Asthma is a chronic inflammatory disease of the airways, that causes hyperresponsiveness, increased mucus production and mucosal oedema.
What this means is that Asthma is a long-term condition where the body has an extreme allergic reaction to environmental factors such as dust, pollen or animal dander. When triggered, this reaction causes inflammation in the airways which in turn causes excessive mucus production and swelling of the airways.
The condition is characterised by an ongoing disease pathway that alternates between periods of mild symptoms which are barely noticeable, and periods where these symptoms flare up and cause an Exacerbation. Depending on the individual, these exacerbations can either cause mild dyspnoea making it uncomfortable to breathe or they can cause severe life-threatening symptoms known as Status Asmathicus.
In these notes, we’ll be going over the Asthma Exacerbation Nursing Care, but before we get into that, make sure that you’ve understood the:
What causes an Asthma Exacerbation?
Asthma Exacerbations are usually triggered by outside factors, with the most common being Viral Respiratory Infections such as the human rhinovirus, influenza and coronavirus. These infections trigger hyper-responsiveness which in turn causes the airways to become severely inflamed leading to an exacerbation. Bacterial Infections can also cause an exacerbation because they damage the mucociliary clearance and increase the production of mucus in the lungs. Altogether this can lead to an inflammation of the lower airways and trigger an exacerbation.
Other factors that can cause an Asthma Exacerbation include Environmental allergens (mould, dust, animal dander) and Air Pollutants (tobacco smoke, occupational dust, exhaust and dirt particles in the air).
What is Status Asmathicus?
Status Asmathicus has become a relatively old term, however, it is sometimes used to describe severe Asthma Exacerbations that do not respond to conventional therapy. The exacerbation would occur without any warning signs and it escalates rapidly. At its worst points, Status Asmathicus could lead to Respiratory Arrest (breathing stops completely) or Respiratory Failure (ventilation would not keep up with the body’s requirements).
Unlike exacerbations, Status Asmathicus could also be triggered by an allergic reaction to medication and inhaler abuse.
Can Asthma Exacerbations be prevented?
In itself, Asthma is a chronic illness and it can not be prevented, but it can be well controlled and Asthma Exacerbations can be prevented. To prevent flare-ups, the patient’s care has to rest on four main pillars:
Patient education and knowledge about Asthma
Regular monitoring of symptoms and lung function
Adjustment of pharmacologic therapy when necessary
Knowing and avoiding the triggering factors
What are the signs and symptoms of an Asthma Exacerbation?
At the early stages, both an exacerbation and status asmathicus would start with similar symptoms, these include:
Laboured breathing
Prolonged exhalation
Distended neck veins
Wheezing
As it continues to worsen and shift into status asmathicus, the patient might notice that the wheezing has stopped entirely. One should not assume that the absence of wheezing means that the patient is improving because it could be an indication of impending respiratory failure. Hypoxemia will likely emerge because the Ventilation-Perfusion Ratio becomes imbalanced and you will also notice abnormalities in the ABG results.
At first, both the PaO2 and PaCO2 would decrease and the pH would be elevated, leading to Respiratory Alkalosis. As the patient’s condition continues to be aggravated, the PaCO2 will start to increase and the pH level decreases, leading to Respiratory Acidosis. If you don’t understand ABGs yet I suggest you hop on ever here, for a quick explanation.
Now that we’ve understood what an Asthma Exacerbation is, we can move on to understand the nurse’s role and how to manage these patients.
Asthma Exacerbation Nursing Care
Asthma Exacerbation Nursing Assessment: Health History
Performing a thorough assessment is crucial to optimising your care, but during an exacerbation, the patient might find it very difficult to talk and you might have very little time before their condition becomes worse. Always assess the severity of the situation and prioritise your care accordingly. Keeping the questions short and direct or using yes/no ended questions can help you obtain a detailed assessment more quickly.
Start by introducing yourself to the patient, and find a private area to initiate the assessment. Once the patient is comfortable, ask about their Exposure to Risk Factors. Specific questions about the type, intensity and duration of exposure will give you a clear indication of what triggered the exacerbation. You might want to ask:
Whether the patient smokes or is around second-hand smoke
If they came across high pollen areas, mould, animal dander, air pollution or occupational dust
If they’ve recently had any symptoms of respiratory infection?
