Journal Of Allergy And Clinical Immunology

Journal Of Allergy And Clinical Immunology

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Journal Of Allergy And Clinical Immunology

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Journal Of Allergy And Clinical Immunology

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Acute asthma can be defined as the obstructive disorder of the airway, a chronic inflammatory disorder of the airways. As mentioned by Costa et al. (2018), the immuno-histopathologic characteristics of the acute asthma can include inflammatory cell infiltration, as indicated by the presence of neutrophils, eosinophils, lymphocytes, Mast cell activation and epithelial cell injury. In order to discuss the pathogenesis of the acute asthma, the main contributing factor to the acute asthma is the airway inflammation which contributes to the airway hyper-responsiveness, airflow limitation, respiratory symptoms and disease chronicity. There are three key pathways that are associated with acute asthma exacerbation, bronchoconstriction or spasm, airway edema, airway hypertension, and airway remodelling. In this case, the case study selected for the assignment mentions the patient named Jackson Smith, an 18 year old male who had been admitted to the health care facility emergency department at 9 pm with the symptom of severe breathlessness. The patient assessment and family enquiry revealed the fact that he had been suffering from a long time from asthma and he had had the diagnosis of acute asthma when he had been 2 years old. It has to be mentioned in this context that the importance of assessment of the clinical manifestations exhibited by the patient is very important in the context so that the proper diagnosis can be done and adequate interventions can be provided to the patient as well. It has to be mentioned in this context that Jackson had been suffering from severe dyspnoea, 32 breaths/ minute respiratory rate, SpO2 of 90%, pulse rate at 130 breaths per minute, and blood pressure of 150/85 mmHg. Along with that, the medical assessment in this case had also been successful in identifying the presence of diminished breathing sounds and widespread wheeze.
Explaining the pathogenesis linked to each of the clinical manifestations that Jackson had been suffering from, first and foremost, the presence of dyspnoea or shortness of breath has to be discussed. It has to be mentioned that inflammation of the respiratory airways has a strong link to the pathophysiology of the asthma. The environmental triggers or allergens cause bronchoconstriction or the narrowing of the airways in asthma patients which is generally mediated by the localized inflammation of the bronchial airways, which in turn disrupts the ability of smooth respiration process and reduced the oxygen availability in the body which in turn leads to the shortness of breath. This is the primary pathogenesis which also leads to high respiratory rate where the body attempts to compensate for the deficiency of oxygen in the body which in turn leads to higher respiratory rate, which had been the case for Jackson as well. The airway constriction and inflammation is also the primary cause leading to the adventitious breathing sounds and widespread wheezing in the patient as well (Ruiz-Bailén et al., 2016).
The next set of clinical manifestations that has to be acknowledgement that needs to be discussed in this case includes 90% SpO2. Hypoxia and hypomexia are very common clinical manifestations of the acute asthma where the oxygen concentration in the blood and the tissues. This also linked to the inflamed and constricted airways not being able to supply enough oxygen to the body which leads to the drop in the concentration (Teach et al., 2015). In case of Jackson as well, this had been the primary cause leading to the low oxygen saturation and also the risk of respiratory acidosis that Jackson is exhibiting from the arterial blood gas report.
Lastly, discussing the pathogenesis of the high pulse rate at 135/min and high BP at 150/85 mmHg, the link is associated with high pulmonary load and in turn high cardiac output. As discussed by Weatherald, Lougheed, Taillé and Garcia (2017), the cardiac asthma where the low oxygen concentration of the body leads to the heavy cardiac load to pump enough oxygen to the body to avoid the risk of necrosis. Along with that, the pulmonary edema which is associated with acute asthma also adds to the cardiac load and results in extremely high pulse rate and in turn high blood pressure as well. In case Jackson as well, these possible contributing factors have led to the condition Jackson had been suffering from.
Jackson has been suffering from acute asthma therefore, the nursing strategy for him would involve pharmacological treatment as well as monitoring asthma 24 hours in the primary care. Considering the pharmacological treatment which is the first strategy, the process should be initiated at the crucial stage that is most appropriate to the severity of asthma. The healthcare service provider should recommend the patient to inhale corticosteroids (ICS) followed by proper gargle. The patient should also be prescribed to use spacers for high doses ICS as it would reduce oropharyngeal disposition. The side effects will also be lessen the side effects of hoarseness of the voice as well as oral candida. A high dose of ICS might be the need depending on the patient’s smoking habit (smoker or non-smoker) or the frequency of smoking for the impaired absorption across the lungs. While prescribing fluticasone, it is necessary to consider that the potential of it is twice compared to the other IC, therefore, the dose would be half that of budesonide or beclomethasone (Amar et al., 2017).
