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Asthma: Pharmacology and Medicines Management

Introduction

Chronic conditions account for a high proportion of mortality and morbidity in the modern world. Asthma is a chronic condition that has now become a global health issue. The knowledge and management of asthma has however remained a mirage to various stakeholders in the healthcare industry. This is because the pharmacology and management of asthma in relation to any given case tends to be both complicated and unpredictable. This paper discusses the existing knowledge on asthma and its management with respect to a specific case scenario. Part A examines the existing knowledge of asthma, while part B is a discussion of its management.

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What is Asthma?

Asthma is a chronic inflammatory disease that affects the pulmonary system. Asthmatic individuals constantly suffer from various degrees of inflammation and constrictions of the smooth muscles of the airways. Asthma causes the mucosa of the airways to be hypersensitive to stimuli. When a stimulus triggers an inflammatory response in the pulmonary tract, some of the body cells release mediators that trigger mucous hypersecretion (Brisson 2005). Tom suffers from asthma and he has been hospitalized on account of his symptoms.

Incidence of Asthma and Implications

The global burden of asthma is estimated to be 300 million cases. It is postulated that this number may increase by 100 million individuals by 2025 partly due to increasing rate of urbanization and pollution. Studies have proven that cases of asthma are higher in the urban areas compared to the less polluted rural areas. Asthma is the leading chronic disease associated with children in industrialized countries including Canada, the EU, the U.S., and East-Asia. Tom started developing asthmatic symptoms at the age of 7 years. 15 million disability-adjusted life years (DALYs) are lost every year to asthma in the entire world. Asthma is responsible for 1 out of every 250 global deaths (Brisson 2005).

Common Signs and Symptoms of Asthma

There are number of common and very distinct signs and symptoms associated with asthma. First, coughing seems intense near midnight and early morning making it hard for the patient to sleep (Borton 2013). Second, the patient produces a whizzing sound when he/she breaths. Third, the patient experiences chest tightness. Shortness of breath is another common symptom (What are the Signs and Symptoms of Asthma? n.d.). Tom has been experiencing all the aforementioned symptoms.

Pathophysiology of Asthma

Asthma is a chronic disease that is accompanied by an inflammation of the pulmonary airways and bronchial hypersentivity. Tom has been experiencing an obstruction of the lower respiratory tracts. This is a reversible process that starts to manifest at childhood, as was the case with Tom. Tom uses salamol to open up his airways and relieve labored breathing. He occasionally used salbutamol to open up the obstructed airways. Bronchial hypersentivity leads to a decrease in airflow through the bronchi following bronchoprovocation with histamine or methacholine.

Biopsy of the sputum from an asthmatic airway shows increased levels of eosinophils, neutrophils, lymphocytes, and plasma cells. During the onset of asthma, there is transfer of leukocytes from the blood to the bronchial airways via activated CD4 T-lymphocytes (Fireman 2003). The T-lymphocytes direct the discharge of inflammatory mediators from lymphocytes, mast cells, and eosinophils (Fireman 2003).

Pathophysiology of Acute Exacerbation of Asthma

The pathophysiology of acute exacerbation of asthma is not yet clear. Research findings of a study by Green et al. (2002) support a central position occupied by eosinophils in the development of asthma. However, this assumption has not been upheld by results of a study involving a reduction of sputum eosinophilia following allergen exposure after treatment with human monoclonal antibodies to interleukin 5, but which had no effect on the initial or late decrease in forced exhaled volume (FEV1) or on the responsiveness of the airways.

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Hyper-resposiveness of airways is more closely related to mast-cell infiltration of the smooth muscles of the airways than with existence of eosinophils, thickening of basement membrane, and activated Th2 cells in the submucosa of the respiratory tract. Nevertheless, the pathophysiology of severe asthma exacerbations is complicated and encompasses mucosal oedema, mucous hypersecretion and constriction of the lumen of the bronchi via impaction with cellular debris and smooth muscle contraction (Green, et al. 2002). In this case, Tom has been exhibiting serious symptoms, and this has necessitated an emergency attention to try and alleviate the symptoms and safe his life as he is likely to suffocate to death if no medical attention is provided.

