 Welcome to Nursing School Explained. Today we'll talk about asthma. Asthma is a condition that can affect children and adults, but most likely in children, symptoms are going to be more severe given their differences in anatomy to the adult population, and we'll get into those differences a little bit deeper here in a moment. So let's look at the path of physiology first. So asthma, they're a genetic and environmental factors that cause problems. Now asthma is hereditary, and then it's also highly dependent on the environment that the patient lives in and grows up in. And what it does, it causes inflammation of the airways or lungs, which leads to increased airway responsiveness, meaning that the airways are kind of more excitable or at risk for going into bronchospasm. And that inflammation and edema causes secretions to accumulate. So let's look at this. This is the diameter of an airway. So normally we have the lining of the bronchial smooth muscle, and then we have the smooth muscle cells in here. And usually the airway diameter is a certain width. Now when we have inflammation of these airways and the airway responsiveness, that means that there is less of a distance or of a lumen that's open here in the middle, because this inflammation causes the airway to swell. The bronchospasm occurs, which means that the bronchioles are now even more constricting, and this inflammation causes edema and swelling, like I already discussed, meaning now the lumen, the inside of the airway is much more constricted causing symptoms. Okay, so we'll talk about how this is typically treated and how the different asthma severities are treated depending on how bad this inflammation gets. Now we talked about genetic and environmental factors that have been very important here, and triggers for asthma can be exercised. You've probably heard of exercise to induce asthma. That's typically in children, so they know that they're going to have a soccer game, for example, or they're going to be running around on the playground, and they're just going to be proactive and then take a puff of the albuterol inhaler in order to prevent any exercise-induced asthma. Now other triggers can be cold air, smoke, so when the parents are smoking or anybody in the house is smoking, that can be very bad for children with asthma, and then upper respiratory infections. Those are the most common trigger for hospitalizations in children especially, but also in the adult population. Stress can lead to asthma exacerbations, allergens, and allergens is a big one. So typically if a patient has asthma, they might also have what's called the trifecta. So it's asthma, allergies, and eczema. So these are the ectopic conditions that a lot of times people have all three of those. So if you have somebody with eczema and allergies, you might want to think maybe they have asthma as well or vice versa. Odors can trigger asthma attacks as well as environmental pollutants. And environmental pollutants, unfortunately, that is highly effective in children or affects children of lower socioeconomic status because they tend to live in areas where there's more factories, where the air quality is not that good, that might be lead in the walls, or there might be other pollutants in the house that might be making their asthma worse. And for allergens, so that can be seasonal allergies, such as pollen, especially in the springtime when everything starts to bloom. Typically these patients with asthma will have more severe symptoms in the springtime. It can also be allergies to pet dandruff, for example, or dust mites and any of those very small things that we don't typically think about. Now signs and symptoms of asthma. So it can be a dry cough and then wheezing. And I put an asterisk here and an exclamation mark because wheezing is the telltale sign of asthma. And depending on the severity of this airway inflammation and narrowing is the severity of the wheezing that we're here. Now I'll get right into this silent chest here. Again, I underlined this with exclamation marks. So if we really think about it, the more inflammation happens here, which means the more constricted the airway becomes, the less air travels through and the more quiet the wheezing or the chest sounds will be. So if somebody comes in with asthma and they have some pretty significant audible wheezing that you don't even need a stethoscope to hear and all of a sudden that audible wheezing stops, maybe even without any treatment given, that's a sign that now the sedema has got worse. So there's more constriction and now they're not moving any air at all. So silent chest and patients with asthma is a really, really bad sign. Don't mistake that for diminished lung sounds because it could be a silent chest and that means the airways are close to being closed altogether and then the patient is basically at risk for respiratory failure. So wheezing and silent chest. Now a lot of times because the airways are so constricted that bronchospasm is occurring, the patient will be complaining of chest pain or tightness. That's a very common complaint as well. Of course, they'll be short of breath depending on the severity of their asthma attack and exacerbation. They might complain of restlessness or they might be apprehensive and anxious. Of course, they're going to increase their respiratory rate because they're trying to move more air in because of this airway edema and then orthopnea, so shortness of breath with exertion. And then in children, they already have smaller airways because of their anatomy and that's just an anatomical fact. As children grow, their airways will stretch out, they'll get bigger. The anatomy of the larynx, the posterior pharynx, the epiglottis will change, but small children are at higher risk for respiratory distress because of any kind of respiratory illness, and particularly asthma here as well because of all this constriction. So children already have smaller airways. Now we put inflammation on top of that and there's a higher risk that that airway will close off all together. And signs and symptoms of those in children are retractions, nasal flaring, use of accessory muscles. There might be triparting, so they might be wanting to lean forward. You might see some tracheal tugging, which basically means that you can see the trachea moving in and out that that's a severe sign of respiratory distress and probably sign of impending