Chronic

• Asthma


  Potentially reversible, chronic disorder
• Asthma patho 


  • Airway inflammation triggered by irritants or allergens
  • Inflammation causes bronchial hyperresponsiveness—extra sensitive to triggers
  • Bronchial constriction, edema, thickening of the bronchial walls, and mucus plug production
  • Obstructive due to airway narrowing and mucus plugs
• Causes of asthma


  Unknown, but innate immunity, genetics, and environment are all factors
• Asthma triggers


  • Irritants
  • Pollution
  • Cigarette smoke
  • Allergic reactions
  • Stress
  • Seasonal
  • Infection
• Asthma exacerbations


  • Acute flare-up of symptoms
  • Triggers begin the inflammatory response
  • Begins about 30-60 minutes after exposure
  • Airways narrow and mucus plugs develop
  • Resolves in about 30-90 minutes
• Asthma complications


  • Status asthmaticus—severe persistent bronchospasm
  • Can lead to right-sided heart failure, pneumothorax, worsening hypoxemia, acidosis, and respiratory or cardiac arrest
  • Airway remodeling—hypertrophy of bronchial smooth muscle, thickening of the tissues in the airways, hypertrophy of mucus glands, air trapping in the alveoli, and hyperinflation of the lungs
• Mechanism of asthma symptoms


  • Muscle spasm
  • Edema of mucous membranes
  • Thick secretions
• Asthma manifestations


  • SOB with use of accessory muscles
  • Expiratory wheeze
  • Thick sputum
  • Anxiety
  • Tachycardia
  • Cough
• Asthma diagnosis


  • Physical exam
  • History
  • ABG
  • CXR
  • Pulse ox
  • Peak flow
  • PFT
• Asthma acute treatment


  • HOB
  • Low flow O2 for hypoxia
  • Anti-inflammatories (Steroids, Mast cell stabilizers, Leukotriene inhibitors)
  • Bronchodilators (routine and before exertion)
  • Calm caregiver
  • Increase fluid intake
  • Smoking cessation
  • Breathing and coughing techniques
  • Peak flow meters
• Bronchodilators


  Relax airways, relax smooth muscle
• Bronchodilator types


  • Adrenergics (Alupent and Albuterol)
  • Anticholinergics (Atrovent)
• Theophylline


  Has a small therapeutic range of 5-15 mcg/mL
• Bronchodilator side effects


  • Tachycardia
  • Nausea/Vomiting
  • Anxiety
  • Tremors/Nervousness
  • Need to decrease xanthine containing foods
  • Nicotine
  • Aminophylline blood levels
  • Overuse = Overdose and toxicity
• Asthma teaching


  • For chronic illness
  • Teach how to prevent respiratory infection
  • Discourage smoking
  • Avoid irritants
  • Pursed lip and abdominal breathing
  • Complications: STATUS ASTHMATICUS
• Inhaler use


  • Always use bronchodilator first
  • Adrenergic inhalers first
  • 1 min between puffs of same inhaler
  • 5 min between puffs of 2 different medications
  • Rinse mouth after steroids
  • Clean equipment
• COPD


  Progressive, irreversible airflow obstruction
• COPD


  • Chronic bronchitis, emphysema, or both
  • May also have asthma
• COPD


  • Progressive disease
  • Affects EXPIRATORY FLOW to cause air trapping
  • Hypercapnia, Hypoxia
  • #1 symptom of early disease is cough
  • No cure, treatment is aimed at controlling the symptoms only
  • Increases risk of pulmonary infection
  • Increases risk of cor pulmonale
• COPD pathophysiology


  • Begins with chronic inflammation of the bronchioles, alveoli, and pulmonary blood vessels
  • Structural changes occur in the lungs
  • Normal defense mechanism and repair processes are disrupted
• Chronic bronchitis


  Symptoms last for at least 3 months/year for 2 consecutive years
• Emphysema


  Chronic alveolar distension resulting in overinflated lungs
• Emphysema etiology


  • Chronic alveolar irritation
  • Enzyme alteration (alpha antitrypsin deficiency)
  • Alveolar walls and or bronchiole walls destroyed
• Emphysema


  • Air trapping
  • Loss of recoil
  • Weak expiration
• Cor pulmonale


  • Damage to heart as a result of lung disease (late stage)
  • Increased pulmonary pressures cause damage to right side of heart
  • Results in Right sided failure
• Cor pulmonale signs


  • Distended neck veins
  • Enlarged liver
  • Edema
  • Indigestion
• Why would patients with COPD develop right sided heart failure before left sided?

  Increased pulmonary pressures cause damage to right side of heart
• COPD complications


  • Cor pulmonale
  • Respiratory failure
  • Infection
  • Pollution
  • Smoking
  • Cardiac disease
  • PE
  • Spontaneous pneumothorax
  • Adverse drug effects
• COPD early signs and symptoms


  • Chronic cough
  • DOE progressing to dyspnea at rest
  • Chest heaviness
• COPD late signs and symptoms


  • Intercostal and accessory muscle use
  • Weight loss
  • Fatigue
  • Polycythemia
  • Signs of cor pulmonale (if that develops)
  • Depression and irritability
• Chronic bronchitis symptoms


  • Productive cough
  • Exertional dyspnea
  • Wheezing
• Emphysema symptoms


  • Main symptom is DOE
  • Can progress to dyspnea at rest
  • Patients are thin
  • Use accessory muscles
  • Barrel chest
• COPD diagnosis


  • PFTs
  • Oximetry
  • Chest x ray
  • 6 minute walk
• 6 minute walk


  • Measures how far a patient can walk in 6 minutes
  • Also measures pulse oximetry
• COPD treatment


  • No cure!
  • Symptom relief, slow progression, prevent/treat complications, improve overall health
  • Smoking cessation is key
  • Flu, pneumonia, Covid vaccines
  • Drug therapy
  • Pulmonary rehab: progressive exercise to maximize health
  • Supplemental oxygen
• COPD drug therapy


  • Bronchodilators
  • Inhaled corticosteroids
  • May use IV or PO steroids for acute exacerbations only
  • Antidepressants
  • Oxygen therapy if needed
• COPD oxygen therapy


  • Low flow
  • Verify pulse ox readings with ABGs
  • High levels not used b/c patients with COPD may rely on hypoxic drive not CO2 retention to breath. Too much oxygen can then decrease their drive to breathe.
• COPD supportive care


  • Breathing exercises
  • Nutrition (small frequent meals, high calorie, high protein)
  • Good oral hygiene
  • Low carb, hi fat
  • Loosen and liquefy secretions
  • Postural drainage
  • Hydration (2000-3000 cc)
  • Humidifier
• Pursed lip breathing


  • In thru nose out thru mouth
  • Expiration should be TWICE as long as inspiration
  • Keeps alveoli open
  • Empty lungs more completely by slowing expiration
  • Improves muscle tone
• Abdominal breathing


  • Expand abdomen with inhalation
  • Contract abdomen with exhalation
  • Make exhalation 2x longer than inspiration
  • More efficient use of respiratory muscles