Asthma Pathophysiology | Nursing Assignment

Nursing Assignment

Part A
Introduction:
Asthma is a chronic allergic, immune mediated and inflammatory disease. Main signs and
symptoms of asthma comprises of shortness of breath, increased respiratory rate, difficulty in
breathing, coughing and wheezing. Occurrence of asthma is more in children which is known as
childhood asthma. Etiological factors of asthma include cold air, exercise, pollen, viruses,
genetic factors, drugs like aspirin and beta blockers. Asthma attacks can occur in many occasions
in a single day or on few days in a week. Approximately, 1 in 9 people in Australia have asthma.
It is more common in male below 14 years of age, however it is more common in female above
14 years of age. Asthma is prevalent in the older and Indigenous Australians also. Asthma is
more prevalent in people with low socioeconomic class. Asthma is a huge financial and social
burden in Australia. 451 per 100,000 population children fewer than 15 years age are
hospitalized due to asthma. Approximately 400 deaths per year occurs due to asthma in Australia
in last 10 years. 34 % people reported interference in daily activities due to asthma and 21 %
children reported off form school or work due to asthma (AIHW, 2016). In this essay, case of 6
years old Zachy is discussed, who is suffering through coughing, wheezing and difficulty in
breathing. Signs and symptoms of Zachy are correlated with pathphysiological changes of
asthma.
Discussion:
Asthma pathophysiology can be studied in four different categories like bronchoconstriction,
airway edema, airway hyperresponsiveness and airway remodeling. Inflammation of the airways
leads to the bronchoconstriction. Type 1 hypersensitivity reactions are responsible for the
initiation of the asthma attack. Allergens are processed by antigen presenting cells and these are
presented to the naïve T lymphocytes like Th0 cells. Th0 cells switch to the Th2 cells after
presentation of the allergens. Th2 cells release different cytokines like IL-4 and IL-13. These
cytokines act on the B lymphocytes to produce immunoglobulin E. These IgE bind to the Fc
receptors present on the mast cells. Binding of the IgE to the receptors on the mast cells is
termed as the sensitization phase of asthma (Bonini and Usmani, 2015). When there is repeated
attack of same allergens in the same person, newly entered allergens bind to the IgE and Fc
receptors complex on the mast cells. This binding leads to the degranulation of the mast cells.

This degranulation of the mast cells lead to the release of different mediators like histamine,
leucotrines and prostaglandins. These mediators produce contraction of the airway smooth
muscle and consequently narrowing of airways and bronchoconstriction. These mediators can
also be released by IgE independent pathway. Aspirin and non-steroidal anti-inflammatory drugs
are responsible for the IgE independent pathway. Bronchoconstriction can also be induced by
physical factors like cold, excercise and irritants. Stress is also responsible for
bronchoconstriction in asthma (Erjefält, 2010).
Inflammation in the asthma can be produced due to inflammatory cells like Th2 lymphocytes,
mast cells, eosinophils, dendritic cells, epithelial cells, macrophases and resident cells of airway.
Progressive and chronic inflammation of the airways can result in the edema formation in the
airways. Mucus hypersecretion and deposition of mucus plugs in the airways can occur due to
inflammation. Sustained inflammation leads to the hypertrophy and hyperplasia of the airways.
This results in the reduced airflow through the airways. Sustained inflammation and the
structural changes in the airways lead to the airway hyperresponsiveness (Patadia et al., 2014).
Airway remodeling comprises of permanent structural changes in the airways which can lead to
the loss of lung function. Features of airway remodeling are sub-basement membrane thickening,
subepithelial fibrosis, hypertrophy and hyperplasia of airway smooth muscle, proliferation and
dilation of blood vessels, mucous gland hyperplasia and mucus hypersecretion. Due to loss of
lung function, there can be insufficient breathing. Insufficient breathing lead to the less exchange
of oxygen at the alveoli and blood capillaries interface. As a result, there is less oxygen in the
blood and less oxygen saturation. In case of Zachy also, less oxygen saturation observed. In
children of Zachy’s age oxygen saturation should be above 95 %, however in case Zachy oxygen
saturation level is 92 %. Due to low level of oxygen in the blood, lung tries to compensate it by
inhaling more air which leads to increase in breathing rate. As a result, there is increase in
respiratory rate in asthma patients. In case of Zachy also, there is increased respiratory rate. In
children of Zachy’s age respiratory rate should be below 20 breath per minute, however it was
observed that in case of Zachy respiratory rate is 37 breaths per minute (Mims, 2015; Chawes,
2011).
Cough can be of two types productive cough and non-productive cough. Productive cough expels
phlegm and it act as defense mechanism. Non-productive cough is dry cough and it occurs due to
irritation of the inflamed airways and constricted airways. In asthma patients, non-productive

