BRONCHIAL ASTHMA

Medical-Surgical Nursing | Adult Health Nursing

UNITY MEDICAL ACADEMY

1. Definition

Bronchial asthma is a chronic inflammatory disease of the airways characterized by variable respiratory symptoms and variable expiratory airflow limitation.

Asthma involves airway inflammation, bronchial hyperresponsiveness, bronchoconstriction, mucosal edema and increased mucus production. These changes cause narrowing of the airways and difficulty in expiration.

NORCET High-Yield:
Asthma is primarily characterized by reversible or variable airway obstruction associated with airway inflammation and bronchial hyperresponsiveness.

2. Pathophysiology

Exposure to a trigger stimulates airway inflammatory cells.
Inflammatory mediators are released.
Bronchial smooth muscle contracts.
Mucosal edema develops.
Mucus secretion increases.
Airway lumen becomes narrowed.
Airflow resistance increases, especially during expiration.
Air trapping and hyperinflation may occur.
Ventilation-perfusion mismatch can produce hypoxemia during severe attacks.

Pathophysiology Flow:

Trigger → Airway Inflammation → Bronchial Hyperresponsiveness → Bronchoconstriction + Edema + Mucus → Airway Narrowing → Increased Airway Resistance → Wheezing/Dyspnea/Cough

3. Common Triggers

Category	Examples
Allergens	House dust mites, pollen, molds, animal dander, cockroach allergens
Respiratory infections	Viral upper respiratory tract infections
Environmental irritants	Smoke, air pollution, strong odors, perfumes, chemical fumes
Drugs	Aspirin/NSAIDs in susceptible individuals, beta-blockers in susceptible patients
Exercise	Exercise-induced bronchoconstriction
Occupational exposure	Dusts, chemicals, flour, latex and other workplace sensitizers
Emotional factors	Strong emotions, stress and laughter may trigger symptoms in some patients
Weather	Cold air and sudden environmental changes

4. Risk Factors

Personal or family history of asthma or allergic disease
Atopy and allergic rhinitis
Occupational exposure to sensitizers
Air pollution
Tobacco smoke exposure
Respiratory infections
Obesity
Genetic susceptibility
Exposure to indoor allergens

5. Clinical Manifestations

Recurrent episodes of wheezing
Shortness of breath
Chest tightness
Cough, often worse at night or early morning
Prolonged expiration
Difficulty speaking during severe attacks
Use of accessory muscles in severe respiratory distress
Tachypnea
Tachycardia
Reduced peak expiratory flow

Clinical clue:
Wheezing is commonly heard during an asthma exacerbation because narrowed airways produce turbulent airflow. In a very severe attack, however, wheezing may become minimal or absent because airflow is extremely reduced.

6. Diagnosis and Assessment

A. History

Pattern and duration of symptoms
Night-time or early morning symptoms
Known triggers
Occupational exposure
Previous exacerbations
Previous hospitalization or ICU admission
Medication history
Smoking and environmental exposure

B. Pulmonary Function Testing

Spirometry is an important objective test for demonstrating variable expiratory airflow limitation.

Common parameters include:

FEV₁: Forced Expiratory Volume in the first second
FVC: Forced Vital Capacity
FEV₁/FVC ratio: Useful for identifying obstructive airflow limitation
Peak Expiratory Flow (PEF): Useful for monitoring variability and response in appropriate patients

C. Bronchodilator Response

Improvement in airflow after administration of a bronchodilator can support the diagnosis of asthma in an appropriate clinical context.

D. Other Investigations

Pulse oximetry
Arterial blood gas in severe or life-threatening exacerbations
Chest X-ray when another diagnosis or complication is suspected
Allergy testing when clinically indicated
Eosinophil assessment and other biomarkers in selected patients

7. Peak Expiratory Flow Monitoring

Peak expiratory flow monitoring can help selected patients identify changes in airflow and recognize worsening asthma.

Important: The patient's personal best PEF is used as the reference for an individualized asthma action plan. Zones and thresholds should follow the plan provided by the healthcare professional.

8. Management of Bronchial Asthma

A. Goals of Treatment

Control current symptoms
Prevent exacerbations
Maintain normal or near-normal activity
Maintain lung function as much as possible
Minimize treatment-related adverse effects
Reduce risk of future exacerbations

B. Non-Pharmacological Management

Identify and reduce exposure to individual triggers.
Stop tobacco smoking and avoid second-hand smoke.
Maintain appropriate physical activity.
Maintain a healthy body weight when appropriate.
Follow the individualized asthma action plan.
Learn correct inhaler technique.
Keep rescue medication available as prescribed.
Attend regular follow-up.

9. Pharmacological Management

Drug/Group	Main Role	Nursing Consideration
Inhaled corticosteroids (ICS)	Reduce airway inflammation; important controller therapy	Teach correct inhaler use; rinse mouth after use to reduce local adverse effects
Short-acting beta₂ agonists (SABA)	Rapid relief of bronchoconstriction	Monitor response, tremor and tachycardia; frequent need may indicate poor control
ICS-formoterol	Can be used as both reliever and controller in appropriate asthma treatment strategies	Use exactly according to the prescribed regimen/action plan
Long-acting beta₂ agonists (LABA)	Longer bronchodilation	In asthma, LABA should generally be used with an ICS rather than as LABA monotherapy
Leukotriene receptor antagonists	Reduce leukotriene-mediated airway effects	Useful in selected patients; monitor adherence and adverse effects
Systemic corticosteroids	Used in moderate/severe exacerbations when indicated	Monitor glucose, infection risk and other systemic adverse effects
Ipratropium	Anticholinergic bronchodilator; may be added in severe acute exacerbations	Monitor response and anticholinergic effects

Exam Point:
SABA provides rapid bronchodilation and symptom relief, but frequent reliance on a reliever indicates the need for reassessment of asthma control and treatment.

