copyright © 2006 by mosby, inc. slide 1 chapter 13 asthma figure 13-1. asthma. dmc, degranulation...

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 13Chapter 13AsthmaAsthma

Figure 13-1. Figure 13-1. Asthma.Asthma. DMC,DMC, Degranulation of mast cell; Degranulation of mast cell; SMC,SMC, smooth muscle constriction; smooth muscle constriction;MA,MA, mucus accumulation; mucus accumulation; MP,MP, mucus plug; mucus plug; HALV,HALV, hyperinflation of alveoli. hyperinflation of alveoli.


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Smooth muscle constriction of bronchial Smooth muscle constriction of bronchial airways (bronchospasm)airways (bronchospasm)

Excessive production of thick, whitish, Excessive production of thick, whitish, tenacious bronchial secretionstenacious bronchial secretions

Hyperinflation of alveoli (air-trapping)Hyperinflation of alveoli (air-trapping)

Mucus plugging and, in severe cases, Mucus plugging and, in severe cases, atelectasisatelectasis


EtiologyEtiology

Extrinsic asthmaExtrinsic asthma Allergic or atopic asthmaAllergic or atopic asthma

Intrinsic asthmaIntrinsic asthma Nonallergic or nonatopic asthmaNonallergic or nonatopic asthma


Figure 13-2. Figure 13-2. The immunologic mechanisms in asthma.The immunologic mechanisms in asthma.


Intrinsic AsthmaIntrinsic Asthma(Nonallergic or Nonatopic Asthma)(Nonallergic or Nonatopic Asthma)

InfectionsInfections

Exercise and cold airExercise and cold air

Industrial pollutants or occupational exposureIndustrial pollutants or occupational exposure

Drugs, food additives, and food preservativesDrugs, food additives, and food preservatives

Gastroesophageal refluxGastroesophageal reflux

Sleep (nocturnal asthma)Sleep (nocturnal asthma)

Emotional stressEmotional stress

Premenstrual asthmaPremenstrual asthma


Figure 13-3. Figure 13-3. Factors triggering intrinsic asthma.Factors triggering intrinsic asthma.


Additional Risk FactorsAdditional Risk Factors

Residence in a large urban area, especially Residence in a large urban area, especially the inner citythe inner city

Exposure to secondhand smokeExposure to secondhand smoke

A parent who has asthmaA parent who has asthma

Respiratory infections in childhoodRespiratory infections in childhood

Low birth weightLow birth weight

ObesityObesity


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with ASTHMAwith ASTHMA

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by BronchospasmBronchospasm (see Figure 9-10) (see Figure 9-10) and and Excessive Bronchial SecretionsExcessive Bronchial Secretions (see Figure (see Figure 9-11)—the major anatomic alterations of the lungs 9-11)—the major anatomic alterations of the lungs associated with asthma (see Figure 13-1).associated with asthma (see Figure 13-1).


Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).


Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.


Vital signsVital signs

Increased respiratory rateIncreased respiratory rate

Increased heart rate, cardiac output,Increased heart rate, cardiac output,blood pressureblood pressure

Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside


Use of accessory muscles of inspirationUse of accessory muscles of inspiration

Use of accessory muscles of expirationUse of accessory muscles of expiration

Pursed-lip breathingPursed-lip breathing

Substernal intercostal retractionsSubsternal intercostal retractions

Increased anteroposterior chest diameter Increased anteroposterior chest diameter (barrel chest)(barrel chest)

CyanosisCyanosis

Cough and sputum productionCough and sputum production



Pulsus paradoxusPulsus paradoxus

Decreased blood pressure during inspirationDecreased blood pressure during inspiration

Increased blood pressure during expirationIncreased blood pressure during expiration



Chest assessment findingsChest assessment findings

Expiratory prolongationExpiratory prolongation

Decreased tactile and vocal fremitusDecreased tactile and vocal fremitus

Hyperresonant percussionHyperresonant percussion

Diminished breath soundsDiminished breath sounds

Diminished heart soundsDiminished heart sounds

Wheezing and rhonchiWheezing and rhonchi



Figure 2-12. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.Percussion becomes more hyperresonant with alveolar hyperinflation.


Figure 2-17. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.lung diseases, breath sounds progressively diminish.


Clinical DataClinical DataObtained from Laboratory TestsObtained from Laboratory Tests

and Special Proceduresand Special Procedures


Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVC FEVFVC FEVTT FEF FEF25%-75%25%-75% FEF FEF200-1200200-1200

PEFRPEFR MVV FEFMVV FEF50% 50% FEVFEV1%1%


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VVTT RV FRC TLC RV FRC TLC

N or N or N or N or

VCVC IC ERV RV/TLC ratio IC ERV RV/TLC ratio

N or N or

N or N or


Arterial Blood GasesArterial Blood Gases

Mild to Moderate Asthma EpisodeMild to Moderate Asthma Episode

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Severe Asthmatic Episode Severe Asthmatic Episode (Status Asthmaticus)(Status Asthmaticus)

Acute ventilatory failure with hypoxemiaAcute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

(Significantly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Acute Ventilatory Failure Acute Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.