cough occurs. If cough is accompanied by other signs and symptoms like chest tightness,
wheezing, fatigue, long duration infection and breathing difficulties, it is considered as cough
due to asthma. In asthma children, there are more incidences of cough in the night (Patadia et al.,
2014). In case of Zachy also, cough is more in the night time. Wheezing is the whistling like
sound of exhaled air. By force passage of air through narrow and constricted airways produces
wheezing sound in the Zachy. Wheezing can be of two types like transient and persistent
wheezing. If wheezing stops at age of 3 years, it is called as transient wheezing. If wheezing
continues after age of 5 years, it is called as persistent wheezing. In case of Zachy, there is
persistent wheezing (West et al., 2013; Krishnan et al., 2012).
Conclusion:
Asthma is a multifactorial disease with diverse etiological factors. Asthma is a very common
disease in children and associated with nocturnal cough. Pathophysiological changes associated
with asthma are inflammation of airways, bronchospasm and airway remodeling. Zachy
exhibited symptoms of asthma like rapid respiratory rate, coughing, wheezing and low oxygen
saturation level with respect to the pathological changes. Multiple mechanisms are involved in
the pathogenesis of asthma and these different mechanisms exhibit respective symptoms. For the
management of symptoms of asthma nurse should have sound knowledge of relevant
pathophysiological mechanisms.

References:
Australian Institute of Health and Welfare (AIHW). (2016). Asthma. Retrived from
http://www.aihw.gov.au/asthma/ on 27.04.2017.
Bonini, M., & Usmani, O.S. (2015). The role of the small airways in the pathophysiology of
asthma and chronic obstructive pulmonary disease. Therapeutic Advances in Respiratory
Disease, 9(6), 281-93.
Chawes, B.L. (2011). Upper and lower airway pathology in young children with allergic- and
non-allergic rhinitis. Danish Medical Bulletin, 58(5), B4278.
Erjefält, J.S. (2010). The airway epithelium as regulator of inflammation patterns in asthma.
Clinical Respiratory Journal, 4(1), 9-14.
Krishnan, J.A, Lemanske, R.F. Jr., Canino, G.J., Elward, K.S., Kattan, M., Matsui, E.C.,
Mitchell, H., Sutherland, E.R., & Minnicozzi, M. (2012). Asthma outcomes: symptoms.
Journal of Allergy and Clinical Immunology, 129(3), S124-35.
Mims, J.W. (2015). Asthma: definitions and pathophysiology. International Forum of Allergy &
Rhinology, 5(l), S2-6.
Patadia, M.O., Murrill, L.L., Corey, J. (2014). Asthma: symptoms and presentation.
Otolaryngologic Clinics of North America, 47(1), 23-32.
West, A.R., Syyong, H.T., Siddiqui, S., Pascoe, C.D., Murphy, T.M., Maarsingh, H., Deng, L.,
Maksym, G.N., Bossé, Y. (2013). Airway contractility and remodeling: links to asthma
symptoms. Pulmonary Pharmacology and Therapeutics, 26(1), 3-12.