The management of supplemental oxygen on basis of urgency to achieve 90 per cent oxygen saturation would be next strategy would be appropriate strategy for the patient. It is known that a health care service user who is with acute exacerbation will be hypoxia suffering. The supplemental oxygen will be able to minimize mismatching and promote bronchodilation. It will also lessen the pulmonary vasoconstriction. The administration of prescribed inhaled bronchodilators need assurance along with the previous process. To smooth muscles the Beta2-agonists stimulate and encourage the beta2 receptors in the airway by releasing bronchoconstriction and reduce the stress of muscles for the purpose of breathing. The resistance to airflow is decreased as well by it (Sorour et al., 2015). Albuterol also known as salbutamol is usual recommendation of SABAs. Terbutaline, pirbuterol, levalbuterol can also be prescribed as per the condition. Considering Jackson’s situation close monitoring is required along with ebulized salbutamol. Lastly, perceiving Jackson’s initial response to SABA therapy if the results are not as good as expected considering I.V. beta2-agonists by the healthcare professional can be done as well.
The three drugs that were given to Jackson were continuous nebulised Salbutamol and nebulised Ipratropium bromide (4/24) and IV Hydrocortisone 100mg (6/24). Nebulized Salbutamol is prescribed as an aerosol to Jackson for the reason it can act at β2-adrenoreceptors on muscles as well as cover the bronchi. The non-covalently to epinephrine’s active site is in the receptor, and it stabilizes the receptor when it is in the active state.  It is the receptor while making more cAMP that tries to stabilizes it. The intracellular cascades is triggered by the resultant cAMP and it releases K+ in the end. Lastly, the free intracellular Ca2+ is decreased by K+  is released and it acts as an hindrance to the ability of contracting of the bronchus muscles. It is highly advisable for the nurse to constantly monitor the effectiveness of the doses that has been provided while making needed changes (Mills, 2015).
The broncholytic action by reducing cholinergic influence on the bronchial muscles shows the Pratropium of Ipratropium. It is the Ipratropium bromide restricts muscarinic acetylcholine not considering the subtype and its specificity. Therefore, it enhances cyclic guanosine monophosphate’s degradation process (Trivedi et al., 2018). As a result the intracellular concentration of cyclic guanosine monophosphate is decreased due to the actions of cyclic guanosine monophosphate on intracellular calcium. It does not diffuse into the blood since it is a nonselective muscarinic antagonistic and prevents any sort of side effect. Therefore, the contractility of smooth muscle in the lung is decreased and it inhibit mucus secretion and bronchoconstriction.
The beta-adrenergic response is enhanced by the Corticosteroids that is present in IV Hydrocortisone which relieve the muscle spasm. By retreating the mucosal edema, lessening vascular permeability by vasoconstriction, and inhibiting the discharge of LTC4 as well as LTD4. Meanwhile, the mucus secretion is reduced by Corticosteroids through inhibiting the discharge of secretagogue from macrophages. The particular’s capability is from the inhibition of LTB4 release. Also, the corticosteroid’s effect can also prevent the cytotoxic effect of basic protein and necessary mediators that eosinophils releases (Kercsmar & Mcdowell, 2019).
Amar, N. J., Shekar, T., Varnell, T. A., Mehta, A., & Philip, G. (2017). Mometasone furoate (MF) improves lung function in pediatric asthma: A double?blind, randomized controlled dose?ranging trial of MF metered?dose inhaler. Pediatric pulmonology, 52(3), 310-318. doi:10.1002/ppul.23563
Costa, L. D. C., Camargos, P. A. M., Brand, P. L., Fiaccadori, F. S., de Paula Cardoso, D. D. D., de Araújo Castro, Í., … & da Costa, P. S. S. (2018). Asthma exacerbations in a subtropical area and the role of respiratory viruses: a cross-sectional study. BMC pulmonary medicine, 18(1), 109. Doi: 10.1186/s12890-018-0669-6
Kercsmar, C. M., & Mcdowell, K. M. (2019). Wheezing in older children: asthma. In Kendig’s Disorders of the Respiratory Tract in Children (Ninth Edition) (pp. 686-721). doi:10.1016/b978-0-7216-3695-5.50060-2
Mills, K. A. (2015). Cyclophosphamide and ifosfamide: mechanisms of cytotoxic action and consequences for normal bladder function. Retrieved from
Ruiz-Bailén, M., Cobo-Molinos, J., Espada-Fuentes, J. C., Castillo-Rivera, A. M., & Martínez-Ramírez, M. J. (2016). The Acute Asthma: It’s just a Respiratory Disease? A Speckle Tracking Echocardiography Study. J Clin Respir Dis Care, 2(122), 2472-1247. Doi: 10.4172/2472-1247.1000122
Sorour, K., Vyas, P. A., Raval, D. S., Donovan, L. M., & Vyas, A. A. (2015). Successful Treatment of Severe Asthma Exacerbation with Sevoflurane Inhalation in the Intensive Care Unit. J Anesth Crit Care Open Access, 3(2), 00092. Retrived from
Teach, S. J., Gergen, P. J., Szefler, S. J., Mitchell, H. E., Calatroni, A., Wildfire, J., … & Matsui, E. (2015). Seasonal risk factors for asthma exacerbations among inner-city children. Journal of Allergy and Clinical Immunology, 135(6), 1465-1473. Doi: 10.1016/j.jaci.2014.12.1942
Trivedi, M., Hoque, S., Biebel, K. M., Byatt, N., Rosal, M., Pbert, L., & Goldberg, R. (2018). AB024. Barriers and facilitators to the real-world implementation of supervised asthma therapy in public schools: a qualitative study of school nurse perspectives. Pediatric Medicine, 1. doi: 10.21037/pm.2018.AB024
Weatherald, J., Lougheed, M. D., Taillé, C., & Garcia, G. (2017). Mechanisms, measurement and management of exertional dyspnoea in asthma: Number 5 in the Series “Exertional dyspnoea” Edited by Pierantonio Laveneziana and Piergiuseppe Agostoni. European Respiratory Review, 26(144), 170015. Doi: 10.1183/16000617.0015-2017

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