STATUS ASTHMATICUS

Status asthmaticus is a critical emergency that requires prompt intervention to avoid acute
and possibly fatal, respiratory failure. In this condition, the asthmatics attacks are unresponsive
to medical therapeutics, with severe bronchospasms creating decreased oxygenation and
perfusion.
During an acute asthmatic attack, the individual may demonstrate varying degrees of
respiratory distress depending on the duration of the attack, the severity of spasm. The
underlying cause of asthma is still as yet unknown, but it thought to be caused by imbalances in
adrenergic and cholinergic control of the airways, and their response to the allergens, infections
or emotional factors with which they come in contact. Intrinsic asthma occurs when the
triggering factors are irritation, infection, or emotions and intrinsic asthma occurs when
precipitated by allergic and complement-mediated factors. Asthma may be drug-induced by
aspirin, indomethacin, tartrazine, propranolol, and timolol.
In asthma, the airways are narrowed because of bronchial muscle spasm, edema,
inflammation of the bronchioles, and thick, tenacious mucus production. The narrowing leads to
areas of obstruction and these become hypoventilated and hypoperfused. Eventually a
ventilation/perfusion mismatch occurs and may lead to hypoxemia and increasing A-a gradient.
When PaCO2 rises to the point of respiratory acidosis, the patient is then considered to be in
respiratory failure.
The most common causes of status asthmaticus are allergen exposure, noncompliance
with medication regime, idiosyncratic drug reactions, and respiratory infection exposure.
Environmental factors, such as excessively hot, cold, dusty areas, may initiate status asthmaticus
because of the effect they have on the air that is breathed.
Wheezing may occur not only with asthma, but with chronic obstructive pulmonary
disease, congestive heart failure, pulmonary embolism, and tuberculosis, and these diagnoses
should be ruled out.
Patient who have status asthmaticus suffer pronounced fatigue because of the continuous
efforts of breathing, and they easily become dehydrated because of hyperpnea. The patient
usually has dyspnea, tachypnea, wheezing, tachycardia, pulsus paradoxus, and severe anxiety.
The goals of treatment include ventilator support, maintainance of adequate airway, and the
prevention of respiratory failure or barotrauma.
MEDICAL CARE
Laboratory: CBC and sputum specimen usually show eosinophilia; elevated WBC;
positive sputum cultures
Chest X-ray: used to observe for infiltrates or hyperinflation to the lungs; may be used to
visualize pneumothorax, hemothorax, or pneumomediastinum; chest X-ray offers little to
confirm status asthmaticus but can be of value to rule out their causes.
Arterial blood gases: to identify problem with oxygenation and acid-base balance;
initially PaCO2 may be low normal or decreased with elevated PH and decreased PaCO 2; with
severe asthmatic attacks a progression to normal or increased PaCO 2 may indicate impending
respiratory failure.

Spirometry: to provide information about severity of an attack, and to asses for

improvement with therapy; FEV1 is forced expiratory volume for 1 second and is usually <1500
cc during an asthmatic attack and will increase 500 cc or more of treatment is successful; peak
expiratory flow rates (PERF) are decreased and maybe <60 L /minute initially; but will increase
to 50% or more of predicted values after one hour if treatment is successful
Oxygen: to provide supplemental available oxygen
Broncodilator: albuterol (Proventil, Ventolin), aminophylline (Aminophylline,
Phullocotin), epinephrine (Adrenaline Chloride, Epi-Pen, Vaponefrin, Bronkaid) ipratropium
bromide (atrovent), isoproterenol (Isuprel, Isuprel Mistometer), Levalbuterol Hydrochloride
(Xopenex), meteproterenol sulfate (Alupent, Metaproterenol), oxtriphylline (CholedylSA),
Pirbuterol acetate (Maxair), salmeterol xinafoate (Serevent), terbutaline (Brethaire, Brethine,
Bricanyl), or theophylline (Aerolate, Elixophyllin, Theoliar, Theostat, theochron) used to relax
bronchial smooth muscle to dilate the bronchial smooth muscle to dilate the bronchial tree to
facilitate air exchange; many inhibit the enzyme that breaks down cAMP to relax pulmonary
blood vessels, some are beta-adrenergic agents
Corticosteroids: dexamethasone (Decadron, Cortastat), hydrocortisone (Cortef, SoluCortef, Cortenema), or methylprednisolone, (Medrol, Depo-Medrol, Solu-Medrol) among others
are used to decrease the inflammatory response and edema; most act by suppression of the
immune response by stabilization of leukocytic lysosomal membranes
Antimicrobials: used when infective process is documented; usually bacterial infection is
not a common precipitating factor
Mechanical ventilation: may be necessary when respiratory failure is present and
hypoxemia persists despite medical therapy
IPPB: used to assist the patient with deep inspiration to facilitate more productive
coughing of thick mucus and to deliver medication by an aerosol route
COMMON NURSING DIAGNOSIS
IMPAIRED GAS EXCHANGE (see MECHANICAL VENTILATION)
Related to: Bronchospasm, inflammation to bronchi, hypoxemia, fatigue, secretions
Defining characteristics: dyspnea, tachypnea, hypoxia, hypoxemia, hypercapnia, restlessness,
anxiety abnormal ABGs, dysrhythmias, decreased oxygen saturation
ANXIETY (see MECHANICAL VENTKILATION)
Related to: dyspnea, change in health status, threat
Defining Characteristics: fear, restlessness, muscle tenderness, --------------, helplessness, sense
of imp---------------, tachycardia, tachypnea
ADDITIONAL NURSING DIAGNOSES
INEFFECTIVE AIRWAY CLEARANCE

Related to: airway obstruction, edema of bronchioles, inability to cough or to cough effectively,
excessive mucus production
Defining Characteristics: adventitious breath sounds, dyspnea, tachypnea, shallow respirations,
cough with or without productivity, cyanosis, anxiety, restlessness, wheezing, chest tightness.
Outcome Criteria
Patient will maintain patency of airway and will be able to effectively clear secretions.
Patients will have clear breath sounds without wheezing
INTERVENTION
Monitor VS q 1-2 hours and prn. Observe for
pulse paradoxus. Notify physician for
significant abnormalities.
Observe respiratory status, patients ability to
maintain airway, work of breathing, nasal
flaring, pursed-lip breathing, and prolonged
expiratory phase
Auscultate lung fields q 1-4hours and prn.
Notify physician for significant changes.

Monitor arterial blood gases, and notify

physician for significant abnormalities.
Administer bronchodilators as ordered.

Monitor lab levels for attainment and

maintenance of therapeutic levels. Observe
patient for anorexia nausea vomiting,
abdominal pain, nervousness, restlessness,
and tachycardia.
Administer

RATIONALES
Pulse rates >110/min pulsus >12mm Hg with
concurrent tachypnea >30/min indicates
severe respiratory distress.
Presence of these symptoms may indicate
impeding respiratory failure.

Expiratory wheezing or rhonchi may be heard

as secretions and air move through the
narrowed airways. Decreased breath sounds
throughout the lung fields is a critical sign
because it means the patient cannot move
enough air to be heard by the clinician, and
oxygenation and perfusion are severely
compromised.
May indicate impending respiratory distress
and failure.
Nebulizers are usually the first line treatment
for asthma. Aminophylline is frequently
prescribed to relax bronchial smooth muscle
and mediates histamine release and cAMP
degradation, which facilitates improved air
flow.
Therapeutic levels of aminophylline range
between 10-20 mcg/ml. symptoms may
indicate theophylline toxicity, which will
require titration of the drug dosage.