Definition

A condition of the lungs characterized by widespread narrowing of the airways due to spasm of the smooth muscle, edema of the mucosa, and the presence of mucus in the lumen of the bronchi and bronchioles. Bronchial asthma is a chronic relapsing inflammatory disorder with increased responsiveness of tracheobroncheal tree to various stimuli, resulting in paroxysmal contraction of bronchial airways which changes in severity over short periods of time, either spontaneously or under treatment. Exacerbation- A worsening. In medicine, exacerbation may refer to an increase in the severity of a disease or its signs and symptoms

Causes
Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or allergens can be seasonal such as grass, tree and weed pollens or perennial under this are the molds, dust and roaches. Common triggers of asthma symptoms and exacerbations include air way irritants like air pollutant, cold, heat, weather changes, strong odors and perfumes. Other contributing factor would include exercise, stress or emotional upset, sinusitis with post nasal drip , medications and viral respiratory tract infections. Most people who have asthma are sensitive to a variety of triggers. A persons asthma changes depending on the environment activities, management practices and other factor.
LABORATORY AND DIAGNOSTIC FINDINGS: Spirometry will detect: a. Decreased for expiratory volume (FEV) b. Decreased peak expiratory flow rate (PEFR) c. Diminished forced vital capacity (FVC) d. Diminished inspiratory capacity (IC)

Clinical Manifestation
The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some instances cough may be the only symptoms. An asthma attack often occurs at night or early in the morning, possibly because circadian variations that influence airway receptors thresholds. An asthma exacerbation may begin abruptly but most frequently is preceded by increasing symptoms over the previous few days. There is cough, with or without mucus production. At times the mucus is so tightly wedged in the narrow airway that the patient cannot cough it up.

Prevention
Patient with recurrent asthma should undergo test to identify the substance that participate the symptoms. Patients are instructed to avoid the causative agents whenever possible. Knowledge is the key to quality asthma care.

Medical Management
There are two general process of asthma medication: quick relief medication for immediate treatment of asthma symptoms and exacerbations and long acting medication to achieve and maintain control and persistent asthma. Because

of underlying pathology of asthma is inflammation, control of persistent asthma is accomplish primarily with the regular use of anti inflammatory medications. y Long-acting control Medication

Corticosteroid are the most potent and effective anti inflammatory currently available. They are broadly effective in alleviating symptoms, improving air way functions, and decreasing peak flow variability. Cromolyn sodium and nedocromil are mild to be moderate anti-inflammatory agents that are use more commonly in children. They also are effective on a prophylactic basis to prevent exercise-induced asthma or unavoidable exposure to known triggers. These medications are contraindicated in acute asthma exacerbation. `Long acting beta-adrenergic agonist is use with anti-inflammatory medications to control asthma symptoms, particularly those that occur during the night these agents are also effective in the prevention of exercise-induced asthma. y Quick relief medication

Short acting beta adrenergic agonists are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They have the rapid onset of acton. Anti-cholinergic may have an added benefit in severe exacerbations of asthma but they are use more frequently in COPD.

Nursing Management
The main focus of nursing management is to actively assess the air way and the patient response to treatment. The immediate nursing care of patient with asthma depends on the severity of the symptoms. A calm approach is an important aspect of care especially for anxious client and ones family. y y y y y This requires a partnership between the patient and the health care providers to determine the desire outcome and to formulate a plan which include; the purpose and action of each medication trigger to avoid and how to do so when to seek assistance the nature of asthma as chronic inflammatory disease

1. Assess respiratory status by closely evaluating breathing patterns and monitoring vital signs 2. Administer prescribed medications, such as bronchodilators, anti-inflammatories, and antibiotics 3. Promote adequate oxygenation and a normal breathing pattern 4. Explain the possible use of hyposensitization therapy 5. Help the child cope with poor self-esteem by encouraging him to ventilate feelings and concerns. Listen actively as the child speaks, focus on the childs strengths, and help him to identify the positive and negative aspects of his situation. 6. Discuss the need for periodic PFTs to evaluate and guide therapy and to monitor the course of the illness. 7. Provide child and family teaching. Assist the child and family to name signs and symptoms of an acute attack and appropriate treatment measures 8. Refer the family to appropriate community agencies for assistance.

Moderate acute exacerbation *Inhaled or nebulized beta2 agonist(3ce in 1 hr, and every hr after) *Oxygen to achieve SaO2 95% or more

*If no immediate response or patient recently took oral steroid oral prednisolone 1-2 mg/kg Severe acute exacerbation Humidified O2
Short-acting 2 agonist via oxygen driven nebuliser(3ce in 1 hr.) Oral prednisolone 1-2 mg/kg

Severe acute exacerbation bronchial asthma (contd.)

If no response after 15 30 minutes Oxygen Oral prednisolone Nebulized salbutamol every 30 mins./continuously Add Ipratropium bromide Severe acute exacerbation bronchial asthma (contd.)

If no response Aminophylline drip

If no response Admit ICU The very severe asthma attack Children who present in extremis with a very severe attack of asthma should immediately be given 100% oxygen and adrenaline 0.3 ml subcutaneously, followed by intravenous salbutamol if they are unable to use a nebuliser. They should be admitted immediately to a high-care facility or ICU for intensive treatment

The very severe asthma attack (contd.) Humidified oxygen Short-acting 2 agonist nebulisation IV aminophylline 5mg/kg stat and aminophylline drip 1mg/kg/hr IV Hydrocortisone sodium succinate Ipratropium bromide 0.25 mg to nebulised beta2 agonist The very severe asthma attack (contd.)

If no response Intubation and mechanical ventilation