Diagnosis and Definition of Exacerbation of Asthma

Exacebation of asthma is clearly described in a study conducted by Cosentini, et al. (2008) to assess the correlation between acute pneumonia infection and the severity of acute exacerbation of bronchial asthma (AEBA). Here, AEBA is defined as incidences of worsening increases in shortness of breath, chest tightness, wheezing, or cough, or a overlap of such symptoms result in emergency visits, and linked to a decline of respiratory airflow quantified by measurements of peak expiratory flow (PEF) or FEV1. Severe exacerbations of asthma is designated by a PEF below 50 percent as per the BTS criteria (British Thoracic Society 2003). It is possible to assess whether Tom’s condition has improved by measuring his PEF with progressive treatment.

The diagnosis of acute exacerbated asthma revolves around eosinophils levels in the lungs. According to Green, et al. (2002), eosinophils are known to have a proinflammatory role in the pathogenesis of asthma. Therefore, examination of the fluids from the lungs show increased levels of eosinophils and their mediator. In addition, sputum eosinophilia establishes many weeks prior to the start of an exacerbation (Green, et al. 2002).

Treatment guidelines for acute exacerbation of asthma

Treatment of this form of asthma involves a combination of elements that have different effects on the patient.

Oxygen

Statistics reveal that majority of the patients diagnosed with acute exacerbated asthma also tend to be hypoxemic. For this reason, when administering supplimentary oxygen, this should be done urgently. In addition, the person administering oxygen should wear a nasal cannulae and a face mask. Moreover, the recomnded flow rates of the Ventura mask shoudl be maintained. Tom is not receiving oxygen as an independent dose but as oxygen driven bronchodilators.

β2 Agonist Bronchodilators

Normally inhaled β2 agonist administered in high amounts relieves bronchospasm quickly and cause minimal adverse effects. Intravenous β2 agonists should be reserved for patients in whom practical use of inhalers is impossible. These bronchodilators inhalers should be driven using oxygen nebulizers. Nevertheless, in serious manifestation of asthmatic symptoms that do not respond to a first dose of β2 agonist, continuous nobulization with a relevant nebulizer is recommended.

Steroids

Steroids should be given in sufficient amounts in cases of acute exacerbation of asthma, either as tablets or injections. Prednisolones 40-50 mg per day or injected hydrocortisone 400 mg per day are efficient as higher doses (Little 2007).

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Ipratropium bromide

Ipratropium bromide is recommended alongside β2 agonist bronchodilators for such cases of acute exacerbated asthma or those manifesting poor early reactions to the later therapy. Tom is receiving 30 mg of Ipratropium bromide per day.

Magnesium Sulphate

Magnesium sulphate is recommended for cases of acute severe asthma that do not respond well to bronchodilators inhalers at the beginning of therapy. They are also recommended for cases of life threatening or close to fatal asthma. Magnesium sulphate is not part of the dose Tom is receiving.

IV Fluids

Some cases of acute asthma may need rehydration and rectification of electrolyte equilibrium, as β2 agonist bronchodilators and/or steroid therapy may cause hypokalaemia (British Guideline on the Management of Asthma: A National Clinical Guideline 2012). In Tom’s case this treatment option is not part of the regimen.

Triggers for Ashtma

Certain factors trigger asthma and they include allergens, infections of the respiratory system, irritants, some medications, exercise, gastro-esophageal reflux, smoke, emotional anxiety and nervous stress. Also fluctuating weather conditions including changes in temperature, atmospheric pressure, humidity, and wind currents can trigger asthmatic attack. Some medications cause as high as 20% of asthmatic attacks in adults. They include aspirin, ibuprofen, naproxen, and indomethacin (NSAID). Also sulfites used as food preservatives have been associated with asthma attacks (Triggers for Asthma Attacks n.d.). Strenuous activities such as running over a long distance often can trigger asthma attacks.