Oxygenation IndicesOxygenation Indices

QQSS/Q/QTT D DOO22 V VOO22 C(a-v) C(a-v)OO22

Normal NormalNormal Normal

OO22ER SvER SvOO2 2


Abnormal Laboratory Tests and Abnormal Laboratory Tests and ProceduresProcedures

Abnormal laboratory tests and procedures Abnormal laboratory tests and procedures Sputum examinationSputum examination

• EosinophilsEosinophils

• Charcot-Leyden crystals (see next slide)Charcot-Leyden crystals (see next slide)

• Casts of mucus from small airwaysCasts of mucus from small airways called Kirschman spiralscalled Kirschman spirals

• IgE level (elevated in extrinsic asthma)IgE level (elevated in extrinsic asthma)


Charcot-Leyden Crystals Charcot-Leyden Crystals

Needle shaped crystals -Needle shaped crystals -

Represents breakdown products of eosinophils Represents breakdown products of eosinophils


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Increased anteroposterior diameterIncreased anteroposterior diameter

Translucent (dark) lung fieldsTranslucent (dark) lung fields

Depressed or flattened diaphragmDepressed or flattened diaphragm


Figure 13-4. Figure 13-4. Chest X-ray of a 2-year-old patient during an acute asthma attack.Chest X-ray of a 2-year-old patient during an acute asthma attack.


Table 13-1. Asthma Classification Table 13-1. Asthma Classification Based on Severity—ExcerptsBased on Severity—Excerpts

DiseaseDisease Symptoms Symptoms

Step 4:Step 4: Continual symptomsContinual symptoms

Step 3:Step 3: Daily symptomsDaily symptoms

Step 2:Step 2: Symptoms > than twice weeklySymptoms > than twice weekly

Step 1:Step 1: Symptoms < than twice weeklySymptoms < than twice weekly

From McCance KL, Huether SE: From McCance KL, Huether SE: Pathophysiology: The biologic basis for disease in adults and Pathophysiology: The biologic basis for disease in adults and childrenchildren, ed 4, St. Louis, 2002, Mosby., ed 4, St. Louis, 2002, Mosby.


Table 13-2. Asthma Zone Management Table 13-2. Asthma Zone Management System—ExcerptsSystem—Excerpts

Green zoneGreen zone 80% to 100% of personal best PEFR80% to 100% of personal best PEFR

Yellow zoneYellow zone 50% to 80% of personal best PEFR50% to 80% of personal best PEFR

Red zoneRed zone <50% of personal best PEFR<50% of personal best PEFR


General Management of AsthmaGeneral Management of Asthma

Environmental controlEnvironmental control

Respiratory care treatment protocolsRespiratory care treatment protocols Oxygen therapy protocolOxygen therapy protocol

Bronchial hygiene therapy protocolBronchial hygiene therapy protocol

Aerosolized medication protocolAerosolized medication protocol

Mechanical ventilation protocolMechanical ventilation protocol

Medications commonly prescribedMedications commonly prescribed XanthinesXanthines

CorticosteroidsCorticosteroids

Anti-inflammatory agentsAnti-inflammatory agents

Leukotriene inhibitorsLeukotriene inhibitors



MonitoringMonitoring Arterial blood gas measurementsArterial blood gas measurements

Pulse oximetryPulse oximetry

Serial PFTsSerial PFTs

• PEFR PEFR

• FEVFEV11

Vital signsVital signs

Chest radiographsChest radiographs



Patient compliancePatient compliance Asthma-symptom/medication-use diariesAsthma-symptom/medication-use diaries Serum theophylline levelsSerum theophylline levels Carboxyhemoglobin determinationsCarboxyhemoglobin determinations Total (circulating) eosinophil countsTotal (circulating) eosinophil counts No-show rates at physician officesNo-show rates at physician offices Rate of medication useRate of medication use Frequency of emergency department visits and Frequency of emergency department visits and

hospitalizationshospitalizations Number of red zone days per months (see Table 13-2)Number of red zone days per months (see Table 13-2)


Classroom DiscussionClassroom DiscussionCase Study: AsthmaCase Study: Asthma

copyright © 2006 by mosby, inc. slide 1 chapter 13 asthma figure 13-1. asthma. dmc, degranulation...

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