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Based on the HPI, ROS, PE, and diagnostic tests, the diagnosis is most likely to be an acute asthma exacerbation. Episodes of an asthma attack are mostly triggered by exposures to an allergen, including: grass, pollen, dust or animal dander (Tillie-Leblond, Gosset, & Tonnel, 2005). Some triggers also include air irritants such as chemical fumes, strong odors (like smoke), and even perfume. Inhaling cold air, stress, and upper respiratory infections (such as cold) could trigger asthma episodes. Sometimes, asthma exacerbation occurs for no apparent reason. The underlying principles point to an overly sensitive immune system which makes the airway inflamed when one is exposed to certain triggers named above (Tillie-Leblonde, et al., 2005). Nonetheless, triggers are not alike with every individual and may vary from one person to another.
The onset of dyspnea and wheezing after heavy exercise outdoors and history of similar asthma exacerbations indicate she may be having asthma-related issues. Because her symptoms were not relived with the rescue inhaler during this exacerbation, it was important to rule out other causes of dyspnea in addition to assessing the need for a readjustment to her current asthma treatment regimen. Her allergies to outdoor dust, hay, rag weed, mold are also an indicator her asthma may be the prime issue. Her history of smoking could have led her to other possible issues causing dyspnea as well, which is why differential diagnoses such as pulmonary embolism, poor physical conditioning, and COPD were ruled out. Patient position slouched forward in tripod position, accessory muscle use, intermittent nasal flaring when speaking for longer than 1 minute, decreased tactile fremitus throughout, hyperresonance noted to bilateral posterior upper lobes, and diminished breath sounds with expiratory wheezes noted over all lung fields are symptoms prompt other test necessary to rule out other conditions. Spirometry results of FVC 2.40, FEV1 1.5, FEV1/FVC 62% on initial assessment was most useful in the initial diagnosis of asthma but can be used to monitor treatment effectiveness as well. In addition, chest radiography findings are normal, which is consistent with an asthma diagnosis.
In both acute and chronic asthma, arterial blood gas sampling is one of the critical steps in assessment to assess the acid-base status and oxygenation levels in patients. This test examines the levels of oxygen and carbon dioxide in the blood. It evaluates the effectiveness of oxygen delivery and carbon dioxide removal from the blood by the lungs (Padmavathi. K, 2013).
Diagnosis is performed using diagnostic tests while also employing the evaluation of clinical presentations. The doctor assesses for signs and symptoms like chest tightness, coughing, wheezing and shortness of breath. Diagnostic tests include peak flow, spirometry, nitric oxide measurement and pulse oximetry (Clancy & Blake, 2013). In a peak flow test, the patient blows into a mouthpiece as hard and as first with just a single expiration. It evaluates how quickly can a patient breath out. (Lynn B Gerald, 2018)
The pathophysiology of asthma is complex and involves intermittent airflow obstruction by airway inflammation and bronchial hyperresponsiveness. Bronchoconstriction is the dominant event which causes clinical symptoms through airway narrowing and interference of airflow (Clancy & Blake, 2013). An acute asthma exacerbation is characterized by a quick smooth muscle contraction response due to exposure to a variety of stimuli, such as allergens. In chronic asthma, as the disease becomes more persistent and inflammation progresses, mucosal edema amplifies bronchial responsiveness by increasing epithelial permeability and altering airway mechanics (Clancy & Blake, 2013). Hyperresponsiveness which is categorized as an exaggerated bronchoconstrictor response due to stimuli is influenced by factors including inflammation, dysfunctional neurological regulation, and structural changes. In some cases, permanent structural changes can occur to the airway also known as airway remodeling. This involves activation of many structural cells, leading to the consequent permanent changes which escalate airflow obstruction and responsiveness.
The characteristic airway inflammation of asthma can result in several consequences, including airway hyperresponsiveness, increased mucus reproduction, and obstruction of the airway. It also constitutes bronchiolar inflammation of the airway causing resistance, which presents as episodes of wheezing, shortness of breath, and coughing (Clancy & Blake, 2013). Asthma is a chronic lung condition that can cause acute exacerbations. For some people, asthma is a minor health problem where acute signs and symptoms present themselves less frequently, with normal lung and airway function. For others with intensified, frequent signs and symptoms, asthma can be persistent and life-threatening
Evaluation, Education, and Health Promotion:
Emergency cases where patients are admitted to emergency rooms for status asthmaticus, intubation and mechanical ventilation for oxygen is paramount since this is a respiratory failure which comes in the worst form of an asthma attack. The doctor places breathing tubes down the throat into the upper airway which are then connected to a ventilator which pumps oxygen into the lungs. Short-acting beta-agonists are administered through a nebulizer. Oral corticosteroids in pill form are administered to reduce lung inflammation and stabilize the airway (Rowe, Spooner, Ducharme, Bretzlaff, & Bota, 2007)
. When the patient’s asthma symptoms improve, the patient is monitored for some time to ensure that his/her condition is sufficiently under control. An asthma plan is afterward developed. This plan includes an inhaler where a patient is instructed to take between two to six puffs (depending on severity) of a quick acting inhaler which has medication such as albuterol.
