Pathophysiology of the Respiratory System - Essay Example

?Table of Contents Introduction………………………………………………………………………… 3 1 Epidemiology……………………………………………………………… 3 2. Pathophysiology…………………………………………………………………….. 4 2.1 Basic pathology……………………………………………………………. 4 2.2 Role of hypersensitivity in the asthma disease manifestation…………….. 5 2.3 Role of IgE antibody………………………………………………………. 5 2.4 Role of mediators………………………………………………………….. 6 2.5 Outcomes…………………………………………………………………... 6 3. Risk factors………………………………………………………………………….. 6 3.1 Genetic predisposition……………………………………………………… 7 3.2. Stress induced asthma……………………………………………………… 7 3.3 Use of drugs…………………………………………………………………. 7 3.4 Family history of allergy……………………………………………………. 8 4. Signs & Symptoms………………………………………………………………… 8 4.1 Symptoms………………………………………………………………….. 8 4.2 Signs……………………………………………………………………….. 9 5. Diagnosis…………………………………………………………………………… 10 6. Management………………………………………………………………………… 10 6.1 Acute attacks……………………………………………………………….. 11 6.2 Inhalers and nebulizers…………………………………………………….. 11 6.3 Bronchodilators in mild acute attacks…………………………………….. 12 6.4 Corticosteroids in severe acute attacks…………………………………….. 12 6.5 Emergency responders……………………………………………………… 13 6.6 Chronic Asthma…………………………………………………………. 13 6.7 Corticosteroids combined with bronchodilators………………………… 14 7. Summary………………………………………………………………………….. 14 Asthma 1.0 Introduction Asthma is considered one of the problematic respiratory diseases in the world. It is chronic in nature and poses a significant burden on the health of the people, the economy of the nation, and the general manpower requisites of most countries (Centers for Disease Control, n.d). This disease is also known to affect all people of all ages and from different countries (CDC, n.d). Its symptoms are also associated with other respiratory diseases including allergic rhinitis, the common cold, and simple allergies. At present, there is no definite and accepted definition for this disease, but its primary features have long been accepted within the health community. These symptoms include respiratory symptoms such as wheezing, difficulty of breathing, shortness of breath, coughing, and bronchoconstriction (Bjerg, et.al., 2011). Other features include the fact that it is chronic in nature, it is episodic and it includes airway obstruction which accounts for its partly reversible nature following treatment. This disease is also considered inflammatory in nature (Bjerg, et.al., 2011). Its treatment process includes the management of its symptoms and its possible complications with some differences in treatment for adults and children suffering from the disease. The burden of asthma based on affected countries is seen in the figure below, where the countries in red indicate high rates of asthma attacks in both adult and child population. As can be seen in the figure below, the burden of the disease is high in countries like Ireland, the UK, Australia and New Zealand (Masoli, et.al., 2004). 1.1 Epidemiology The occurrence of this disease is more common in western developed countries like the US, the UK, and some parts of Europe (US Department of Health and Human Sciences, 2004). However, in recent years, its prevalence has increased in less developed countries in Asia and Africa. In the UK, its rates have increased since the 1960s and in Australia, about 2 million individuals are now suffering from this disease (Department of Health and Human Services, 2004). Its prevalence seems to be more common among boys before the adolescent years, however during adulthood years, the occurrence of the disease seems to be more common among girls. Its occurrence is also higher within urban areas and even more so for metropolitan cities. For those in the lower socioeconomic bracket, the prevalence of the disease is also considered higher (Department of Health and Human Services, 2004). In general, however, when considering the entire age population, the disease is highest in prevalence among school-age children. 