10. Acute Asthma Exacerbation

An acute exacerbation is a worsening of asthma symptoms and lung function compared with the patient's usual status.

Assessment

Respiratory rate
Heart rate
Oxygen saturation
Ability to speak
Level of consciousness
Work of breathing
Accessory muscle use
Wheezing or markedly reduced breath sounds
PEF when feasible

General Acute Management Principles

Assess severity immediately.
Provide oxygen when indicated to correct hypoxemia.
Administer rapid-acting bronchodilator therapy as prescribed.
Add inhaled anticholinergic therapy in appropriate severe exacerbations.
Administer systemic corticosteroids when indicated.
Monitor response continuously.
Identify and treat precipitating factors.
Escalate care if the patient deteriorates or fails to respond.

Life-Threatening Warning Signs

Severe breathlessness
Inability to speak normally because of dyspnea
Altered level of consciousness
Exhaustion
Cyanosis
Very poor or absent air entry
Severe hypoxemia
Worsening respiratory failure

11. Silent Chest

Silent chest is an emergency sign.
In severe asthma, wheezing may disappear because airflow becomes critically reduced. Absence of wheezing does NOT necessarily mean improvement.

12. Status Asthmaticus

Status asthmaticus refers to a severe, persistent asthma exacerbation that does not respond adequately to initial standard treatment and may progress to respiratory failure.

Nursing Priorities

Maintain airway and assess breathing continuously.
Administer prescribed emergency medications promptly.
Monitor SpO₂ and other vital signs.
Prepare for escalation of respiratory support if required.
Maintain IV access when indicated.
Monitor ABG and other investigations as ordered.
Provide calm reassurance while avoiding unnecessary delay in treatment.
Prepare for ICU transfer if deterioration occurs.

13. Nursing Management

Assessment

Assess respiratory pattern and effort.
Monitor respiratory rate and oxygen saturation.
Assess breath sounds.
Assess cough and sputum.
Assess ability to speak.
Identify possible triggers.
Assess anxiety and activity tolerance.
Monitor medication adherence and inhaler technique.

Nursing Interventions

Place the patient in a comfortable upright position, commonly High Fowler's.
Maintain a patent airway.
Administer oxygen as prescribed when indicated.
Administer prescribed bronchodilators and anti-inflammatory medications.
Monitor response to treatment.
Encourage effective breathing techniques when appropriate.
Reduce exposure to known triggers.
Maintain adequate hydration when clinically appropriate.
Provide psychological support.
Educate the patient about medication adherence and inhaler technique.

14. Patient Education

Understand personal asthma triggers.
Use controller medication regularly as prescribed.
Know the difference between controller and reliever medicines.
Demonstrate correct inhaler technique.
Use a spacer when prescribed/recommended for a metered-dose inhaler.
Follow the written asthma action plan.
Recognize early warning symptoms.
Seek urgent medical care for severe symptoms.
Avoid cigarette smoke and known environmental triggers.
Do not stop prescribed controller therapy without professional advice.

15. Inhaler Technique — Key Steps

Check the inhaler and remove the cap.
Shake the inhaler if the device requires it.
Exhale gently before inhalation.
Place the mouthpiece correctly.
Begin inhaling as directed while activating the inhaler for a pressurized metered-dose inhaler.
Continue a slow, deep inhalation.
Hold the breath briefly if appropriate.
Exhale slowly.
Wait the prescribed interval before a second puff if required.
Rinse the mouth after inhaled corticosteroid use.

Nursing Education Point:
Always assess the patient's inhaler technique by asking the patient to demonstrate it. Merely asking, "Do you know how to use your inhaler?" may miss technique errors.

16. Complications

Severe hypoxemia
Respiratory failure
Status asthmaticus
Air trapping and hyperinflation
Pneumothorax or pneumomediastinum, rarely
Fatigue and exhaustion
Reduced quality of life
Medication-related adverse effects

17. Asthma vs COPD — Quick Comparison

Feature	Asthma	COPD
Typical pattern	Variable symptoms and airflow limitation	Persistent respiratory symptoms and airflow limitation
Airflow limitation	Often variable/reversible	Usually persistent
Common association	Atopy/allergy may be present	Strong association with smoking and other exposures
Symptoms	Often episodic	Often chronic/progressive

18. NORCET High-Yield Points

1 Asthma is a chronic inflammatory airway disorder. 2 Airway obstruction is variable and may improve with treatment. 3 Wheezing is common during exacerbation. 4 A silent chest can indicate extremely severe airflow limitation. 5 Prolonged expiration is common because expiration is difficult. 6 Inhaled corticosteroids are important anti-inflammatory controller medicines. 7 SABA provides rapid bronchodilation. 8 Frequent reliever use requires reassessment of asthma control. 9 Correct inhaler technique is an essential part of asthma management. 10 Severe asthma can progress to respiratory failure.