Part B
Introduction:
Asthma is a complex disease involving different mechanisms like immune, allergic and
inflammatory. Due to these different mechanisms, different types of receptors, enzymes and
cytokines are responsible for the different symptoms and pathological changes in asthma.
Asthma patients should be treated with different drugs acting on different targets for the
management of different symptoms. Asthma is a chronic disease, hence different types of drugs
or different types of treatments should be planned at different stages of the disease. In acute stage
of the asthma treatment should be planned for the management of symptoms while in chronic
stages treatment should be planned to reverse pathological changes. In addition to the medication
treatment, asthma patients should also be managed by incorporation of the non-medication
treatment. In this essay, Zachy’s medication and non-medication treatments are discussed.
Discussion:
Ipratropium is an anticholinergic and muscarinic receptor antagonist drug, which acts on the
airway smooth muscle. Inhibition of muscarinic acetylcholine receptors results in the degradation
of cyclic guanosine monophosphate (cGMP). As a result, there is reduced action of cGMP on
intracellular calcium which lead to reduced contractibility of smooth muscle of airways and
inhibition of bronchoconstriction. It results in the smooth muscle relaxation and consequently
bronchodilation. Nurse should educate Zachy and her parents about the use of ipratropium
inhaler. Zachy should be encouraged to use mouthpiece instead of face mask. Nurse should
monitor asthma symptoms in Zachy, prior to and after administration of ipratropium inhalation
(Aaron, 2001).
Prednisolone is glucocorticosteroidal anti-inflammatory drug which also exhibits
immunosuppressant action. It produces effect on the feedback mechanism of immune system to
produce immunosuppressant and anti-inflammatory effect. It exhibits its effect by binding to the
glucocorticoid receptor which results in the activation of the glucocorticoid receptors. Activation
of glucocorticoid receptors lead to transactivation and transrepression. These two mechanisms
exhibits anti-inflmmatory effect. Transactivation comprises of upregulation of the anti-
inflammatory genes like lipocortin I, p11/calpactin binding protein, secretory leukoprotease
inhibitor 1 (SLPI), and mitogen-activated protein kinase phosphatase (MAPK phosphatase).

Repression of expression of proinflammatory proteins in cytosol occurs in transrepression. As a
result, translocation of transcription factors like NF-κB from cytosol to nucleus gets inhibited.
Hence, transcription of inflammatory genes like NF-κB gets prevented. Nurse should monitor
electrolyte balance and occurrence of infection in Zachy because consumption of prednisolone
may disturb electrolyte balance in Zachy and increase susceptibility to infection (Olin and
Wechsler, 2014; Zhang et al., 2014).
Salbutamol through inhalation route is useful as bronchodilator in the asthma patients.
Salbutamol is a short acting β2 adrenergic receptor agonist. Bronchial smooth muscle of the lung
contains abundant amount of β2 adrenergic receptors. Adenyl cyclase enzyme gets activated due
to activation β2 adrenergic receptors. Adenyl cyclase acts as catalyst for the conversion of
adenosine-tri-phosphate (ATP) to adenosine-mono-phosphate (cyclic AMP). This increase in the
cyclic AMP results in the relaxation of the airway smooth muscle and decrease in the airway
resistance due to decrease in the amount of intracellular calcium ions. This increased level of
cyclic AMP prevents release of mediators such as leukotreine and histamine which are
responsible for bronchoconstriction (van Buul and Taube, 2015; Neininger et al., 2015).
Amoxicillin is administered to Zachy through per oral route for the prevention of bacterial
infection. Amoxicillin antibiotic comes under penicillin class. Amoxicillin produce bactericidal
action against the bacteria at the stage of active multiplication. It produces bactericidal action by
inhibiting cell wall biosynthesis. It inhibits cell wall biosynthesis by inhibiting cross-linkage of
linear peptidoglycan polymer chains. Nurse should perform hypersensitivity tests for amoxicillin
in Zachy prior to its administration. Zachy should consume amoxicillin along with food because
it can produce GI upset on empty stomach. Parents of Zachy should be educated about
discontinuation of amoxicillin. Amoxicillin should not be discontinued and should be consumed
for scheduled course, even if infection disappeared (Ghoshal et al., 2012; Francis et al., 2015).
Paracetamol is administered in Zachy for treating pain. Exact mechanism of action of
paracetamol has not been established. However, few mechanisms are proposed for mechanism of
paracetamol for pain. These mechanisms include inhibition of COX activities, modulation of
endogenous cannabinoid system in the brain and activation of transient receptor potential cation
channel subfamily V member 1 (TRPV1). Nurse should monitor hypersensitivity to paracetamol
in Zachy (Karakaya and Kalyoncu, 2003)

