Question

Case study
Poppy is a 9 year old female, weight
40Kg.
She presented to ED with worsening respiratory symptoms over the past few hours. Her parents state she
is unable to talk in full sentences or undertake a peak flow. In ED Poppy has been given 3 x 20 minutely
nebulised Salbutamol with 6LPM of O2, IVF commenced, Stat dose of Prednisone administered, Chest X-
ray shows hyperinflation of both lung fields. She was admitted to ICU due to her deteriorating respiratory
function with a diagnosis of acute exacerbation of asthma.
EXCERPT OF RELEVANT ICU NOTES
Past History

Diagnosed with asthma age 2 (infrequent intermittent asthma).

Current medications: - Ventolin PRN.
IUTD (immunisations up to date)
Nursing Assessment
A. Clear, speaking in single words
B. RR 42bpm, SpO2 87% RA, 92% on 6LPM O2 + nebuliser, auscultation decreased AE bibasally, inspiratory
and expiratory wheeze
C. HR 160bpm, ST, peripherally
warm D. GCS 14/15 (E4, V4, M6)
E. Accessory muscle use, shoulder shrugging on inspiration, tracheal tug
F. IVF NaCl 53
ml/hr G.
a. Mg- low 0.60mmol/L (0.70-1.10mmol/L) all other pathology is normal.
b. BGL 9.0mmol/L
c. Beta-agonist- Salbutamol
d. Anticholinergic - Atrovent
e. IV Hydrocortisone
f. ABG shows respiratory acidosis, (PH 7.32, PaCO2 49, PaO2 70, HCO3 27, BE -2.1, Lactate
1.4)

Plan
- Keep SpO2 92-95%%
- Beta- antagonist Salbutamol continuous via nebuliser
- Anticholinergic Ipratropium bromide (Atrovent) 500ug 4/24
- Hydrocortisone 100mg 6/24
- MgSO4 6.4mmol/20 minutes
- IVF 53ml/hr
- Repeat ABGs in 1hour
- Monitor BGL
- Peakflow /spirometry

Question 1
Explain the pathogenesis causing the clinical manifestations with which Poppy presents.
Question 2

1. Sit Poppy in a High Fowlers position
– How does positioning a patient with acute asthma in a High Fowlers position assist to
alleviate respiratory distress?
2. Apply and titrate oxygen
– What oxygen delivery device will you use?
– Why did you choose this device?
– How does providing supplemental oxygen work and, how will it assist Poppy?
Question 3
For each medication below explain
– The mechanism of action.
– Why your patient is receiving this medication in relation to her symptoms and diagnosis?
– What are the nursing considerations for this medication?
– What clinical response you expect?
– What continuing clinical observations will you need to undertake?
Salbutamol
via nebuliser
Hydrocortiso
ne IV
Ipratropium Bromide via nebuliser

Answer 1

Question No1)

Poppy was diagnosed with acute exacerbations of asthma.

So according to question the pathogenesis causing clinical manifestations of asthma is

Airflow limitation in asthma is recurrent and caused by a variety of changes in the airway. These include:

▪ Bronchoconstriction. In asthma, the dominant physiological event leading to clinical symptoms is airway narrowing and a subsequent interference with airflow. In acute exacerbations of asthma, bronchial smooth muscle contraction (bronchoconstriction) occurs quickly to narrow the airways in response to exposure to a variety of stimuli including allergens or irritants. Allergen-induced acute bronchoconstriction results from an IgE-dependent release of mediators from mast cells that includes histamine, tryptase, leukotrienes, and prostaglandins that directly contract airway smooth muscles. Aspirin and other nonsteroidal anti-inflammatory drugs can also cause acute airflow obstruction in some patients, and evidence indicates that this non-IgE-dependent response also involves mediator release from airway cells . In addition, other stimuli (including exercise, cold air, and irritants) can cause acute airflow obstruction. The mechanisms regulating the airway response to these factors are less well defined, but the intensity of the response appears related to underlying airway inflammation. Stress may also play a role in precipitating asthma exacerbations. The mechanisms involved have yet to be established and may include enhanced generation of pro-inflammatory cytokines.

