Understanding Asthma: Symptoms, Pathogenesis, and Nursing Strategies

This article discusses the symptoms, pathogenesis, and nursing strategies for managing asthma. It covers the etiology and risk factors of asthma, the clinical manifestations of an asthmatic attack, and the nursing interventions for optimal breathing pattern and effective airway clearance. It also explains the mechanism of action of nebulized salbutamol, nebulized ipratropium, and hydrocortisone.

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Name of the Student
Name of the University
Author Note

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Question 1
This case scenario reveals the fact that Jackson Smith has possibly suffered from an asthmatic
attack. The normal clinical manifestation of asthma is chest tightness, cough, and respiratory
distress. Some of the important symptoms of asthma that is common to most of the patients
with asthma are, airway obstruction due to airway inflammation, formation of mucus plug
and wide spread wheezing. The pathogenesis of the airway obstruction is due to a variety of
changes taking place in the airways, such as the bronchoconstriction (Bonini & Usmani,
2015). This is caused due to the contraction of the bronchial smooth muscles in response to
the exposure to a variety of stimuli including the allergens and the irritants.
Bronchoconstriction is again caused due to the release of the IgE dependant mediators like
tryptase, histamine and prostaglandins. In addition to this airway oedema formed due to the
inflammation of the airways also restricts the passage of airway causing widespread
wheezing. Wheezing is the musical sound that is produced when air is passed through a
limited area through the airways. A wide spread wheezing can be noticed in this patient
which is the most important symptoms of asthma. Other stimuli such as exposure to cold,
dust and other irritants can also trigger asthmatic attacks (Bonini & Usmani, 2015).
Airway hyper responsiveness is an important manifestation that is mainly caused due
to airway inflammation. Permanent or partial structural changes may occur in the airways
causing a gross loss in the lung function that cannot be recovered by any current therapy.
Airway remodelling also involves the activation of a number of cells, that can increase the
airway obstruction and airway responsiveness, which normally renders the patients less
responsive to any kind of therapies.
The case study reveals that the patient suffered from acute dyspnoea. It has to be
remembered that dyspnoea is the primary symptom of asthma. The exertional dyspnoea in

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case of asthma is due to some complex pathological mechanisms like dynamic hyperinflation,
an increased ventilatory demand, impaired capacity, hypercapnia, hypoxemia and the neuro-
mechanical dissociation. A large number of inflammatory cells are responsible for the
inflammation of the airways. Activation of the mucosal mast cells releases
bronchoconstriction mediators. Increased number if eosinophil have been observed in
patients suffering from asthma.
It is also evident from the case study that smith was having a low oxygen saturation
level than the normal value, which is above 95 %. Low oxygen saturation is common during
an asthma attack. This is due to the fact that low amount of oxygen reaches the blood. The
respiratory rate in the patient was found to be much higher than the standard value ( Papazian
et al., 2016). This can be explained simply by the fact that the amount of air entering the
lungs in each of the breath is reduced and hence the person needs to take more breaths to
cope up with the normal oxygen demands of the body ( Papazian et al., 2016). Diminished
breath sound is another symptoms of asthma. Decreased sound signifies air or fluid round the
lungs or the increased thickness of the chest walls or reduced flow of air in to the lungs.
Serum lactate level has been found to increase during asthmatic attack. According to a study,
high serum lactate levels has been observed in patients taking IV or nebulised salbutamol
(Rodrigo, 2014). The aggressive attack of the Beta agonists during asthmatic attack have
been found to be responsible for the increased lactate concentration. When a chest x-ray was
performed a hyper-inflated lungs was noticed. Hyper inflated lungs can be caused due to the
blockages in the air passage that interferes with the expulsion of air from the lungs. Normally
mild inflation of the lungs takes place at the time of asthma exacerbation. However
hyperinflation of the lungs are more common in patients with chronic obstructive pulmonary
disease (COPD). The recorded pulse rate of Jackson Smith is greater than the standard value.

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Rapid pulse during an asthmatic attack is probably due to the fact that the heart pumps more
rapidly to send blood to different parts of the body. Rapid pulse during an asthmatic attack
can also be due to psychological reasons. Panic attack due to breathlessness can be the cause
of an elevated pulse rate.
Question 2
Two high priority nursing strategy for managing Jackson
 One of the clinical nursing priority to manage asthma in Jackson Smith is to maintain an
optimal breathing pattern in the patient. This can be evidenced by relaxed breathing in the
patient, normal respiratory pattern and absence of dyspnoea in the patient. Optimal
breathing pattern in the patient is facilitated by administering medicines like short acting
beta-2-adrenergic agonist like Albuterol, Terbutaline (Murphy et al., 2013). Optimal
breathing is also facilitated by encouraging the patient to use a pursed lip breathing for
the inhalation. Management of effective breathing pattern also involves proper
monitoring of the oxygen saturation level and assessing the presence of the paradoxical
pulse of greater than 12mm Hg (Lalloo et al., 2013).
Rationale: Short acting beta agonist acts as bronchodilators. They tend to relax the inner
muscular lining of the airways. The inhaled corticosteroids helps in the reduction of the
inflammation of the airways that carry air to the lungs (Cates, Welsh & Rowe, 2013).
Pursed lip breathing can help in improving the breathing pattern by moving the used air
out of the lungs and oxygen to enter the lungs. Paradoxical pulses should be assessed
because paradoxical pulse occurs when there is an abnormal decrease in the systolic
pressure at the time of inspiration.