Treatment should be initiated with quick relief medication like salbutamol inhalation. It should
be initiated with 2 puffs each time and it should be repeated every four hours. It should not be
given earlier than four hours without consultation of the doctor. Zachy and her parents should be
educated to use inhaler in the initial period. By this, they can use it in absence of hospital staff
and it would avoid medication discontinuation. Zachy should not be given any cough
suppressant. Inhaler should be use with spacer because it would increase amount of drug
reaching to lungs. Zachy should be encouraged to consume lot of fluid because it would be
helpful in keeping Zachy in hydrated condition and facilitate thinning of phlegm. Humidifier
should be provided in the room, if there is more dry air in the room. Dry air can exaggerate
cough in Zachy. Zachy should be advised to maintain hygienic condition by using face mask.
Also, hospital staff and visitors should be advised use all personal protective equipments (PPEs)
before entering in the room. Due to asthma, Zachy is more susceptible to infection. As oxygen
saturation level is low in Zachy, supplemental oxygen should be immediately started in Zachy to
achieve oxygen saturation level above 95 %. Corticosteroid like prednisolone should be
administered in Zachy within first hour of admission to the hospital. Nurse should assess
breathing pattern and cough in Zachy every hour. If these symptoms are not responding to the
given treatment, nurse should consult doctor for change in medications or changing frequency of
medications. Nurse should monitor Zachy for approximately one hour after the resolution of the
breathing difficulty (Howcroft et al., 2016; Heffner, 2011).
Nurse should assess breathing pattern in Zachy by hearing sounds and measuring breathing rate.
Along with medication administration, nurse should provide non-medical interventions for
Zachy to improve breathing pattern. Zachy should sit in upright position with proper body
alignment, as it is helpful in chest expansion. Zachy should take deep and diaphragmatic
breathing because it reduces air trapping in the lung, relaxes muscle and increase oxygen
saturation level. Nurse should advise Zachy to perform suitable exercise because it increases
working capability of respiratory muscle. Zachy should take frequent meals with small quantities
because it would keep stomach empty and ventilation would be improved. Nurse should record
body weight and nutritional requirements of Zachy prior to initiation of the treatment because
asthma patients tend to consume less food. Nurse should also record physical and vital signs of
Zachy. Nurse should provide Zachy with good environment and parents company while taking
meals. Zachy should consume high protein containing liquids because it provide high calorie.