The mechanism of emotional anxiety and stress works to trigger asthma attack through its effects on the immunity. In the case study exposure to emotional anxiety and stress associated with academic demands associated with pursuing a degree is responsible for Tom’s current condition. Other triggers of asthma include gastroesophageal reflux.

Pharmacokinetics and Pharmacodynamics

Salbutamol

Different formulations of this drug are available for administration through a number of routes including inhalation, oral, and parenteral routes. The parental route entails intramuscular, intravenous, and subcutaneous injection. Tom is receiving this drug through salbutamol nebulizers.

The key factors that determine drug absorption are the method of administration, and their formulation. Between 10 and 30 percent of the inhaled drug is absorbed through the lungs, while the rest goes to the GIT. Once absorbed, salbutamol distribution occurs via protein carriers. Salbutamol binds and releases from plasma protein accordingly (Salbutamol n.d).

In addition, the rate of drug metabolsim is also determined by the route of administration. Salbutamol administered through the mouth enters the GIT and undergoes a substantial first pass metabolism in the liver, where it is metabolized into phenolic sulfate. The inhaled salbutamol interacts with the smooth muscles of the upper airways overlapping the hepatic metabolism. The drug and its metabolite are primarily excreted through the urinary system (Mann 2000).

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Use of salbutamol in the treatment of asthma has a number of side effects. First, salbutamol causes palpitations, which Tom manifests this side effect as his pulse is slightly higher than the normal range. Other side effects include sinus tachycardia, anxiety, tremors and hypertension. To avoid this risks, full assessment of cardiac, hemodynamic, and renal status is necessary to identify high risk patients so as to tailor their treatments.

Ipratropium bromide

Ipratropium is transformed in the body into eight different compounds through a phase 1 metabolism in the liver. The bioavailability of inhaled formulation is approximately 6.9% while oral availability is 2%. 2 mg of inhaled Ipratropium bromide do not cause remarkable changes in heart rate and blood pressure. However, 2 mg of IV administered Ipratropium increases heart rate to 33.5 beats/min, systolic BP of 4.5 mm Hg and diastolic BP of 10.0 mm Hg. The onset of effect of this drug is 0.5 hours after administration, the maximum effect last between 1 and 2 hours while the duration of effects last for 6 hours (Burton et al. 2006). This drug is mainly responsible for the higher than normal blood pressure indicated by Tom. Consequently, thus the nurse should withdraw this drug because of these side effects and administer hypotensive drugs to reduce blood pressure to normal.

Side effects associated with ipratropium include headache, pain, influenza-like symptoms, back pains, chest pains. Cardiovascular related disorders include hypertension, or aggravated hypertension. Those associated with central and peripheral nervous system are dizziness, insomnia, tremor, and nervousness (Burton et al. 2006). on the other hand, the administration of Ipratropium bromide also causes side effects to the GIT, including constipation and nausea.

Prednisolone

Prednisolone belong to the glucocorticoid group of chemicals. They are adrenocortical steroids. They inhibit production of interleukins, cytokines, and prostaglandins. Predisolone has a wide range of side effects affecting most aspects of the body physiology. They include retention of sodium, retention of fluid, congestive heart failure in high-risk patients, potassium loss, hypokalemic alkalosis, and hypertension. In addition, the drug is also associated with osteoporosis, and vertebral compression fractures. It can also lead to the development of peptic ulcer, esophagitis, pancreatitis, abdominal distension, and ulcerations (Burton 2013). Prednisolone also impair wound healing, and makes skin thin and fragile, in addition it suppress reactions to skin assessment, increased perspirations, facial erythema, patechiae and ecchymoses.

Specificity and Selectivity of the Beta2agonist

Therapeutic use of activation of beta2agonist receptors relates to the conditions of the lungs and the uterus only. Beta2receptors agonist offer a relief of symptom associated with constriction of airways due to response of the airways to a class of elements that trigger asthmatic attacks.