You should also ask questions to evaluate how controlled the patient’s condition usually is. Check if their symptoms have been:
Disturbing their sleeping patterns
Affecting their daily activities, work or sports
Needing quick-relief medication, or if they’ve used it more frequently than usual
Driving them to seek medical attention at the ED or GP
Next up, you should ask your patient about their past medical history specifically about any previous hospitalisation, respiratory conditions, including allergies, sinus infections or nasal polyps. This should also include their closest family relatives, so note down the patient’s family history concerning respiratory illnesses.
Lastly, you should ask questions to understand the patient’s knowledge and current management about the condition as well as their social and familial support system.
Once you’ve obtained a thorough medical history, you can move on to the physical assessment to get a better understanding of the patient’s physiological status.
Asthma Exacerbation Nursing Assessment: Physical Assessment
Before starting, take a quick look at your patient’s position, both when sitting and standing. During an exacerbation, they might rest their hands onto their knees to support their breathing. Then, you can take their hands and check:
Pulse
Oxygen Saturation
Blood pressure
Pulsus Paradoxus
Central Cyanosis
Record everything onto the patient’s file and move on to assessing their Respirations:
Are their respirations forced?
Can the patient finish off a sentence in one breath?
Are they contracting their abdominal muscles, or using their shoulders during inhalation?
Is the expiration time prolonged?
Can you note any unusual breath sounds? (Wheezing/ Crackles)
Some patients will present with a Cough, if you note that it’s productive you should also assess their Sputum in terms of colour, amount and consistency.
Along with the physical assessment, there’s a series of tests that the patient will be asked to perform. These tests will determine the severity of the disease and guide the medical team when selecting the treatment.
Asthma Exacerbation Nursing Assessment: Medical Tests
Pulmonary Function studies will confirm the diagnosis, its severity and monitor the disease progression.
Spirometry evaluates the level of airflow obstruction and the reversibility of obstruction after the use of bronchodilators.
Arterial Blood Gases check the baseline oxygenation and gas exchange. Respiratory alkalosis (low PaCo2) is the most common early finding in patients with ongoing asthma exacerbation because of hyperventilation
Chest X-ray will exclude any alternative diagnoses.
Sputum or blood test could indicate elevated levels of Eosinophils
Serum Blood test will check for elevated levels of IgE antibodies.
Asthma Exacerbation Nursing Diagnosis
From your assessment, you might find the following nursing diagnosis:
Ineffective Respirations
Ineffective Airway Clearance
Inadequate nutrition
Activity intolerance
Anxiety
Deficient knowledge
Asthma Exacerbation Nursing Care Plans
1. Managing Ineffective Respirations
During an Asthma Exacerbation, the airways swell up and spasm narrowing the lumen and more often than not they will be plugged by mucus and secretions. This results in dyspnoea, rapid shallow breathing and a feeling of suffocation.
Instruct your patient to sit in an elevated position, either on the chair or by elevating the bed and have the chin parallel to the floor or tilted slightly upwards to obtain an open airway. Once the position is set, encourage your patient to breathe using the pursed-lip technique. This technique makes it easier to breathe during an exacerbation and gives a sense of control to your patient.
Next up, you should administer the prescribed medication. Typically the medications selected to treat an Asthma Exacerbation would include:
Short-Acting Beta-2 Adrenergic Agonists (SABA)
Anticholinergics
Corticosteroids
Oxygen Therapy might be necessary if the patient’s oxygen saturations decrease, and Antibiotics are prescribed if the exacerbation was triggered by a respiratory infection.
If the patient’s condition does not improve after receiving treatment, or if their condition becomes increasingly worse (Status Asmathicus), they might require intubation and mechanical ventilation. In such cases, make sure that you have the necessary equipment for emergency intubation nearby.
2. Managing Ineffective Airway Clearance
In continuation with the previous point, ineffective respirations could be a result of ineffective airway clearance. This means that the patient has a build-up of secretion and mucus blocking the airways.
Teach your patient how to cough up secretions effectively and how to perform deep breathing exercises to maximise ventilation. You should also ensure that they’re adequately hydrated, as fluids make secretions less viscous and easier to be expectorated. If your patient is too frail to consume fluids orally or is severely dehydrated, they might need extra supplementation through an IV route.
Chest physiotherapy can be very useful to loosen up secretions and prevent aspirations, but if you notice that your patient does not have the strength to cough up secretions you should consider using a Suction Set and remove them manually.
Along with the previously mentioned medications, patients with ineffective airway clearance might also be prescribed Mucolytic Agents to decrease the viscosity of secretions.
