Asthma

Posted by Brandy D. Burgess, APRN-CNS, RN-MSN on 02/12/2018

 

What is Asthma?

Asthma is a mixed chronic inflammatory disease of the respiratory tubes of the lungs that causes extreme tightening of airways, blocks airflow and abnormally increased responsiveness of the airways.

Airway inflammation, irritation or swelling contributes to

    • Increased uncontrolled asthma
    • More patients with chronic obstructive pulmonary disease (COPD)
    • Increased hospitalizations and death
    • Frequently worsening respiratory symptoms
    • Chronic disease 

Asthma is a common and potentially serious disease that can be controlled and is generally reversible but is not curable. According to the Centers for Disease Control and Prevention:

  • 1 in 13 people have asthma which is 7.6 % of adults and 8.4 % of children
  • As of 2015, 11.5 million people in United States (US)
  • More common in adult women than adult men and in African-Americans over other races and ethnicities
  • Accounts for > 14 million physician office visits and almost 2 million ED visits per year
  • Ten Americans die daily from asthma with total of 3,615 in 2015
  • Annual cost related to asthma is greater than $56 billion per year

Asthma Symptoms included but are not limited to:

  • Wheezing
  • Shortness of breath
  • Chest tightness
  • Cough that varies in occurrence, frequency and intensity or worse at night/early AM
  • Bronchoconstriction
  • Expiratory airflow limitation
  • Increased mucus

Asthma Triggers and Risk Factors included but are not limited to:

  • Viral and bacterial infections
  • Allergens
  • Change in weather
  • Car exhaust, fumes, smoke (smoking), strong smells and/or fragrances
  • Exercise
  • Laughter
  • Stress
  • Certain medications (Examples: Beta-blockers and NSAIDs)
  • Obesity
  • Gastroesophageal reflux disease (GERD)
  • Depression and/or anxiety

Diagnosing Asthmas

Diagnosing asthma is a combination of the history of patterns of symptoms, evidence of airflow limitations identified by pulmonary function testing, bronchodilator (medications that open airways) reversibility testing and response to medications prescribed.

There are multiple types of asthma which include:

  • Allergic asthma which is the type that occurs when a patient’s symptoms are set off by an allergen or allergic reaction
  • Asthma without allergies which is the type when the airways are overreactive without an allergy but may be triggered by a cold, the flu or upper respiratory viruses
  • Aspirin Exacerbated Respiratory Disease (AERD) which is the type caused by an adverse reaction to the medication aspirin
  • Exercise induced asthma which is the type triggered by physical exercise and has three phases:
    • The early phase which is the most severe phase (occurs 6 to 8 minutes into exercising and last 30 to 60 minutes before ending on its own)
    • Refractory phase which is often known as the grace period (starts less than 1 hour after exercise and lasts up to 3 hours)
    • Late-phase is the least severe (may no occur in some people but when it does it occurs 9 to 16 hours after exercise and last up to 24 hours)
  • Cough variant asthma is often related to people having less sun exposure and lower vitamin D levels that is characterized by a dry hacking cough that can occur while awake or asleep
  • Occupational asthma is asthma symptoms associated when something on the job sets of an attack

Treatments for Asthma

Types of medications and examples used for treatment of asthma 

  • Short-Acting Beta-Agonists (SABA) are used as rescue medications to provide quick relief of asthma symptoms
    • Examples: Albuterol sulfate and levalbuterol (Xopenex)
  • Long-Acting Beta-Adrenoceptor Agonists (LABA) are used as controller medications that helps to relax smooth airway muscle to open the airways for 12 hours or more
    • Examples: Aracapta Neohaler (indacaterol), Brovana (arformoterol), Foradil (formoterol), Serevent (salmeterol), and Striverdi Respimat (olodaterol) 
  • Inhaled corticosteroids (ICS) are anti-inflammatory medications that reduce airway over responsiveness, swelling and help to block late phase reactions
    • Examples: Aerospan (flunisolide), Alvesco (ciclesonide), Arnuity Ellipta (fluticasone), Asmanex (mometasone), Azmacort (triamcinolone), Flovent (fluticasone), Pulmicort Flexhaler (budesonide) and Q-Var (beclomethasone)
  • Anticholinergic (AC) are agents that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system stopping the body’s response
    • Examples: Atropine, Ipratropium bromide (Atrovent), Tiotropium bromide (Spiriva), Acetylcholine, Hyoscine and Muscarinic antagonist
  • Muscarinic receptor antagonist (LAMA) is a type of anticholinergic agent that blocks the activity of the muscarinic acetylcholine receptor. Acetylcholine is a neurotransmitter; whose receptor is a protein found in synapses of the brain and other cell membranes. 
    • Examples: Atropine, ipratropium bromide, Tiotropium bromide (Spiriva), and aclidinium bromide (Tudorza)

There are multiple steps to treating asthma: (The follow is a summarized version of these steps)

  • Step 1: Introduce SABA as needed and consider using a low-dose ICS
  • Step 2: Continue SABA as needed, add Low-dose ICS and leukotriene receptor antagonists (LTRA) or low dose theophylline
  • Step 3: Continue SABA as needed and leukotriene receptor antagonists (LTRA) or low dose theophylline but add a combination ICS/LABA
  • Step 4: Continue SABA as needed, add Low-dose ICS and leukotriene receptor antagonists (LTRA) or low dose theophylline but increase to a medium to high-dose ICS/LABA combination
  • Step 5: Continue SABA as needed and step 4 but refer to a specialist and consider adding anti-IgE (Xolair) or anti-IL5 (Examples: Mepolizumab, reslizumab or benralizumab)

(Centers for Disease Control and Prevention, 2018)(Global Initiative for Asthma, 2017)
Brandy D. Burgess, APRN-CNS, RN-MSN

Tags: Asthma