1. What is the underlying mechanism of M.A.'s asthma? What are the three airway responses that occur during an asthma episode?
An autoimmune response to allergens from cats and plants is the underlying mechanism for the patient’s condition. These allergens, though nonpathogenic, trigger an inflammatory cascade wherein lymphocytes, eosinophils, mast cells, neutrophils, macrophages and dendritic cells exert their effects on the respiratory tract (Linzer 87). As an example, B lymphocytes synthesize immunoglobulin E which helps signal the release of histamine, leukotrienes, prostaglandin and cytokines which are proteins that promote vasodilation and hyperactivity in mucus-producing goblet cells (Murdoch & Lloyd 27). Prostaglandin causes the smooth muscles in the airway to constrict. Along with vasodilation and increased mucus production, bronchial constriction account for the signs and symptoms of wheezing, coughing and airway obstruction during an asthma attack.
During an asthma episode, the three airway responses are airway remodeling, airway hyperresponsiveness and pulmonary inflammation (Killeen & Skora 13). In airway remodeling, the anatomy of bronchial tissues is altered. The smooth muscle cells enlarge as do goblet cells, the former narrowing the lumen of the airway and the latter resulting in excessive mucus production leading to airway obstruction. The basement membrane beneath the epithelium thickens as the epithelial cells of the mucosa slough off. There is also tissue edema. Airway hyperresponsiveness is characterized by bronchial constriction which limits airflow in the lung (Killeen & Skora 14). It occurs simultaneously with airway inflammation mediated by the inflammatory cascade described above.
2. In addition to bronchodilator therapy with intermittent albuterol, what other pharmacotherapy is important in the management of asthma?
Aside from short or rapid-acting beta adrenergic agonist like albuterol, the use of steroids is another component of the first-line or conventional management of asthma. Corticosteroids such as prednisone, methylprednisolone, prednisolone and dexamethasone and also glucocorticoids such as budesonide are the categories of commonly prescribed steroids. These drugs benefit the patient by reducing inflammation, blunting the inflammatory response and preventing relapse within the week following an acute episode (Linzer 90).
Inhaled corticosteroids (ICS) are found to be highly effective both as a rescue drug and as maintenance (Szefler 36). When combined with a long-acting beta adrenergic agonist (LABA) such as salmeterol, a synergistic effect often occurs where LABA targets airway hyperactivity and ICS targets inflammation leading to better control (Szefler 38). Leukotriene receptor antagonists (LTRA), such as montelukast and zafirlukast, have also been shown in trials to be as effective as ICS (Price et al. 1695).
The administration of low flow, humidified and warmed oxygen is likewise important given that airway obstruction causes life-threatening hypoxemia. A flow rate of 1-2 liters per minute delivered via nasal cannula is usually sufficient to increase the oxygen saturation beyond 90% (Linzer 91). If first-line management fails, as is often the case in severe exacerbations, second-line pharmacotherapy is employed as adjunct treatment. Magnesium sulfate is a smooth muscle relaxant used to relieve bronchial constriction (Linzer 91).
3. How should M.A.'s current problem be managed? What parameters should be assessed to monitor response to therapy?
Based on the Global Initiative for Asthma (GINA) guidelines, signs and symptoms of acute exacerbation should be assessed and first-line treatment given to obtain relief (Pocket Guide 3). Response should be monitored and second-line treatment provided if response is suboptimal. Following symptom relief, symptom control needs to be established using maintenance or controller drugs. Control must be monitored to determine whether there is a need to step-up or step-down on medications. Parameters indicative of treatment response include peak flow rates, oxygen saturation, arterial blood gas values, vital signs especially respiratory rate, and signs and symptoms as well (Pocket Guide 3). As exposure to allergens trigger the attacks, the patient and his family need to implement environmental control measures to minimize such exposure and thus the number and severity of exacerbations.
4. What teaching would you consider for M.A. and his parents?
Since asthma is a chronic disease, the patient should learn self-management. Compliance to medications is needed to establish optimum control and this can be attained in part if the patient and his family understand the purposes and differences of maintenance and relief drugs (Pocket Guide 3). Avoiding cats, plants and other potential sources of allergens is another important learning need. How to self-monitor parameters, including peak flow rates if possible, must also be taught (Pocket Guide 3). The patient and his family also need to know how to interpreting signs and symptoms and identify a worsening condition which requires prompt action such as seeking medical advice. 5. Research at least one article regarding one of the questions and cite it in your paper, include article.
The article detailing the GINA guidelines was very helpful especially in answering the third question. Chronic diseases need to be managed very well to improve the health and quality of life of sufferers. Short and long-term management addressing disease manifestation and the modifiable contributory factors are clearly necessary. The guidelines are presented in an easy to read, understand and use format using tables, figures, flowcharts and bullets. The pocket guide, developed for use by health care professionals, covers the four major components of management namely establishing provider-patient partnership; identifying and reducing risk factors; assessing, treating and monitoring the condition; and managing exacerbations (Pocket Guide 3). The guidelines represent the consensus of experts on asthma management.6. Include two nursing diagnoses for this patient.
As the condition affects the respiratory system, priority nursing diagnoses should relate to the functions of this system and the effects on the patient. One nursing diagnosis is ineffective airway clearance manifesting as dyspnea with a respiratory rate of 32 and expiratory wheezing. Owing to the narrowing of the airways, coughing is ineffective and the patient has difficulty expelling the excessive mucus produced in the lungs. Another nursing diagnosis is impaired gas exchange, again related to airway obstruction. Manifestations are respiratory distress and oxygenation deficit or hypoxemia with an oxygen saturation of 90%. The ability to clear the airway and attain sufficient oxygenation rests on bronchodilator therapy and anti-inflammatory drugs to reduce the impact of the autoimmune response.7. What education would you use for this patient and family, develop a onepage handout about asthma and what the family should know.
The use of a variety of instructional methods, including lecture/discussion, demonstrations and return demonstrations and video instruction, is more likely to facilitate learning as does a participative approach. The educational activity should build on what the patient and his family knows and must address their learning needs. The following is a handout summarizing what the family has to know about the child’s condition.
“Global Initiative for Asthma Patient Guide: You Can Control Your Asthma.” ginasthma.org. Global Initiative for Asthma (GINA), 2007. Web. 3 May 2013.
Killeen, Kathryn and Elizabeth Skora. “Pathophysiology, Diagnosis, and Clinical Assessment of Asthma in the Adult.” The Clinics of North America 48.1 (2013): 11-23.
Linzer, Jeffrey. “Review of Asthma: Pathophysiology and Current Treatment Options.” Clinical Pediatric Emergency Medicine 8.2 (2007): 87-95.
Murdoch, Jenna and Clare Lloyd. “Chronic Inflammation and asthma.” Mutation Research 690.1-2 (2010): 24-39.
“Pocket Guide for Physicians and Nurses: Asthma Management and Prevention (For Adults and Children Older than 5 Years).” ginasthma.org. Global Initiative for Asthma (GINA), 2012. Web. 3 May 2013.
Price, David, et al. “Leukotriene antagonists as first-line or add-on asthma-controller therapy. The New England Journal of Medicine 364.18 (2011): 1695-1705.
Szefler, Stanley. “Advances in Pediatric Asthma in 2012: Moving Toward Asthma Prevention.” Journal of Allergy and Clinical Immunology 131.1 (2013): 36-46.