Zachy should not consume caffeinated and carbonated liquids because it gives false feeling of
satiety and reduces hunger (Chow et al., 2015; Janssen et al., 2012).
Irrespective of the age of the patient and severity of the disease, patient and family members
education should be the integral part of asthma management. It is evident from the literature that
patient and family members education can reduce hospitalization and improve quality of life in
children. Several guidelines indicated education about pathophysiology of asthma, use of inhaler
and medication adherence as the components of education programme in asthma patients. Zachy
and her parents should be informed openly about the possible side effects of medications. Action
plan for nursing intervention should be given in written format for Zachy’s parents. This action
plan should also comprise of signs and symptoms and extent of its worsening (Klok et al., 2015).
Zachy should cough for 2-3 times in sequence and should change position on regular basis
during coughing. Zachy should keep himself away from dust and allergens because these can
exaggerate asthma condition in Zachy. Different professionals like pharmacist, clinical
laboratory scientist, dieticians and physical trainers should be incorporated in the management of
Zachy. Pharamcist should take care of the medication management in Zachy. Clinical laboratory
scientist should perform required tests for the assessment of Zachy’s condition. Dietician should
plan proper diet in Zachy, so that consumption would be increased and would provide high
calorie to Zachy. Physical trainer should teach Zachy about suitable exercise to improve
breathing pattern (VanGarsse et al., 2015; Young, 2011).
Conclusion:
For the treatment of asthma in Zachy different drugs like anti-inflammatory prednisolone,
bronchodilator salbutamol and ipratropium, antibiotic amoxicillin and paracetamol for pain relief
are incorporated. These drugs are useful in the management of different symptoms and
pathological changes. Non-medication management provided for Zachy in the form of education
about the disease, medication management, diet, infection prevention, exercise and nebulization
use. Different professionals like pharmacist, clinical laboratory scientist, dieticians and physical
trainers are incorporated in the management of asthma in case of Zachy. In summary, targeted
treatment would definitely be useful in improvement of asthma signs and symptoms of Zachy.

References:
Aaron, S.D. (2001). The use of ipratropium bromide for the management of acute asthma
exacerbation in adults and children: a systematic review. Journal of Asthma, 38(7), 521-
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Chow, L., Parulekar, A.D., and Hanania, N.A. (2015). Hospital management of acute
exacerbations of chronic obstructive pulmonary disease. Journal of Hospital Medicine,
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Francis, S., Smith, F., and Malkinson, J. (2015). Integrated Pharmacy Case Studies.
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Ghoshal, A.G., Dhar, R., and Kundu, S. (2012). Treatment of Acute Exacerbation of COPD.
Journal of the Association of Physicians of India, 60, 38 - 43.
Howcroft, M., Walters, E.H., Wood-Baker, R., and Walters, J.A. (2016). Action plans with brief
patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane
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Heffner, J.E. (2011). Advance care planning in chronic obstructive pulmonary disease: barriers
and opportunities. Current Opinion in Pulmonary Medicine, 17(2), 103-9.
Janssen, D.J., Engelberg, R.A., Wouters, E.F., Curtis, J.R. (2012). Advance care planning for
patients with COPD: past, present and future. Patient Education and Counseling, 86(1),
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Karakaya, G., and Kalyoncu, A.F. (2003). Paracetamol and asthma. Expert Opinion on
Pharmacotherapy, 4(1):13-21.
Klok, T., Kaptein, A.A., and Brand, P.L. (2015). Non-adherence in children with asthma
reviewed: The need for improvement of asthma care and medical education.
Pediatric Allergy and Immunology, 26(3), 197-205.
Neininger, M.P., Kaune, A., Bertsche, A., Rink, J., et al., (2015). How to improve prescription
of inhaled salbutamol by providing standardised feedback on administration: a controlled
intervention pilot study with follow-up. BMC Health Services Research, 15, 40.
Olin, J..T, & Wechsler, M.E. (2014). Asthma: pathogenesis and novel drugs for treatment.
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van Buul, A.R, & Taube, C. (2015). Treatment of severe asthma: entering the era of targeted
therapy. Expert Opinion on Biological Therapy, 15(12), 1713-25.
VanGarsse, A, Magie, R.D., and Bruhnding, A. (2015). Pediatric asthma for the primary care
practitioner. Primary care, 42(1), 129-42.

Young, C. (2011). Patient education. Avoiding asthma triggers: a primer for patients. Journal of
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Zhang, L., Prietsch, S.O., and Ducharme, F.M. (2014). Inhaled corticosteroids in children with
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