If the asthma attack is severe, the patient is not only advised to administer the initial step of using quick action inhaler but also immediately visit the doctor or urgent care facility for further treatment. If the exacerbation is severe, there would be more wheezing than normal, extreme shortness of breath that is worse than normal characterized by shallow and rapid breathing. (E. Evensen, 2010) Also there would be large mucus production and the mucus can have changes in color such as yellow, green or bloody (Vogelmeier, 2018). If the asthma attack is triggered by outside allergens, the doctor will assist through an allergy test to identify the allergic triggers and educate the patient on how to minimize his/her exposure. The patient can avoid flowery gardens if pollen is an allergen. She is further advised to avoid dusty and smoky environments. In addition, if a cold environment is found to trigger an asthma attack, the patient is advised to cover her/his face using a scarf to ensure warm air is breathed in.
Taking all medications as prescribed is critical to maintain good asthma control. If symptoms of asthma are worsened and quick relief is needed, she can safely use her inhaler as often as 30-60 minutes after an average period of 2 to 3hours. Keeping an inhaler close is also crucial as in some occasion, an asthma attack can be so severe that one cannot be able to fetch his/her inhaler from wherever they left if, and as a result, it is always safe to ensure that the inhaler is close with the patient. In both routine prevention therapy and in emergency cases, every patient should own and regularly employ a spacer and know how to use it correctly (Walter Vincken, 2018). And even though many patients use their inhalers correctly, they fail to carry out proper techniques needed for the medication to properly reach the lungs. Spacers make the process of use much easier while also delivering the medication more efficiently (Walter Vincken, 2018).
Washing your hands frequently is helpful in reducing the chances of catching a cold virus and reduces the spread of bacterial that can cause other respiratory infections. Most importantly, education on social smoking and second hand smoke is necessary to decrease risk of exacerbations as well as other comorbidities associated with it. (Jennifer L. Perret, 2016) Smoking cessation is highly encouraged because smoke increases the risk of exacerbations, acute asthma exacerbations can hence quickly progress to chronic (Jennifer L. Perret, 2016).
- Clancy, J. & Blake, D. (2013, September). Pathophysiology and pharmacological management of asthma from a nature-nurture perspective. Primary Health Care, 23(7), 34-41. DOI: 10.7748/phc2013.09.23.7.34.e725
- E. Evensen, A. (2010, March). Management of COPD Exacerbations. American Family Physician, pp. 607-613. Retrieved: https://www.aafp.org/afp/2010/0301/p607.html
- Gobbi, A. Gulotta, C., Suki, B., Mellano, B., Pellegrino, R., Brusasco, V., & Dellacà, R. (2019, June). Monitoring of respiratory resistance in the diagnosis of mild intermittent asthma. Clinical & Experimental Allergy, 49(6), 921-923. DOI: 10.1111/cea.13376
- Jennifer L. Perret, B. B. (2016, June 24). Smoking cessation strategies for patients with asthma: improving patient outcomes. Journal of Asthma and Allergy. Retrieved: doi: 10.2147/JAA.S85615
- Lynn B Gerald, T. F. (2018, October 23). Peak expiratory flow monitoring in asthma. UpToDate. Retrieved: https://www.uptodate.com/contents/peak-expiratory-flow-monitoring-in-asthma
- Padmavathi. K, S. S. (2013, November). ARTERIAL BLOOD GAS ANALYSIS IN ACUTE AND CHRONIC BRONCHIAL ASTHMA. Bulletin of Pharmaceutical and Medical Sciences, pp. 1-6. Retrieved: https://pdfs.semanticscholar.org/560c/c0fabf7e0f10065847e20293a65236ad3c5a.pdf
- Rowe, B., Spooner, C., Ducharme, F., Bretzlaff, J., & Bota, G. (2007, July 18). Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database of Systematic Reviews, 2007(3), 1-28. DOI: 10.1002/14651858.CD000195.pub2
- Tillie-Leblond, I., Gosset, P., & Tonnel, A. (2005, January). Inflammatory events in severe acute asthma. Allergy, 60(1), 23-29. DOI: 10.1111/j.1398-9995.2005.00632.x
- Vogelmeier, C. F. (2018). Exacerbations of COPD. European Respiratory Review. Retrieved: DOI: 10.1183/16000617.0103-2017
- Walter Vincken, M. L. (2018). Spacer devices for inhaled therapy: why use them, and how? ERJ Open Research. Retrieved: DOI: 10.1183/23120541.00065-2018
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