Answer 1: Pathogenesis of Acute Severe Asthma
Concept map:
Jackson Smith is an 18 year old patient who was admitted to the Emergency Department with severe breathlessness. Review of his family history revealed that he has history of asthma which was diagnosed when he was two years. Based on the current clinical manifestations of high respiratory rate, wheezing, severe dyspnoea and review of vital signs, blood gas analysis and chest x-ray results, a diagnosis of acute severe asthma was made. Acute severe asthma is a clinical condition associated with acute exacerbation of asthma resulting in symptoms of chest tightness, wheezing, laboured breathing, dry cough and dyspnea. It is a condition also named as status asthmaticus and the main challenges is that it is a severe form of asthma unresponsive to repeated course of beta-agonist therapy such as inhaled albuterol and epinephrine (Powell, 2016). Hence, in case of Jackson Smith, it can be said that his condition is an emergency condition that will require immediate recognition and treatment.
There are many predisposing factors that predispose patients to risk of acute severe asthma. These includes non-compliance to medical treatment, allergen exposure (from pets) in severely atopic patients, inhalation of irritants like smoke and paint and insufficient use of inhaled corticosteroids and poor use of inhaled corticosteroids (Sanya et al., 2014). Longer duration of breastfeeding, use of kerosene and environmental tobacco smoke also contribute to risk of wheezing in children. Some of the main pathological changes that contribute to acute exacerbation of asthma include anatomic changes in airway leading to narrowing of the airways, plugging of the airway with mucus and inflammatory infiltrates and hyperinflation. In case of acute exacerbation, the main issue is that brochoconstriction occurs very quickly resulting in narrowing of the airways in response to different stimuli or allergens. This type of bronchoconstriction occurs because of release of mediators like histamine and prostaglandins from mast cells (Dunican & Fahy, 2015). Fahy (2009) showed that patient with severe acute asthma have high level of neutrophils, plasma , lymphocytes and eosinophils. This occurs because of exposure to a trigger and complex interplay of activities like mast cell degranulation and epithelial cell damage. T cell and B cell differentiation promotes cytokine release and activation of inflammatory cascade. This is followed by subsequent inflammation, mucus production and bronchoconstriction resulting in gas exchange and airway obstruction (Neame et al., 2015). This explains the cause behind acute severe asthma and clinical symptoms of wheezing and breathing difficulty in Jackson Smith.
Answer 2: High Priority Nursing Strategies for Management of Acute Severe Asthma
Infiltration of the airways with neutrophils and eosinophils is the main factor contributing to unresolved inflammation in patients with asthma. Bruijnzeel, Uddin and Koenderman (2015) revealed that in patients with severe asthma, more number of pro-neutrophilic factors are generated that result in delays of apoptosis and persistence of apoptosis resistance neutrophils in the airway of patients. The ultimate effect of these physiological changes in the body of patient is that it impedes timely clearance of neutrophils and delays the process of termination of airway inflammation. Hence, different types of neutrophils may circulate in the body of patient and this may exacerbate inflammatory process instead of suppressing it. Hence, treatment option is decided as per clinical manifestations of patient.
For Jackson Smith, the main issue was that he was suffering from severe breathlessness and this was affecting his ability to engage in speak clear sentences. In case of obstructive lung diseases such as asthma, dyspnea is a common symptom for patients. This event is triggered by exposure to allergens, activation of immune response in bronchial muscles and bronchospasms in patient. This change is evident from clinical manifestation of wheezing and dyspnea in patient. Hence, in case of Jackson, it can be said that dyspnea is a clinical manifestation of episodic bronchospasm. The severity of breathing difficulty may vary based on severity of the asthma attack. Some patients have poor perception about dyspnea resulting in life threatening consequences (Antoniu, 2010). However, as Jackson was admitted with acute symptom of breathlessness, it is evident that his main clinical issue was dyspnea. Dyspnea is associated with chest tightness and heavy work of breathing indicating that he had severe airflow obstruction and hyperinflation than those with less severe asthma. Hence, complete documentation of dyspnea descriptors would help to take proper decision making regarding appropriate therapeutic options for patient.
After the review of vital signs, clinical symptoms and several laboratory test of Jackson, it has been found that the blood gas test values are normal. However, some adverse symptoms found in patient is symptom of hypoxemia evidenced by SpO2 value of 90%. In normal case, it should be at least more than 95%. Brill and Wedzicha (2014) states that SaO2 value of less than 90% is clinically hypoxemic as the risk of hypoxemic tissue damage increases in such condition. Hence, the first high priority nursing strategy is to provide oxygen therapy to patient either by face mask or nasal canulae. This nursing strategy is important to prevent respiratory failure in patient. Frat et al. (2015) suggest that delivery of supplemental oxygen in moderate concentration can help to overcome hypoxia. Oxygen should be given before and after treatment with beta-2-agonist as this would help to prevent life threatening attacks in patient.
Answer 3: Nursing Role and Responsibilities in Pharmacological Interventions
The auscultation of lungs of Jackson has revealed diminished breathing sounds and widespread wheezing. This is evidenced by symptom of high breathing rate evidenced by value of 32breaths/minutes (normal rate is 12-20 breaths/minute). Furthermore, breathlessness and heavy work of breathing is a significant issue for Jackson. This is an indication of ineffective airway clearance in patient. Hence, to effectively manage Jackson, the second high nursing strategy is to provide pharmacological drug anticholinergics along with beta-2 agonist for the treatment of acute asthmatic exacerbation. The main rational behind this is that people with acute severe asthma fail to respond to beta-2 agonist and adding anticholinergic drugs like ipratropium bromide results in rapid improvement in airflow obstruction (Restrepo et al., 2015). Research evidence supports this treatment as the study revealed that add-on therapy of inhaled anticholinergics can reduce hospital admission and promote better lung function (Ortiz-Alvarez et al., 2012).
