to frequent infections and eventual bronchiectasis

Respiratory failure

leading cause of mortality in CF

Bronchiectasis

- recurrent infection related to CF characterized by thick secretions "layered sputum"

- most commonly associated with pseudomonas infection

Management of CF

- Antibiotics (Aminoglycoside)

- Pancreatic enzyme supplement

- Diet

- CPT

- Genetic testing/counseling

high in calories, fat, and protein

diet for px with CF

Pancreatic enzyme

- supplements used to aid the absorption of nutrients in a child with CF

- taken with or just before every meal

- should be swallowed whole or sprinkled on an acidic food

- should not be crushed or chewed

- should not be taken withmilk

airway

priority when addressing multiple needs of a client with cystic fibrosis

Polycythemia

- complication of chronic bronchitis

- increased RBC to compensate for chronic hypoxic levels

Codeine

- contraindicated in px with COPD

- depresses cough reflex which leads to accumulation of secretions leading to respiratory distress

Theophylline

- cause more harm than benefit

- second line of treatment

- narrow therapeutic index causing seizures and SVT

Incentive Spirometry

- not generally used for COPD

- not as effective

huff cough

more effective in mobilizing and expectorating secretions in clients with COPD