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 Effective airway clearance is another clinical priority of Jackson Smith suffering from
asthmatic attack. It is necessary to clear the secretions or obstructions from the respiratory
tracts for maintaining a clear airway. Ineffective airway clearance is mainly evidenced by
abnormal arterial blood gases, adventitious wheezes and changes in the respiratory rate
and rhythm (Cates, Welsh & Rowe, 2013). The nursing intervention for an effective
airway clearance includes auscultation of the lungs for the adventitious breath sounds,
encourage the increased fluid intake, administration of oxygen, encouraging the patient in
effective coughing (Lalloo et al., 2013).
 Rationale: effective coughing can be natural way to clear the secretion from the throat.
Wheezes heard at the time of lung auscultation may suggest partial blockage of the lungs.
Increasing fluid intake might help in minimising the mucosal drying and increases the
ciliary action for removing the secretions (Lalloo et al., 2013).
Question 3
Nebulised Salbutamol- Salbutamol acts at the β2-adrenoreceptors present on the smooth
muscles enveloping the bronchi. By binding, it stabilizes the receptor at the active state. The
receptor stays at the active state for more time and as a result generates more cAMP. The
development of the cAMP triggers the intercellular cascade to reduce the intracellular Ca2+.
This prevents the smooth muscles to contract (Sue Jordan, 2011). This cause the smooth
muscles in the airway to relax and allows the airways to open making it easier for the patient
to breathe. This is how Salbutamol can cease the smooth muscle contraction of the airways in
Jackson Smith during asthma exacerbations.
Nebulised Ipratropium-Ipratropium is an anticholinergic agent that blocks the muscarinic
receptors of acetyl choline and also appear to inhibit the vagally mediated reflexes by the
antagonisation of the action of the acetyl choline released from the vagus nerves. It is the

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cholinergic nerves that stimulates the smooth muscles cells in the airways to contract. The
anticholinergic effect of the ipratropium stops the effects of the cholinergic nerves (Cates,
Welsh & Rowe, 2013).
Hydrocortisone- It helps in reducing the mucus secretion in the airways by the inhibition of
the release of secretagogue from the macrophages. They inhibit the late phase reaction by the
inhibition of the inflammatory response (Alangari, 2014). The intravenous application of
hydrocortisone Jackson Smith was given to decrease the bronchoconstriction.
b) Nursing implications
Nurses should conduct a careful monitoring of the blood pressure and pulse rate after
the administration of the salbutamol. It can cause several changes like hypokalaemia and
might increase the blood glucose level. It is necessary to monitor for tachycardia and cardiac
dysrhythmias in the patient. Nebulised salbutamol solution more than 5mg should not be
given.
While administering the dosage, the dilution of the solution should be adjusted as per
the equipment and the length of the administration. A mouthpiece should be used rather than
a facemask. Nurses should check for any history of hypersensitivity before the application
and side effects like nausea, dizziness after the application. The heart rate, depth, rhythm and
the lung sounds should be assessed.
Before the initiation of the treatment with hydrocortisone, the contraindications and
the cautions have to be kept in mind. Hydrocortisones can exacerbate several long term
complications like peptic ulcer disease, hypertension (This, 2012). It is necessary to establish
the baseline and the continuing data on the vital signs. It is necessary to report for any
changes in the mood and the behaviour of the patient (Alangari, 2014).

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References
Alangari, A. A. (2014). Corticosteroids in the treatment of acute asthma. Annals of Thoracic
Medicine, 9(4), 187–192. http://doi.org/10.4103/1817-1737.140120
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), 281-293. https://doi.org/10.1177/1753465815588064
Cates, C. J., Welsh, E. J., & Rowe, B. H. (2013). Holding chambers (spacers) versus
nebulisers for beta‐agonist treatment of acute asthma. The Cochrane Library.
Lalloo, U. G., Ainslie, G. M., Abdool-Gaffar, M. S., Awotedu, A. A., Feldman, C.,
Greenblatt, M., ... & Otto, W. (2013). Guideline for the management of acute asthma
in adults: 2013 update-Part 2: March 2013. SAMJ: South African Medical Journal,
103(3), 189-200. Retrieved September 17, 2018, from
http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-
95742013000300031&lng=en&tlng=en..
Murphy, K. R., Meltzer, E. O., Blaiss, M. S., Nathan, R. A., Stoloff, S. W., & Doherty, D. E.
(2012, January). Asthma management and control in the United States: results of the
2009 Asthma Insight and Management survey. In Allergy & Asthma Proceedings
(Vol. 33, No. 1). https://doi.org/10.1016/j.rmed.2015.11.002
Papazian, L., Corley, A., Hess, D., Fraser, J. F., Frat, J. P., Guitton, C., ... & Ricard, J. D.
(2016). Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review.

