11 Dec 2011

Essay Topic: Severe Exacerbation of Asthma

A known case of asthma on medication, B.T.’s signs and symptoms show a severe exacerbation of asthma, a life-threatening medical emergency which is best managed at the emergency department (Global Initiative for Asthma [GINA], 2010, p. 71).  During an exacerbation, the “patient experiences increasing shortness of breath, coughing, wheezing, and chest tightness” (Pruitt & Lawson, 2011, p. 50).  These manifestations may happen alone or in combination and may build up over minutes to hours depending on the nature and severity of the attack.  Despite treatment, B.T. exhibited difficulty of breathing .  The best action of the wife at this time would have been to call for help like 911 that could dispatch an ambulance and have him brought to the nearest emergency room while initiating treatment.  However, the nearest facility could have been the clinic which provided immediate care.

Assessment.

Along with providing prompt treatment, a short history and physical examination relevant to the exacerbation are done.  B.T.’s relevant history is his unresponsiveness to the given treatment at home, with the use of accessory muscle for breathing and with inability to lie down secondary to dyspnea.  It appears that the cause of his present exacerbation is anxiety.  It has been suggested that the connection between anxiety and asthma may be part of a wider relationship between “psychological distress and chronic disease” (Cooper et al., 2007, p. 1).  B.T. is also highly allergic to dust and pollen.  Allergens and irritants activate exacerbations, resulting to an inflammatory cascade that obstructs the airway (House & Ramirez, 2008, p. 122).

In the physical examination (P. E.), exacerbation and severity are assessed through the patient’s ability to speak, respiratory rate, pulse rate, use of accessory muscles, and other signs (see Table 1).  Any complicating aspects such as pneumonia and pneumothorax are recognized.  GINA (2010a) strongly recommends functional assessments such as PEF (peak expiratory flow) and FEV1 (forced expiratory volume) and measurements of arterial oxygen as P.E. alone may not fully show the severity of exacerbation.  As shown in Table 1, B.T.’s manifestations (unable to lie down, use of accessory muscles, respiratory rate of 42/min, pulse of 124/min, PaCO2 48mm Hg, and SaO2 88%) all fall under the severe category.  Succeeding measurements are intermittently done until there is a clear response to treatment.  Oxygen saturation is closely monitored.  Chest X-ray is not routinely done in adults but performed if complicating factors are suspected and for those needing hospitalization.  Arterial blood gases (ABGs) are not regularly measured except for patients with PEF of 30 to 50% predicted, unresponsive to initial treatment, or when deterioration is a concern.

As outlined in GINA (2010a, pp. 73-74), the following treatments are usually provided concurrently to attain the fastest resolution of the exacerbation:

1.  Oxygen is given by nasal cannulae or by mask to attain arterial O2 saturation of 90%.  Oxygen treatment is measured through pulse oximetry.

2.  Rapid acting inhaled B2 –agonists are given at regular intervals through meter dose inhaler (MDI) and a spacer device.

3.  Better bronchodilation may be achieved with a combination of nebulized B2-agonist with ipratropium bromide, an anticholinergic, and should be given before considering methylxathines.

4.  Except for the mildest exacerbations, systemic glucocorticosteroids are used because they hasten resolution, especially if the rapid acting inhaled B2-agonist did not achieve lasting improvement, the exacerbation continues to build up even when the patient is already on oral glucocorticosteroids, and past exacerbations required oral glucocorticosteroids.

Table 1. Severity of Asthma Exacerbations.  From GINA (2010b, p. 21).