silent chest and that the patient is about to to have respiratory failure. Now let's see the classifications here. So you will see in your textbooks and other literature that asthma typically gets classified into four different categories. And sometimes that can be a little bit difficult to understand and I've tried to outline it here where we have the classifications and then later when we talk about medications and treatments, so hopefully it'll be somewhat easy to understand. So first of all, step one is intermittent asthma. So that means the patient intermittently has symptoms. So that might be somebody who has exercised induced asthma and now it's springtime and everything is in bloom and maybe they get a small respiratory infection, but because their airways are already hyper responsive that they now have an asthma exacerbation. But typically intermittent asthma means that they have symptoms intermittently where they don't really need anything to decrease the inflammation they might just need to use their albuterol before they exercise for example. And the different steps here are based on the patient is classified into the step category based on their symptom frequency. So are they having daily symptoms? Are they having symptoms twice a week? There are certain tables that the providers will follow. And then the use of their Saba, their short acting beta adrenergic agonist, which is basically the albuterol inhaler, the bronchodilator. Are they using it daily? Are they using it once a week, twice a week, depending on that. Also ADL interference. So is the asthma interfering with their ability to go about their life, to go to school, to go to work, to go exercise, to do all these things that we like to do. And then the number of exacerbation. So has the patient been hospitalized for asthma before? Do they get hospitalized every spring because when they catch just a regular cold their asthma really flares up and they require hospitalization as well as nighttime symptoms. So that's particularly important in children because their symptom might be coughing a dry cough and maybe some chest tightness, but that child is not able to really communicate that. And nighttime symptoms will often be reported by the parents as the child waking up with a dry cough or waking up with an episode of shortness of breath. Then they console the child, they go back to sleep and that's okay. But nighttime symptoms are also important in classifying the steps here of asthma. So we've already determined the intermittent asthma. Then step two will be mouth-persistent asthma. So that is somebody who might have symptoms of this inflammation every day, but it doesn't really interfere with their ability to go about their ADLs. They can maybe participate in sports, but they might be more prone to these exacerbations. Now step three moderate persistent. You can see every step the symptoms get a little bit more severe. So moderate persistent is somebody who might have symptoms every day and they might be needing to use their SAVA, they're all beautiful, maybe once a day or twice a day before they go outside, before they exercise, before any kind of activity. And then step four is severe persistent. So those are patients who are pretty ill and need to be managed usually by a pulmonologist where the asthma does have an influence on their ability, on their daily activities, as well as they have frequent exacerbations and they frequently have nighttime symptoms as well. For diagnostic tests, so pulmonary function tests are the gold standard for diagnosing any sort of respiratory disorder and that mostly pertains to asthma and then COPD, chronic obstructive pulmonary disease, as well as emphysema. And those are specialized tests that will tell about the patient's lung capacity, the volume that they have, and is a very specialized test. And then the peak flow meter. So peak flow meter is a very simple device that the patient will blow into as it's a forceful exhalation. It'll be kind of like if you have a child, you can kind of tell them it's like if you would blow in and an error would come out. And it measures the peak expiratory flow. So how much volume are they able to exhale? And then the peak flow meter will give them a red, yellow, or green zone. So if they're green, means the lung capacity is doing really well. If they're in the yellow zone, that means they might be, you know, on the verge of having an exacerbation. And then red zone usually means call your doctor or go to the closest emergency room because now your lungs are really constricted that edema is happening, that we need to make sure we get you seen right away and get you treated. Now everybody with asthma should have what's called an asthma action plan, which is basically a one sheet piece of paper that tells the patient here's the medications you need to be taking daily. If you have increased symptoms, so let's say now you've caught that upper respiratory infection that common cold that's going around. So now you have increased number of uses of your albuterol and maybe it interferes with your ability to go about your day. So then the patient uses the peak flow meter and it'll gauge the yellow or the red zone. And so that piece of paper that asthma action plan will tell them if you're in the green zone, take your daily medications don't make any changes. But now you're feeling maybe some chest tightness, you have some dry cough, you have some wheezing, you use your peak flow meter and now you're in the yellow zone. So that would mean that now whatever the action plan that the provider has come up with, the patient will adhere to. And the goal is really to keep the patient from going into the red zone and having a severe exacerbation that might require hospitalization. So asthma action plan is super important here and the peak flow meter is a very simple tool that helps us determine the patient's lung volume and severity of that airway responsiveness. And there are tables available and they're based on the patient's height and gender because it depends on how tall you are and if you're male or female, what the normal lung capacity should be. And so for this is mostly for for monitoring and diagnostic tests and the peak flow meter again is a very great tool to make sure that the patient doesn't get in trouble. Now management of asthma, number one is avoidance of triggers. So if you are allergic to certain allergens