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Intensive care medicine, 42(9), 1336-1349. https://doi.org/10.1007/s00134-016-4277-
8
Rodrigo, G. J. (2014). Serum lactate increase during acute asthma treatment: a new piece of
the puzzle. Chest, 145(1), 6-7. DOI: https://doi.org/10.1378/chest.13-2042
Sue Jordan, M. B. (2011). Bronchodilators: implications for nursing practice. DOI
10.7748/ns2011.03.15.27.45.c2999
This, B. N. I. (2012). Corticosteroids: implications for nursing practice. DOI:
10.7748/ns2012.12.17.12.43.c3312

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Concept map for Asthma
Definition: Asthma is an inflammatory reaction caused in the airways where
the airway of the person becomes narrow due to inflammation of the airways,
production of excessive mucus and the contraction of the airway smooth
muscles (1).
Etiology: The etiology and the risk factors of asthma are- Genetics, Diet and
nutrition, prenatal tobacco smoke, diet and nutrition, stress and antibiotic use,
congestive heart failure, having a blood relative with asthma, allergies from pollen,
dander, mites, molds, dust and air pollution, GERD and obesity (5).
 Pathogenesis- Inflammation of the airways occurs
due to lymphocytes, eosinophil, mast cells, that
releases the inflammatory mediators (1).
 At the time of inflammation, TH2 cells stimulates the
B cells to differentiate into IgE to produce the plasma
cells (6).
 The inflammatory cells migrate and then proliferate
(1).
 Fibroblast activate causing airway remodeling.
Asthma
Clinical manifestation- Bronchospasm, chest
tightness, hyperinflation of the lungs, wheezing,
non-productive cough, edema of the bronchial
mucosa.
Diagnosis- Spirometry test, physical examination,
allergy testing, inhalation challenge test, pulmonary
function testing (1).
Treatment- Corticosteroids,
bronchodilators, Anticholinergic,
Air humidifiers (1).
Prevention- To avoid the asthma
triggers like maintaining the
optical humidity,
decontamination of the decor,
prevention of the mold spores,
reducing pet dander, use of
inhalers.
Prognosis-
 Symptoms usually resolve after the removal of the
triggering agent (2).
 Permanent lung function impairment can be caused
and is a risk among the smokers.
 Patients having previous admissions to intensive
care units and those having brittle asthma have high
risk of death due to lung diseases (4).
Progression of the disease
 Decline in the airway function
 Bronchoconstriction, airway hyper-responsiveness
 Thickened basement membrane, epithelial desquamation in the airways, thickening of the basement
membrane (4)

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References
1. Subbarao, P., Mandhane, P. J., & Sears, M. R. (2009). Asthma: epidemiology, etiology and risk factors.
CMAJ : Canadian Medical Association Journal, 181(9), E181–E190. http://doi.org/10.1503/cmaj.080612
2. Lange, P., Çolak, Y., Ingebrigtsen, T. S., Vestbo, J., & Marott, J. L. (2016). Long-term prognosis of
asthma, chronic obstructive pulmonary disease, and asthma-chronic obstructive pulmonary disease
overlap in the Copenhagen City Heart study: a prospective population-based analysis. The Lancet
Respiratory Medicine, 4(6), 454-462.
3. Lange, P., Çolak, Y., Ingebrigtsen, T. S., Vestbo, J., & Marott, J. L. (2016). Long-term prognosis of
asthma, chronic obstructive pulmonary disease, and asthma-chronic obstructive pulmonary disease
overlap in the Copenhagen City Heart study: a prospective population-based analysis. The Lancet
Respiratory Medicine, 4(6), 454-462. https://doi.org/10.1016/S2213-2600(16)00098-9
4. Tuomisto, L. E., Ilmarinen, P., & Kankaanranta, H. (2015). Prognosis of new-onset asthma diagnosed at
adult age. Respiratory medicine, 109(8), 944-954. https://doi.org/10.1016/j.rmed.2015.05.001
5. Beasley, R., Semprini, A., & Mitchell, E. A. (2015). Risk factors for asthma: is prevention possible?. The
Lancet, 386(9998), 1075-1085. https://doi.org/10.1016/S0140-6736(15)00156-7
6. Holgate, S. T. (2012). Innate and adaptive immune responses in asthma. Nature medicine, 18(5), 673.
https://www.nature.com/articles/nm.2731

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