Parameter Mild Moderate Severe Respiratory arrest imminent
Breathless Walking

Can lie down

Talking

Prefer sitting

At rest

Hunched forward

Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated Drowsy of confused
Respiratory rate Increased Increased Often >30/min
Accessory muscles and suprasternal retractions Usually not Usually Usually Paradoxical thoraco-abdominal movement
Wheeze Moderate, often only and expiratory Loud Usually loud Absence of wheeze
Pulse/min. < 100 100-120 >120 Bradycardia
Pulsus paradoxus Absent

< 10 mm Hg

May be present

10-25 mm Hg

Often present

> 25 mm Hg

Absence suggests respiratory muscle fatigue
PEF after initial bronchodilator

% predicted or

% personal best

Over 80 % Approx. 60-80% < 60% predicted or personal best
PaO2 (on air)

and/or

paCO2

Normal Test not usually necessary

< 45 mm Hg

> 60 mm Hg

< 45 mm Hg

< 60 mm Hg

Possible cyanosis

> 45 m Hg

SaO2 (on air) > 95% 91-95% < 90%
Note: The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation.

5.  The combination of high-dose inhaled glucocorticosteroids and salbutamol in one study provided better bronchodilation than salbutamol alone in acute asthma and better benefit than supplementing systemic glucocorticosteroids across all factors (GINA, 2010a, p. 74).

6.  Intravenous magnesium sulphate (2g infusion over 20 minutes) is not routinely recommended but may be given to patients unresponsive to initial treatment.  It has also been shown to decrease hospitalization rates.

The treatments not recommended for acute asthma exacerbations include sedatives which are strictly avoided due to respiratory depressant effect, mucolytics which may aggravate coughing, chest physiotherapy which may heighten patient distress, excessive hydration, antibiotics except for concomitant bacterial infection like pneumonia, and epinephrine which is indicated for anaphylaxis and angioedema but not for asthma attacks (GINA, 2010b, pp. 19-20).

Check treatment response.

Assess patient’s signs and symptoms, PEF, and oxygen saturation.  Consider measuring ABGs if with hypoventilation, severe distress, exhaustion, and PEF 30-50% predicted.  Give supplemental oxygen as indicated and medications as prescribed.  Preferred patient outcomes are better ventilation and oxygenation and reduced respiratory distress.  There is good response to therapy if there is a continued 60 minute response, distress is absent on P.E., PEF greater than 70%, and O2 saturation is more than 90% (GINA, 2010a, p. 72).

Assess if for discharge at emergency department or for hospitalization.

Patients usually need hospitalization if with a FEV1 or PEF less than 25% predicted or personal best before treatment, or FEV1 or PEF less than 40% after treatment.  Patients with lung function of 40-60% predicted after treatment may be discharged as long as sufficient follow-up is accessible in the community and compliance is guaranteed (GINA, 2010a, p. 74).

For discharged patients at emergency room.

GINA (2010a, pp. 74-75) recommends a 7-day course of oral glucocorticosteroids, along with bronchodilator therapy.  B. T. was prescribed with both, although the oral glucocorticosteroids was only for five days.  Based on symptomatic and objective improvement, the bronchodilator is used as needed until the patient returns to the pre-exacerbation use of rapid acting B2-agonist.  Ipratropium bromide is discontinued.  Inhaled glucocorticosteroids are started or continued.  Inhaler and peak flow meter use for home treatment monitoring is assessed.  B.T. did not demonstrate the proper use of MDI with spacer.  First, the mouthpiece cap is removed from the spacer and the MDI.  The MDI is then placed into the end of the spacer without the cap.  Make sure that the MDI is fully pushed. The space and the MDI are shaken together two or three times.  Then holding the MDI upright with the index finger on top and thumb on the bottom, the mouthpiece is placed in the mouth, closing the lips tightly around the mouthpiece.  The patient exhales normally and then presses down firmly on the canister releasing one dose of medication.  The patient inhales slowly and deeply. If the patient inhales too fast, the coaching device on the spacer sounds.  The spacer is removed from the mouth while holding breath for 5 to 10 seconds, then exhale normally.  After use, detach the MI from the spacer and put on the capon the MDI and spacer (GINA, n.d.).  B.T. should also be advised on the possible side effects of his medications.

Patients have a better home treatment response if discharged with peak flow meter and action plan.  The precipitating factors of exacerbation and the action plan are reviewed.  The patient or family is counseled to get in touch with the primary health care professional or asthma specialist within 24 hours after discharge, then to follow-up after a few days to ascertain that treatment is continued until baseline control parameters are achieved.  B.T. was advised to contact a pulmonary specialist; however, he was not provided with sufficient education on the precipitating factors of his attack, as well as a peak flow meter and an action plan.

