Chapter 29: Obstructive Pulmonary Diseases
Asthma is a chronic inflammatory lung disease that results in recurrent episodes of airflow
obstruction, but it is usually reversible. The chronic inflammation causes an increase in airway
hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness,
and cough, particularly at night or in the early morning.
Although the exact mechanisms that cause asthma remain unknown, triggers are involved.
o Allergic asthma may be related to allergies, such as tree or weed pollen, dust mites,
molds, animals, feathers, and cockroaches.
o Asthma that is induced or exacerbated during physical exertion is called exercise-
induced asthma. Typically, this type of asthma occurs after vigorous exercise, not during
o Various air pollutants, cigarette or wood smoke, vehicle exhaust, elevated ozone levels,
sulfur dioxide, and nitrogen dioxide can trigger asthma attacks.
o Occupational asthma occurs after exposure to agents of the workplace. These agents
are diverse such as wood and vegetable dusts (flour), pharmaceutical agents, laundry
detergents, animal and insect dusts, secretions and serums (e.g., chickens, crabs), metal
salts, chemicals, paints, solvents, and plastics.
o Respiratory infections (i.e., viral and not bacterial) or allergy to microorganisms is the
major precipitating factor of an acute asthma attack.
o Sensitivity to specific drugs may occur in some asthmatic persons, especially those with
nasal polyps and sinusitis, resulting in an asthma episode.
o Gastroesophageal reflux disease can also trigger asthma.
o Crying, laughing, anger, and fear can lead to hyperventilation and hypocapnia which can
cause airway narrowing.
The characteristic clinical manifestations of asthma are wheezing, cough, dyspnea, and chest
tightness after exposure to a precipitating factor or trigger. Expiration may be prolonged.
Asthma can be classified as mild intermittent, mild persistent, moderate persistent, or severe
Severe acute asthma can result in complications such as rib fractures, pneumothorax,
pneumomediastinum, atelectasis, pneumonia, and status asthmaticus. Status asthmaticus is a
severe, life-threatening asthma attack that is refractory to usual treatment and places the patient
at risk for developing respiratory failure. Diagnosis: there is some controversy about how to best diagnose asthma. In general, the health
care provider should consider the diagnosis of asthma if various indicators (i.e., clinical
manifestations, health history, and peak flow variability) are positive.
Patient education remains the cornerstone of asthma management and should be carried out by
health care providers providing asthma care. Desirable therapeutic outcomes include (1) control or
elimination of chronic symptoms such as cough, dyspnea, and nocturnal awakenings; (2)
attainment of normal or nearly normal lung function; (3) restoration or maintenance of normal
levels of activity; (4) reduction in the number or elimination of recurrent exacerbations; (5)
reduction in the number or elimination of emergency department visits and acute care
hospitalizations; and (6) elimination or reduction of side effects of medications.
Medications are divided into two general classifications: (1) long-term–control medications to
achieve and maintain control of persistent asthma, and (2) quick-relief medications to treat
symptoms and exacerbations.
o Because chronic inflammation is a primary component of asthma, corticosteroids, which
suppress the inflammatory response, are the most potent and effective
antiinflammatory medication currently available to treat asthma
o Mast cell stabilizers are nonsteroidal antiinflammatory drugs that inhibit the IgE-
mediated release of inflammatory mediators from mast cells and suppress other
inflammatory cells (e.g., eosinophils).
o The use of leukotriene modifiers can successfully be used as add-on therapy to reduce
(not substitute for) the doses of inhaled corticosteroids.
o Short-acting inhaled β -adrenergic agonists are the most effective drugs for relieving
acute bronchospasm. They are also used for acute exacerbations of asthma.
o Methylxanthine (theophylline) preparations are less effective long-term control
bronchodilators as compared to β 2adrenergic agonists.
o Anticholinergic agents (e.g., ipratropium [Atrovent], tiotropium [Spiriva]) block the
bronchoconstricting influence of parasympathetic nervous system.
One of the major factors for determining success in asthma management is the correct
administration of drugs.
Inhalation devices include metered-dose inhalers, dry powder inhalers, and nebulizers.
Several nonprescription combination drugs are available over the counter. An important teaching
responsibility is to warn the patient about the dangers associated with nonprescription
A goal in asthma care is to maximize the ability of the patient to safely manage acute asthma
episodes via an asthma action plan developed in conjunction with the health care provider. An
important nursing goal during an acute attack is to decrease the patient’s sense of panic. Written asthma action plansshould be developed together with the patient and family, especially
for those with moderate or severe persistent asthma or a history of severe exacerbations.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state
characterized by airflow limitation that is not fully reversible. The airflow limitation is usually
progressive and associated with an abnormal inflammatory response of the lungs to noxious
particles or gases, primarily caused by cigarette smoking.
In addition to cigarette smoke, occupational chemicals, and air pollution, infections are risk factors
for developing COPD. Severe recurring respiratory tract infections in childhood have been
associated with reduced lung function and increased respiratory symptoms in adulthood.
α1-Antitrypsin deficiency, an autosomal recessive disorder, is a genetic risk factor that can lead to
Aging results in changes in the lung structure, the thoracic cage, and the respiratory muscles, and
as people age there is gradual loss of the elastic recoil of the lung. Therefore some degree of
emphysema is common in the lungs of the older person, even a nonsmoker.
The term chronic obstructive pulmonary disease encompasses two types of obstructive airway
diseases, chronic bronchitis and emphysema.
o Chronic bronchitis is th