Home Care Resources for Clients with AsthmaAmerican Academy of Allergy, Asthma and Immunology

• American Lung Association
• American Thoracic Society
• Asthma and Allergy Foundation of America
• Asthma and Indoor Environments (U.S. Environmental Protection Agency)
• Asthma: Organizations
• National Heart, Lung & Blood Institute

References

Burke, P. & Lemone, P. (3rd Edition). (2004). Medical-Surgical Nursing: Critical Thinking in Client Care. New Jersey, USA. Pearson Education, Inc.

COPD (Chronic Obstructive Pulmonary Disease) is a general term used to describe lung diseases associated with airflow obstruction. Emphysema and chronic bronchitis fall into this category. The World Health Organization (WHO) estimates that COPD as a single cause of death shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebrovascular disease and acute respiratory infection). Chronic bronchitis causes limitation in airflow that is not fully reversible. It is characterized by a productive cough lasting 3 or more months in 2 consecutive years. The lungs undergo permanent structural change, which leads to varying degrees of difficulty of breathing and productive coughing. The major precipitating factor associated with this disorder is cigarette smoking.

Quitting smoking produces a lot of multi-system benefits even after the diagnosis of bronchitis. It improves lung function by inhibiting further damage brought by nicotine to the bronchial mucosa. However, smoking cessation requires tremendous effort and determination. Studies shows only 6% of smokers accomplish successful long-term abstinence. Nicotine patches or gum and an antidepressant such as bupoprion improve the chances of success.

Exposure to other airway irritants and allergens should be avoided. Air filtering systems or air conditioning dust air conditioning may be useful.

Pulmonary hygiene measures, which include adequate fluid intake, effective cough, percussion, and postural drainage, are utilized to facilitate clearance of airway secretions. Maintaining adequate fluid intake is essential to thin tenacious secretions. Leaning forward and repeatedly “huffing”, with relaxed breathing between huffs is more effective than forceful coughing. Percussion and postural drainage may be necessary if the client is unable to clear secretions by usual means.

Unless contraindicated by your physician because of cardiac disability, a regular exercise program is beneficial in improving exercise tolerance, and preventing worsening of physical condition. A program of regular aerobic exercise (e.g. walking for 20 minutes at least three times weekly) intended to gradually increase exercise tolerance is recommended.

Pursed-lip breathing helps maintain open airways during exhalation. Abdominal breathing relieves the work of accessory muscles of respiration.

For clients with severe and progressive low oxygen blood levels, long-term oxygen therapy is prescribed. Oxygen may be used from time to time, at night, or continuously. However, for severely hypoxemic clients, continuous oxygen is recommended.

The administration of oxygen in clients with COPD is cautioned. In a normal person, elevated carbon dioxide levels in the blood serve as a stimulus for the brain to breathe. However in clients with COPD, chronic elevated carbon dioxide levels in the blood inhibit this normal stimulus to breathe, leaving only the stimulus of low blood oxygen. If oxygen is administered at high flow rates, this can reduce the remaining stimulus, leading to respiratory insufficiency or arrest.

Lung transplantation may be an alternative if medical therapy is not effective. Single and bilateral lung transplants have a 2-year survival rate of 75%. Lung reduction surgery is an option for clients with advanced lung hyperinflation. The procedure improves elastic recoil and decreases the overall volume of the lung because it is reshaped.

Cigarette smoking is the main risk factor for chronic bronchitis. People exposed to secondhand smoke can also acquire this condition. The WHO estimates that passive smoking is associated with a 10 to 43 percent increase in risk of COPD in adults. Irritant gases can also contribute to the disease development. Although cigarette smoking is the primary cause of COPD, the WHO estimates that there are 400,000 deaths per year from exposure to biomass fuels. Air pollution, infection, and allergies can also worsen chronic bronchitis.

To protect oneself from respiratory infections which can precipitate chronic bronchitis, immunization against pneumococcal pneumonia and influenza vaccine are recommended. If an infection is diagnosed, broad spectrum antibiotic is prescribed. Broad spectrum antibiotics target both Gram negative and positive bacteria. Studies show that clients with thick, tenacious sputum and increased difficulty of breathing will likely benefit from antibiotic therapy.

Bronchodilators are prescribed to improve airflow and reduce the retention of carbon dioxide in the lungs, improving the manifestations. Bronchodilators may be given by metered-dose inhaler (MDI), by nebulizer, or orally.

The signs and symptoms of chronic bronchitis are the following:

• Productive cough with copious amounts of thick, tenacious sputum
• A rattling or whistling respiratory sound resembling snoring heard upon auscultation, caused by secretions
• Bluish-purple discoloration of skin and mucous membranes usually resulting from a deficiency of oxygen in the blood

In advanced chronic bronchitis, peripheral airways are obstructed, thereby compromising the lung’s capacity for gas exchange, producing abnormally low levels of oxygen in the blood.

Pulmonary hypertension, which develops late in the course of severe chronic bronchitis, is the major cardiovascular complication and is associated with the development of cor pulmonale (right sided heart failure). This is characterized by distended neck veins, edema, liver engorgement, and an enlarged heart.

Diagnostic Tests for Chronic Bronchitis

1.    Pulmonary Function Testing is executed to evaluate the extent and progress of chronic bronchitis. There is no need for fasting since this is not a noninvasive test; however, tobacco products, bronchodilators, and eating a heavy meal should be avoided for 4 to 6 hours prior to testing.
2.    Ventilation-perfusion scanning may be performed to find out the extent to which lung tissue is ventilated but not perfused, or perfused but inadequately ventilated. A radioactive substance is injected or inhaled to illustrate areas of shunting and absent capillaries.
3.     Arterial blood gases (ABGs) are drawn to assess gas exchange particularly during acute exacerbation of chronic bronchitis. Oxygen saturation levels are low due to low levels of oxygen in the blood.
4.    Pulse oximetry is used to monitor oxygen saturation of the blood. The normal oxygen saturation is between 96% to 100%.
5.    Exhaled carbon dioxide (capnogram) may be measured to evaluate alveolar ventilation. The normal reading is 35 to 45 mmHg; it is evaluated when ventilation is inadequate, and decreased when pulmonary perfusion is impaired.
6.    Chest X-ray may show changes in the respiratory anatomy like the flattening of the diaphragm due to hyperinflation and evidence of pulmonary infection.

Asthma is a chronic inflammatory disorder of the airways marked by recurring episodes of wheezing (a whistling noise in the chest during breathing when the airways are narrowed or compressed), breathlessness, coughing, and chest tightness. The extensive airflow obstruction that happens during acute episodes usually resolves either spontaneously or with treatment.