Other Components of Asthma Therapy

The goal of asthma therapy is to attain and sustain control of the clinical manifestations for protracted periods (GINA, 2010b, p. 8).  When asthma is controlled, most attacks are prevented, troublesome symptoms are avoided, and the patient can be physically active.  Thus, the management of B.T.’s exacerbation is just one of five interrelated components of asthma therapy.  The rest of the components are to: (1) develop patient/health care provider (HCP) collaboration, (2) recognize and decrease exposure to risk factors, and (3) evaluate, treat, and monitor asthma (GINA, 2010a, p. 53).

Develop patient/HCP collaboration.

Successful management of asthma entails the development of collaboration between the afflicted and the health care team.  The goal of this collaboration is guided self-management, giving patient the capacity to control one’s condition with assistance from health care professionals.  The partnership is reinforced as the patient and HCP discuss and concur on treatment goals, create a personalized self-management plan, and occasionally assess the patient’s treatment and degree of asthma control.  Education is an essential part of all interactions.  Asthma education is a continuing process that is crucial to “achieving control, improving outcomes, and minimizing medication use” (S. Corbridge & T. Corbridge, 2010, p. 32).  As such, incorporated into every patient visit is a needs assessment of the patient’s major knowledge deficiency, followed by targeted education.  Personalized action plans, created in partnership with the patient, have been shown to improve patient-provider communication and outcomes (Kaya et al., 2009).  Individualized action plans help patients modify treatment in response to changes in the degree of asthma control, as signified by symptoms and/or PEF, according to written preset plan.

Identify and lessen exposure to exacerbating or risk factors.

Steps avoiding the risk factors should be taken for better asthma control and reduced medication needs.  Completely avoiding some of these factors are nearly impossible because patients react to multiple factors commonly present in the environment.  Medications that sustain asthma control are thus important because when the asthma is controlled, the patient is less susceptible to these risk factors (GINA, 2010b, p. 11).  Those with moderate to severe asthma are advised to receive a yearly influenza vaccination.

There are many strategies that the patient and family can employ to avoid some triggering factors.  For B.T. who is highly allergic to dust and pollen, some measures include staying indoors when there is a very high count of pollen.   Carpets can be changed with hard floorings.  On B.T.’s anxiety, once detected, the degree of anxiety should be identified.  He should be encouraged to discuss his feelings and his present condition.  Advise effective coping approach such as meditation and physical activity to alleviate tension.  Desired results are B.T.’s awareness of his anxiety, successful use of support systems, and use of positive techniques (Pruitt & Lawson, 2011, pp. 51-52).

Assess, manage, and monitor asthma.

The goal of asthma therapy can be achieved in most patients through an uninterrupted sequence that involves (GINA, 2010b, p. 12):

(1) Evaluating asthma control where each patient is assessed to establish present treatment regimen, compliance to the present regimen, and degree of asthma control.

(2) Treating to attain control.  As per level of control, treatment is directed by stepping up or down in a sequence of five steps.  Therapy is stepped up for uncontrolled asthma and continued until control is attained.  If there is control for at least 3 months, treatment is stepped down.  As necessary, reliever medication is provided at every step for speedy symptom relief.  Controller medications are given at steps 2 through 5 as preventive measures against symptoms and attacks.  Patients with unacceptable degree of control at step 4 are assessed as having “difficult- to-treat-asthma.”  Specialized care may be needed such as with an asthma specialist.

(3) Monitoring to sustain control.  Constant monitoring is essential to sustain control and ascertain the lowest step and treatment dose to lessen cost and adverse effects.  Treatment is occasionally modified in response to loss of control (GINA, 2010b, p. 16).

Asthma is a serious disease that can place severe restrictions on daily life if uncontrolled and can be fatal. It is a considerable burden not just in health care expenditure but also of lost productivity and diminished participation in family life (GINA, 2010a, p. ii).  However, it is a disease that can be controlled and managed with the partnership of the patient and health care providers.  Awareness of the latest guidelines in asthma therapy such as the Global Initiative for Asthma (GINA) is imperative to achieve the goals of treatment and return B.T. to his optimum level of functioning.