3. Managing Inadequate Nutrition
During an Asthma Exacerbation, most patients will have severe dyspnoea which can interfere with their eating habits. The shortness of breath can make a task as simple as eating seem stressful and tiring, so patients would eat smaller portions or avoid eating altogether. Moreover, secretions make it difficult for patients to swallow the food.
Ensure that the patient gets a rest period before and after eating, position them upright and maintain a clear airway. Provide high-calorie meals or meal replacements such as shakes that come in small volumes, and encourage the patient to drink sports drinks that have additional electrolytes. You should also provide the patient with nasal prongs to supplement oxygen while they’re eating.
If these steps are not enough, the patient might need additional support such as intravenous fluids and enteral feeding.
4. Managing Activity Intolerance
The effects of an asthma exacerbation can linger for days, and very often dyspnoea would interfere with the patient’s activities of daily living and their social life.
Assess the patient’s needs and figure out what their concerns are, and then find coping mechanisms that work for that patient. Teach the patient to plan their activities, so they can schedule a rest period before and after each activity. Explain that they can use energy-conserving techniques.
Teach your patients breathing exercises and low impact physical exercises to rebuild their stamina and regain independence. In some hospitals, you could also refer the patient to a pulmonary rehab specialist so they can learn to cope with their condition over time.
5. Managing Anxiety
Many patients who have experienced an Asthma Exacerbation say that it felt as if they were suffocating and that they were scared they might die. Such an experience will increase stress and anxiety levels, and unfortunately, most patients would be too scared to open up about these feelings. Often because they do not want to seem childish or they don’t want to burden others with their worries.
As their nurse, you should create a safe space where your patient can voice their feelings and express their concerns. Explain the situation to the patient, what symptoms they have and how you’re treating them. Give them an expected timeline of when they can start to feel relief from the symptoms and how they are progressing. Use deep breathing exercised and the pursed-lip technique to regain control of their breathing, as well as distraction techniques to shift their focus onto other things.
6. Managing Knowledge Deficiency
In some cases, exacerbations can be avoided but it’s almost impossible to avoid them if the patient doesn’t understand the disease in the first place.
Once all the urgent diagnoses have been dealt with, you should take time to sit down with your patient and talk about Asthma. Start by asking the patient and their relatives what they know about the condition, its triggers and how to avoid them.
Highlight the connection between viral infections and worsening of asthma, as well as the environmental allergens. Especially how the common cold and other respiratory infections affect an individual with asthma more severely. In fact, it is recommended that asthma patients take yearly influenza and COVID vaccine to avoid exacerbations.
Lastly, ask about their treatment adherence and explain why it is important. Teach the patient how to effectively take the inhalers, and the proper mouth care required after administration. If you identify any challenges that stop the patient from adhering to the treatment you should discuss ways to overcome them and also inform the medical team.
Asthma Exacerbation Nursing Discharge
After having gone through all the diagnoses and management, you will need to re-evaluate the situation and see if there’s been any improvement or deterioration in your patient. If you don’t notice any improvement, or you notice that your patient’s overall condition is worsening you will need to contact the medical team and alter the treatment plan accordingly.
But if your patient improves you can plan their discharge to ensure that they regain independence and avoid future exacerbations.
References
Castillo, J. R., Peters, S. P., & Busse, W. W. (2017). Asthma Exacerbations: Pathogenesis, Prevention, and Treatment. The journal of allergy and clinical immunology. In practice, 5(4), 918–927. https://doi.org/10.1016/j.jaip.2017.05.001
Nguyen JD, Duong H. Pursed-lip Breathing. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545289
Bruton, A., Lee, A., Yardley, L., Raftery, J., Arden-Close, E., Kirby, S., Zhu, S., Thiruvothiyur, M., Webley, F., Taylor, L., Gibson, D., Yao, G., Stafford-Watson, M., Versnel, J., Moore, M., George, S., Little, P., Djukanovic, R., Price, D., Pavord, I. D., … Thomas, M. (2018). Physiotherapy breathing retraining for asthma: a randomised controlled trial. The Lancet. Respiratory medicine, 6(1), 19–28. https://doi.org/10.1016/S2213-2600(17)30474-5
Hodder, R., Lougheed, M. D., FitzGerald, J. M., Rowe, B. H., Kaplan, A. G., & McIvor, R. A. (2010). Management of acute asthma in adults in the emergency department: assisted ventilation. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 182(3), 265–272. https://doi.org/10.1503/cmaj.080073