▪ Airway edema. As the disease becomes more persistent and inflammation more progressive, other factors further limit airflow . These include edema, inflammation, mucus hypersecretion and the formation of inspissated mucus plugs, as well as structural changes including hypertrophy and hyperplasia of the airway smooth muscle. These latter changes may not respond to usual treatment.

▪ Airway hyperresponsiveness. Airway hyperresponsiveness—an exaggerated bronchoconstrictor response to a wide variety of stimuli—is a major, but not necessarily unique, feature of asthma. The degree to which airway hyperresponsiveness can be defined by contractile responses to challenges with methacholine correlates with the clinical severity of asthma. The mechanisms influencing airway hyperresponsiveness are multiple and include inflammation, dysfunctional neuroregulation, and structural changes; inflammation appears to be a major factor in determining the degree of airway hyperresponsiveness. Treatment directed toward reducing inflammation can reduce airway hyperresponsiveness and improve asthma control.

▪ Airway remodeling. In some persons who have asthma, airflow limitation may be only partially reversible. Permanent structural changes can occur in the airway ,these are associated with a progressive loss of lung function that is not prevented by or fully reversible by current therapy. Airway remodeling involves an activation of many of the structural cells, with consequent permanent changes in the airway that increase airflow obstruction and airway responsiveness and render the patient less responsive to therapy . These structural changes can include thickening of the sub-basement membrane, subepithelial fibrosis, airway smooth muscle hypertrophy and hyperplasia, blood vessel proliferation and dilation, and mucous gland hyperplasia and hypersecretion . Regulation of the repair and remodeling process is not well established, but both the process of repair and its regulation are likely to be key events in explaining the persistent nature of the disease and limitations to a therapeutic response.This is the pathogenesis of the clinical manifestations of asthma

Question no 2)

Part 1)
positioning a patient with acute asthma in a High Fowlers position assist to alleviate respiratory distress by  relaxing of tension of the abdominal muscles, allowing for improved breathing. In immobile patients and infants, the high fowler's position alleviates compression of the chest that occurs due to gravity which helps to improve respiratory status of the patient.

Part 2)

Subpart. A ) the device that I will use for delivery of oxygen would be high-flow nasal cannula  (HFNC) that is proven to be a safe and effective technique in the management of asthma  in children.

Subpart.b)The child's spo2 value is 87% so a high flow nasal cannula would be effective to increase the expiratory flow and increase the ventilation and perfusion ratio which will improve the spo2 of the child dramatically.

Subpart c)As the spo2 of the child is 87% there is a need for supplymental oxygen in the child and high flow nasal cannula will help in improving the saturation value and there by reducing the respiratory acidosis of poppy.

Question no 3)a)

Subpart 1)salbutamol via nebuliser mechanism of action

The mechanism of action  for salbutamol is  essentially relaxing the smooth muscles of the airways. It activates the beta2-adrenergic receptors in the lungs, which begins a cascade of actions  that result in bronchodilation .salbutamol  is effective in opening the airways regardless of the cause of bronchoconstriction.

Subpart 2) As Poppy is having asthma and respirator muscles need to be relaxed salbutamol is given.it helps in bronchodilation and helps in increase of spo2

Subpart 3)nursing consideration for salbutamol

• Assess lung sounds, PR and BP before drug administration and during peak of medication.
• Observe fore paradoxical spasm and withhold medication and notify physician if condition occurs.
• Administer PO medications with meals to minimize gastric irritation.
• Extended-release tablet should be swallowed-whole. It should not be crushed or chewed.
• If administering medication through inhalation, allow at least 1 minute between inhalation of aerosol medication.
• Advise the patient to rinse mouth with water after each inhalation to minimize dry mouth.
• Inform the patient that salbutamol may cause an unusual or bad taste.

Subpart4) expected clinical response

Relief from asthma ,wheezing,Improving of spo2 values and stop the usage of accessory muscle for respiration

Subpart 5)

Check for adverse effects

The most common side effects are fine tremor, anxiety, headache , muscle cramps, dry mouth, and palpitation. Other symptoms may include tachycardia, arrhythmia, flushing of the skin, myocardial ischemia (rare), and disturbances of sleep and behaviour etc .