Universal Intellectual Standards of Quality Thinking

In this case study, I have applied clarity, accuracy, precision, relevance, depth, consistency, and fairness.  Clarity portrays the strength in the writer’s position as to how the subject being discussed is thoroughly understood and is conveyed effectively to the reader.  The main gauge is to ascertain how well others are able to understand the position being forwarded. By removing aspects that could mislead like ambiguity or double meanings, one forwards an idea without any distraction.   Accuracy was observed at all times as the medical field uses exact standards.  The next thing is to ascertain that the data being used are precise.  Precision reflects how well one has gone to specific details on a certain subject.  It shows the extent one has painstakingly taken to enhance depth on what is discussed.  If changes are needed, the appropriate corrections are adopted.  This is possible by being consistent on the data and indicators so that the reader can identify with situations or issues presented.  To get this across, fairness was observed so that the work is devoid of any biases.  Lastly, relevance is very important to keep the work in focus.  Nursing is composed of many different facets, it would be good to take extra care in making sure that everything is connected to the topic and that the necessary components have been discussed.

American Nurses Association (ANA) Standards of Professional Performance

In the clinical decision-making process, I have applied quality of care, education, collaboration, research, and resource utilization.  Quality of care is essential in the nursing profession.  It ensures that the patient receives safe, effective, and excellent nursing care, as well as respect and compassion.  I applied education to obtain and maintain current nursing practice especially applicable to asthma patients.  Treatment guidelines are constantly updated as new studies find the more effective approach.   Likewise, I applied research as it is an essential element in health care; it helps in developing treatments that offer the best level of care.  With research, significant advances are made in health and treatments and new changes are implemented.  It can also explain the newest findings on the pathophysiology of disease which aids in the patient’s understanding and acceptance of his or her condition.  I applied collaboration which is an important component in asthma therapy.  Collaboration helps in achieving the goal of therapy by providing the patient an ability to deal with his condition with assistance from health care providers and other support systems like the family.  Lastly, I applied resource utilization to improve safety and effectiveness of therapy while minimizing cost.  Resource utilization also educates the patient and his family on the cost, benefits, and risks of treatment options making them informed consumers.  They are also guided in recognizing and securing available and suitable services to address health needs.

References

Cooper, C. L., Parry, G. D., Saul, C., Morice, A. H., Hutchcroft, B. J., Moore, J., & Esmonde, L.(2007).  BMC Family Practice, 8(62), 1-7.

Corbridge, S., & Corbridge, T. C.  (2010).  Asthma in adolescents and adults: Guideline-baseddiagnosis and management.  American Journal of Nursing, 110(5), 28-38.

Global Initiative for Asthma.  (2010a).  Global strategy for asthma management and prevention,updated 2010.  Retrieved November 18, 2011 from http://www.ginasthma.org/pdf/GINA_Report_2010.pdf

Global Initiative for Asthma.  (2010b).  Pocket guide for asthma management and prevention(for adults and children older than 5 years).  Retrieved November 18, 2011 from http://www.ginasthma.org/pdf/GINA_Pocket_2010a.pdf

Global Initiative for Asthma.  (n.d.).  How to use the able spacer.  Retrieved November 18, 2011from http://www.ginasthma.org/other-resources-able-spacer.html

House, D. T., & Ramirez, E. G.  (2008).  Emergency management of asthma exacerbations.

Advanced Emergency Nursing Journal, 30(2), 122-138.

Kaya, Z., Erkan, F., Ozkan, M., Ozkan, S., Kocaman, N., Ertekin, B. A., & Direk, N.  (2009).

Self-management plans for asthma control and predictors of patient compliance.  J .Asthma, 46(3), 270-275.

Pruitt, B., & Lawson, R.  (2011).  Assessing and managing asthma: A global initiative for asthma update.  Nursing2011, 41(5), 46-52.

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