Asthmatic patients mainly inhale most types of β2 agonists. Part of the reason for chosing this mode of administration is that it aids in reducing side effects. Nevertheless, inhalation does not guarantee safety as severe systematic toxicity may occur from overdosing with inhaled sympathomimetics (American Breathing Easier n.d.). Therefore, nurses must caution Tom against overdosing with inhalers or nebulizers. Because salbutamol is selective to β2 receptors, it generates minimal activation of β1 receptors than isoproterrenol. Consequently, salbutamol and other β2 selective drugs have substituted isoproterenol for therapy.

Role of Steroids in Acute Exacerbations of Asthma

Steroids are recommended in all acute exacerbations of asthma because they minimize mortality, relapses, consequential hospitalization and need for β2 agonist regimen. The favorability of the outcome depends on the time they are prescribed to the asthmatic (British Guideline on the Management of Asthma: A National Clinical Guideline 2012). Once Tom stabilizers, the nurse can withdraw salbutamol and Ipratropium but continue predisolone alone.

Effects of the Pharmacology of the Medication on Nursing Care

Because of the pharmacology of the bronchodilators a nurse attending to Tom must remain with him following the start of the treatment or at least explicit improvement is evident (Aldington & Beasley, 2007). The nurse must ensure that Tom is assessed regularly by measuring heart rate and lung function a minimum of each 15 minutes. Once Tom indicates improvement, the nurse must monitor the parameters before and after bronchodilator treatment. Once he stabilizes, the nurse can then transfer Tom to a medical ward where oxygen treatment will be continued if he is hypoxic and salbutamol be administered every 2 to 4 hours. The nurse should discontinue ipratropium bromide treatment past the initial 12-24 hour regimen (Aldington et al. 2007).

Nurses attending to Tom should ensure that they continue the admission of prednisolone throughout the admission. They should bear in mind that a single morning dose of the same may not protect Tom from the circadian obstruction of the airways that occurs at night. The nurse should understand that the peak effect of prednisolone, oral steroids, happens at approximately 9 h and then falls, and not provide adequate pharmacological effect through the 24 dosing regimen (Aldington et al., 2007). Thus, nurses must ensure that they administer prednisolone twice daily, in the morning and at 15:00 following morning dose.

6 Rs of Medicine Management

The 6 Rs of management include time, the route, the patient, dose, medicine, and records. The medication prescribed for this patient is right for his current condition as recommended in the BTS guideline. The route of administration for the prescribed drugs are varied. Tom is prescribed salbutamol, ipratropium bromide, and prednisolone. The first two are administered orally via oxygen nebulizers while the later is administered orally for 5 days. The dosage for salbutamol is 5 mg four times a day, while Ipratropium bromide is given 0.5 mg four times per a day. The dosage for prednisolone is 30 mg a day and is administered one every day for 5 days. These dosages are relevant for adults individuals.

Care and Management of Nebulizers

Either Tom or the nurse should first clean their hands thoroughly with clean soapy water. Thereafter, they should wash the nebulizer with clean and warm soapy water. The mouthpiece and cap should also be cleaned and rinse thoroughly. After cleaning the nebulizer, the nurse or Tom should disinfect the cup and mouthpiece placing in boiling water for not more than five minutes to avoid melting. Alternatively, the nebulizers can be disinfected using microwave in water for five minutes. Another approach is placing the nebulizer in dishwater above 1580c for half an hour. The last alternative is to soak in 70% isopropyl alcohol for five minutes (Care of Nebulizer and Compressor n.d.). The disinfecting approach depends on the manufacturer’s directions.

Education Regarding Nebulizers And Specific Drug Therapy For This Patient

Patient education on use of nebulizers should focus on explaining to the patients on the process of using the nebulizer and cleaning it. Patient education handouts are normally provided in hospitals to assist patient self-treat themselves. Tom should be taught how to use nebulizer as any miscalculated step in using it can lead to overdosing or under-dosing of self. The patient must also be trained to clean the nebulizer in order to avoid infection.