- a) Three drugs were given to Jackson for treatment of acute severe asthma. The mechanism of action of each of the three drugs are as follows:
Mechanism of action of Salbutamol: It is a short-acting selective beta2-adrenergic receptor agonist which is used in the treatment of asthma. It stimulates the beta-2-adrenergic receptor thus resulting in relaxation of bronchial smooth muscles. It is related to the pathophysiology of asthma as the drug promotes smooth muscle relaxation and brochodilation of the airways (Pacifici & Allegaert, 2015).
Mechanism of action of Ipratopium bromide: Ipratopium bromide is an anti-cholinergic agent which works to block the muscarinic cholinergic receptors. This results in decrease of cyclic guanosine monophosphate and decreased contractility of smooth muscles (Gosens & Gross, 2018). Hence, in this way, it can work to address smooth muscle contraction that occurs during acute severe asthma.
Mechanism of action of Hydrocortisone: Hydrocorisone acts as a corticosteroid hormone receptor agonist that promotes protein catabolism, gluconeogensis, inflammatory response and capillary wall stability. It has immunosuppressive action that works to initiate immune response to various stimuli (Patel & Yong, 2017).
- b) While providing the three medications to Jackson, the following nursing implications need to be considered for each drug:
Nursing implications for Salbutamol: Other medications taken by Jackson should be considered because as certain medication can intensify the action of the drug. In addition, patient must be educate regarding correct dose and usage of drugs (Kaufman, 2015).
Nursing implications for Ipratopium bromide: While providing Ipratopium bromide, it is necessary for nurse regularly monitor changes in respiratory statues of patient and auscultate lungs before and after inhalation of the drug. Due to the side effects of exacerbation of symptoms, patients must be educated regarding the risk and the need to immediately report about respiratory failure (Kaufman, 2015).
Nursing implications for Hydrocortisone: It is necessary to regularly monitor BP, weight and blood glucose level of patient. The patient should be regularly monitored for any side-effects and look for changes in mood and behaviour of patient (Judd et al., 2014).
Conclusion
References
Antoniu, S. A. (2010). Descriptors of dyspnea in obstructive lung diseases. Multidisciplinary respiratory medicine, 5(3), 216.
Brill, S. E., & Wedzicha, J. A. (2014). Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease, 9, 1241–1252. https://doi.org/10.2147/COPD.S41476
Bruijnzeel, P. L., Uddin, M., & Koenderman, L. (2015). Targeting neutrophilic inflammation in severe neutrophilic asthma: can we target the disease?relevant neutrophil phenotype?. Journal of leukocyte biology, 98(4), 549-556.
Dunican, E. M., & Fahy, J. V. (2015). The role of type 2 inflammation in the pathogenesis of asthma exacerbations. Annals of the American Thoracic Society, 12(Supplement 2), S144-S149.
Fahy, J. V. (2009). Eosinophilic and neutrophilic inflammation in asthma: insights from clinical studies. Proceedings of the American Thoracic Society, 6(3), 256-259.
Frat, J. P., Thille, A. W., Mercat, A., Girault, C., Ragot, S., Perbet, S., … & Devaquet, J. (2015). High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. New England Journal of Medicine, 372(23), 2185-2196.
Gosens, R., & Gross, N. (2018). The mode of action of anticholinergics in asthma. European Respiratory Journal, 52(4), 1701247.
Judd, L. L., Schettler, P. J., Brown, E. S., Wolkowitz, O. M., Sternberg, E. M., Bender, B. G., … & Joëls, M. (2014). Adverse consequences of glucocorticoid medication: psychological, cognitive, and behavioral effects. American Journal of Psychiatry, 171(10), 1045-1051.
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Neame, M., Aragon, O., Fernandes, R. M., & Sinha, I. (2015). Salbutamol or aminophylline for acute severe asthma: how to choose which one, when and why?. Archives of Disease in Childhood-Education and Practice, 100(4), 215-222.
Ortiz-Alvarez, O., Mikrogianakis, A., & Canadian Paediatric Society, Acute Care Committee. (2012). Managing the paediatric patient with an acute asthma exacerbation. Paediatrics & Child Health, 17(5), 251–256.
Pacifici, G. M., & Allegaert, K. (2015). Bronchodilator and Antihyperkalemic Effects of Salbutamol (Albuterol) in Neonates and Young Infants. Journal of Pediatric Biochemistry, 5(03), 082-087.
Patel, M., & Yong, R. J. (2017). Mechanism of action. Pain Medicine: An Essential Review, 181.
Powell, C. V. (2016). Acute severe asthma. Journal of paediatrics and child health, 52(2), 187-191.
Restrepo, R. D., Tate, A., Gardner, D. D., Wittnebel, L. D., Wettstein, R., & Khusid, F. (2015). Current approaches to the assessment and treatment of acute severe asthma. Indian Journal of Respiratory Care, 4(1), 521.
Sanya, R. E., Kirenga, B. J., Worodria, W., & Okot-Nwang, M. (2014). Risk factors for asthma exacerbation in patients presenting to an emergency unit of a national referral hospital in Kampala, Uganda. African Health Sciences, 14(3), 707–715. https://doi.org/10.4314/ahs.v14i3.29
Satoskar, R. S., Rege, N., & Bhandarkar, S. D. (2015). Pharmacology and Pharmacotherapeutics-E-Book. Elsevier Health Sciences.
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