or some certain grasses that bloom in the spring, then you want to avoid going outside in the spring time. You want to avoid playing soccer, you want to avoid those things. If you're allergic to pets, maybe you shouldn't have a dog, you shouldn't have a cat. If your trigger is the environment or smoke and you live with somebody who smokes, maybe they should consider stopping smoking, which would probably be the best, or at least removing themselves when they smoke. So avoidance of triggers is the number one treatment because if we avoid the triggers, we might not have any of this inflammation and everything will be great. Now when the avoidance of triggers is not enough or now the patient requires treatment, it depends on there's a whole variety of different medications. So for medications, the first line treatment is always a Saba, a short-acting beta adrenergic agonist, which is also called a bronchodilator. And really the only drug we have for that is albuterol. And bronchodilator means because we have in this bronchospasm, this constriction, the albuterol will open up the airway and let the airflow go through. So very effective treatment. And then I made here an asterisk, so that's usually somebody with intermittent asthma. If they only have intermittent symptoms, they only need to take their bronchodilator intermittently. Now when that is not enough or the patient is in this mouth-persistent category, then what we need to do, second line treatment is a low-dose ICS and that's an inhaled corticosteroid. So that's another inhaler that the patient will be prescribed. And I wrote here OWN, they usually end in OWNs, any of the anti-inflammatory steroids, so keep that in mind. So the patient will take this low-dose inhaled corticosteroid and this is a daily medication. So depending again on the patient's severity, how bad their lungs are, it'll be a once or twice a day medication. And in addition, they'll still have their sabre in case they have an exacerbation or they feel short of breath or they get sick, they can use their sabre to help them with their shortness of breath. Now third line treatment would be a low-dose inhaled corticosteroid and a laba. So a laba is the same as a sabre except that it's long acting, which is what the L stands for. So it works exactly the same way in dilating the bronchioles, but it's just longer acting. So now we have a patient who has more severe symptoms and this is usually the patient with moderate persistent asthma here, the step three. So now they're going to need more treatment, they're going to need more dilation of the bronchioles that they usually get in a once a day or twice a day dose. So third line treatment, low-dose inhaled corticosteroid plus a laba and an example of a laba is salmeterol. And again, notice that this ends in O so that would also hint you that this is a bronchodilator. Now they do make combination medications of inhaled corticosteroids and labas and the reason is that it just enhances patient compliance. So it's much easier to use one inhaler once or twice a day than using two different inhalers two times a day. The patient is less likely to adhere to that medication protocol. Now if the patient has severe persistent asthma, so these are the patients that we talked about, they have frequent exacerbations, it interferes with their ability to perform their activities of daily living. So then what they'll do is they'll just go increase that inhaled corticosteroid use and that will be a medium dose. Inhaled corticosteroids are also available in a high dose. So it'll be low, medium and high dose but it'll all depend on how the patient is doing. So typically they'll start them on a low dose because we always want to start low and see how the patient's doing, reevaluate and then see if we need to go a step higher. So fourth line, medium dose, so higher dose than the slow dose here plus a laba and again this can be the combined inhaler like an adverb would be an example. Now when the patient has an exacerbation, so now they are having a lot of symptoms, they're using the pre-peak flow meter at home and they're in the red zone. So they need to go to the hospital, the treatment there will be that they may need an increased dose or frequency of the inhaled corticosteroid. So maybe they'll call their provider and say I am now having all these symptoms, I'm asthmatic and I usually take a low dose in-health corticosteroid and the laba once a day. So that plan of action might be instead of once a day, use it twice a day now. The other option is that if the regular inhaler, the meter dose inhaler doesn't work, some patients might also have a nebulizer at home which is a machine where it's kind of like what they use at the hospital that's a mask that has a reservoir for the medication and it'll be nebulized so it'll be medication that's inhaled over long longer periods of time three to five minutes or so that nebulizes the medication and it's just a little bit more of a significant treatment rather than just one puff of their amputero inhaler. Now with the exacerbation they might also need systemic corticosteroids so that will usually be done IV or PO and usually a very short course would be sufficient here and I wrote down here again dexamethasone and methylprednisolone and those will be IV or PO medications and again they end in OWN because we know the OWNs are our steroids whether it's inhaled or PO and IV. Now one very important point why do we use the steroids here because the physiology tells us that there is inflammation and when there's inflammation steroids work well to reduce the inflammation, reduce the edema, reduce the bronchospasm and open up the airway. Now we don't want the patient to continuously be using their amputero because remember it has side effects of tachycardia maybe jitteriness, anxious, those are not very comfortable symptoms plus it doesn't really help treat the underlying cause. The underlying cause is inflammation so the underlying cause needs to be if the patient has mouth persistent symptoms that inhaled corticosteroids and then again if they get worse, if they have exacerbations then it'll be IV or PO medications. So I hope this video about asthma has helped enlighten you about the different treatments and why we use certain medications for certain steps in asthma here. I'll be curious to hear your feedback about this. 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