Education and Advice Regarding Asthma Management

Education relating to self-management of asthma should be incorporated into all dimension of asthma care. Education of Tom regarding use and care of nebulizers should be repeated to reinforce the knowledge. It should administer by practice nurse or RN at the time of diagnosis and continued during the entire follow-up care. Education regarding asthma treatment and management should also involve all affiliates of the care team (Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007) involved in treating Tom.

Importance of Prescribing Nebulizers Via Oxygen Driven Nebulizer

Most patients with acute exacerbated asthma are hypoxemic. Thus, it is necessary to use oxygen driven nebulizers partly to normalize oxygen levels in the patients. In addition, oxygen-driven nebulizer is choice for nebulising β2 agonist bronchodilators, as air-driven compressors pose a risk of oxygen desaturation (British Guideline on the Management of Asthma: A National Clinical Guideline 2012). Nurse should administer bronchodilators via oxygen driven nebulizers.

Legal, Professional and Ethical Points

Tom is experiencing a very high risk condition. His condition requires that medical practitioners observe great caution as any delays in administering the prescribed drug can cause very severe outcomes, or even death. It is the obligation of any professional nurse, pharmacist or doctor to ensure Tom’s safety and full recovery from his current condition. Any delay in administering the second dose of prednisolone may cause severe obstruction of airways at night that may lead to death. In case of death, the facility and the nurse involved could be faced with a lawsuit from Tom’s family. This situation may lead to decertification of the facility and dismissal of the nurse on duty.

Conclusion

While there is substantial knowledge in literature on the ordinary asthmatic condition, accurate knowledge on the pathophysiology of acute exacerbated asthma seems to evade the medical fraternity. However, high levels of eosinophils seem to be the most supported explanation for the condition. In addition, management of asthma involves a combination of drugs whose pharmacodynamics and pharmacokinetics vary substantially, despite them acting as synergy to one another. Steroids seem to sustain the effects of beta2agonist drugs and prevent a relapse of acute exacerbated asthma. A deep understanding of the pharmacodynamics and pharmacokinetics of drugs used for management of acute exacerbated asthma is very critical.

Reference List

Aldington, S & Beasley, R 2007, ‘Asthma Exacerbations 5: Assess and management of severe asthma in adults in hospital’, Thorax, vol. 62, no. 5, pp. 447-458.

American Breathing Easier n.d.. Web.

Borton, C 2013, Bronchial Asthma.

Brisson, L P 2005, Asthma: A Resource for Canadian Journalist, Ottawa, ON: Canadian Lung Association. Web.

British Guideline on the Management of Asthma: A National Clinical Guideline 2012. Web.

British Thoracic Society 2003, ‘British Guideline on the Management of Asthma’, Thorax, vol. 58 no. 1, pp. 1-94.

Burton, ME, Shaw, LM, Schentag, JJ & Evans, WE 2006, Applied Pharmacokinetics & Pharmacodynamics: Principles of Therapeutic Drug Monitoring, Lippincott Williams & Wilkins, Philadelphia.

Care of Nebulizer and Compressor n.d. Web.

Cosentini, R, Tarsia, P, Canetta, C, Graziadei, G, Brambilla, AM & Aliberti, S 2008, ‘Severe Asthma Exacerbation: Role of Acute Chlamydophila Pneumoniae and Mycoplasma Pneumoniae Infection’, Respiratory Research, vol. 9, no. 48, pp. 1-6.

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007.

Fireman, P 2003, ‘Understanding Asthma Pathophysiology’, Allergy Asthma Proc , vol. 24, no. 2, pp. 79-83.

Green, RH, Brightling, CE, McKenna, S, Hargadon, B, Parker, D & Bradding, P 2002, ‘Asthma Exacerbations and Sputum Eosinophil Counts: A Randomsed Controlled Trial’, Lancet , vol. 360, no. 9347, pp. 1715-21.

Little, F 2007, Can Emotional Stress Exacerbate Asthma? Web.

Mann, J 2000, Murder, Magic and Medicine, Oxford University Press, London. Salbutamol n.d. Web.

Triggers for Asthma Attacks n.d. Web.

What are the Signs and Symptoms of Asthma? n.d. Web.

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