Question no 3) b

Subpart 1) mechanism of action of hydrocortisone IV

The short term effects of hydrocortisone are decreased vasodilation and permeability of capillaries, as well as decreased leukocyte migration to sites of inflammation. Hydrocortisone binding to the glucocorticoid receptor mediates changes in gene expression that lead to multiple downstream effects over hours to days.

Hydrocortisone inhibit neutrophil apoptosis and demargination; they inhibit phospholipase A2, which decreases the formation of arachidonic acid derivatives; they inhibit NF-Kappa B and other inflammatory transcription factors; they promote anti-inflammatory genes like interleukin-10.

Lower doses of corticosteroids provide an anti-inflammatory effect, while higher doses are immunosuppressive.

Subpart 2)poppy is having hyperinflation f both lungs and inflammation of bronchus so administration of hydrocortisone help in reducing inflammation.

Subpart 3)

• Monitor signs of thrombophlebitis (lower extremity swelling, warmth, erythema, tenderness) and thromboembolism (shortness of breath, chest pain, cough, bloody sputum). Notify physician or nursing staff immediately, and request objective tests (Doppler ultrasound, lung scan, others) if thrombosis is suspected.

• Monitor and report signs of peptic ulcer, including heartburn, nausea, vomiting blood, tarry stools, and loss of appetite.

• Monitor signs of hypersensitivity reactions or anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.

• Assess any muscle or joint pain. Report persistent or increased musculoskeletal pain to determine presence of bone or joint pathology (aseptic necrosis, fracture).

• Assess signs of increased intracranial pressure in children, including changes in mood and behavior, decreased consciousness, headache, lethargy, seizures, and vomiting. Notify physician immediately of these signs.

• Assess muscle strength periodically to determine degree of muscle wasting during long- term use.

• Measure blood pressure periodically and compare to normal values. Report a sustained increase in blood pressure (hypertension) to the physician.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema . Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.

• Monitor personality changes, including depression, euphoria, restlessness, hallucinations, and psychosis. Notify physician if symptoms seen

Subpart 4)clinical response expected in poppy are reduction in inflammatory of airway and increase of spo2 values . wheezing sound reduction.

Subpart5)Nausea, heartburn, headache, dizziness, menstrual period changes, trouble sleeping, increased sweating, or acne may occur. If any of these effects  persist or worsen, tell your doctor or pharmacist promptly. Because this drug works by weakening the immune system, it may lower your ability to fight infections. The adverse effects should be continually checked

Question no3 )c

Subpart 1 ) mechanism of action of ipratropium bromide via nebuliser

Ipratropium acts as an antagonist of the muscarinic acetylcholine receptor. This effect produces the inhibition of the parasympathetic nervous system in the airways and hence, inhibit their function. The function of the parasympathetic system in the airway is to generate bronchial secretions and constriction and hence, the inhibition of this action can lead to bronchodilation and fewer secretions.

At the cellular level, the diameter of the airways is controlled by the release of acetylcholine into the muscle cells causing them to contract and producing a narrow airway. Thus administration of ipratropium stops the activity of acetylcholine in the smooth muscle preventing the contraction and producing relaxed airways.

Subpart 2) As Poppy is having asthma there is high chance for . occurrence of airway narrowing that is constriction of airway so ipratropium bromide helps in bronchodilation there by increasing the spo2 level .

Subpart 3)

Check nebuliser technique.

- Ensure that patients are able to correctly use the delivery device for their medications

- administering by nebulisers use a mouthpiece rather than face mask.

- administered by nebuliser the dilution of the solution should be adjusted according to equipment and length of administration.

- Paradoxical bronchospasm has occurred with nebulised solution, therefore first dose should be used under medical supervision.

- Caution should be taken not to confuse Atrovent with Alupent.

- Evaluate therapeutic response.

Subpart 4)

The clinical response expected in poppy is reduction of secretion and bronchodilation there be increase in value of spo2 .

Subpart5)

• Bladder pain.
• bloody or cloudy urine.
• cough producing mucus.
• difficult, burning, or painful urination.
• difficulty with breathing.
• frequent urge to urinate.
• lower back or side pain.
• shortness of breath

Clinical observations for these symptoms should be done