2.0 Pathophysiology 2.1 Basic pathology Asthma is generally defined and identified through the hyperreactive airways among patients which is often further qualified with its partly or wholly obstructed airways. Persistence of inflammation is also common (Ozier, et.al., 2011). The obstruction of the airways is mostly attributed to the shortening of the muscles in reaction to a variety of stimuli. Such obstruction is often made worse due to mucous plugging of the airways. Due to increased reactivity, other stimuli would be triggered to contribute to the inflammatory cells activation (Ozier, et.al., 2011). These stimuli may include pollens, dust, smoke, exhaust fumes, cold, exercise, and sometimes, certain drugs. Where these stimuli are introduced into the airways, the mast cells, macrophages, and eosinophils as inflammatory cells are recruited. Immediately, mast cells (IgE) unleash the inflammatory mediators which then trigger contraction of the smooth muscles and edema in the mucosa (Choy, et.al., 2011). In combination, these symptoms compromise the lumen linings of the airways. The action of the lymphocytes causes a sequence of reactions which then lead to bronchospasm and other symptoms. The figure below demonstrates the difference between the normal and the asthmatic airway. (Carolina Allergy and Asthma, 2013) 2.2 Role of hypersensitivity in the asthma disease manifestation The immune response has a major function in managing inflammation observed in asthma. A balance in the T1 and T2 helper cells occur (Choy, et.al., 2011). The hygiene hypothesis relates asthma to the occurrence of the T2 helper cytokine pattern which has been observed in the newborn which then causes the production of IgE antibody in reaction to various environmental antigens (Burrowes, et.al., 2013). Atopy is one of the major indicators for asthma. Patients with this indicator have a very reactive response to environmental activity, even the most routine antigens (Burrowes, et.al., 2013). One of the usual features for these antigens is its proteinase activity. The cellular foundation of these proteinases and their inflammatory reactions has not yet been established (Bara, et.al., 2010). 2.3 Function of Immunoglobulin E The disease may be considered allergic or non-allergic asthma, based on environmental allergens reacting to IgE antibodies. There are IgE receptors with high affinity seen on mast cells (Otsuka, et.al., 2011). These cells react with the antigens leading to the discharge of inflammatory cells from the mast cells which then cause bronchoconstriction and triggering the inflammation of the airways. IgE is needed for allergic reactions and for inflammation. Monoclonal antibodies which have also been constructed as IgE have manifested encouraging results in the intervention process (Jin, et.al., 2011). This indicates the vital role which they play in the management of the disease. 2.4 Role of mediators For the asthmatic inflammatory response, various mediators react with the release of the effector cells. The activation of the mast cells and IgE dependent is the next step (Jin, et.al., 2011). TNF-? is discharged supporting the migration of the neutrophils and cells of the dendrites. The basophils are needed in order to differentiate T2 helper cells and they also discharge interleukin (IL) 4 & 6. The function of the eosinophils in asthma is unclear (Kowalski, et.al., 2011). However, interventions against IL 5, which helps support eosinophil survival, has been used to decrease the worsening of the disease. Chemoattractant IL 8 functions to increase the neutrophils in the airways (Kowalski, et.al., 2011). Leukotrienes come from mast cells. Eosinophils are considered to be strong bronchoconstrictors. As inflammatory mediators have limited actions, an improvement in the lung functions is observed (Muller, et.al., 2010). Aside from cytokines and leukotrienes, the histamine as well as nitric oxide also assist in the producing the inflammatory reaction (Muller, et.al., 2010). 2.5 Outcomes The outcome of exposure to allergens, as well as anaphylactoid reactions, and the activation of the IgE and mast cells, airway inflammation becomes the result (Galli and Tsai, 2012). Airway remodeling includes subephithelial fibrosis, including hyperplasia, hypertrophy of the smooth muscles, as well as hypersecretion of the mucosa (Galli and Tsai, 2012). 3.0 Risk Factors 3.1 Genetic predisposition Based on family and twin studies, a genetic link for this disease has been established. The various causes of asthma are varied. There is no proper gene which has been indicated in relation to asthma (Vaillancourt, et.al., 2012). The interactions of gene to gene and gene to the environment can cause the manifestation of the disease process. Various genes have been considered vulnerable to asthma. These genes include the skin and the mucosal defense, the recognition of the antigen, the immunoregulatory process, as well as the T2 helper cells differentiation (Vaillancourt, et.al., 2012). The single nucleotide polymorphisms have been considered for asthmatics. The chromosomes which indicate vulnerability to asthma including the locus on chromosome 5 related to serum IgE has been acknowledged (Lotval, et.al., 2011). However, whether or not they lead to asthma has yet to be answered. 3.2 Stress induced asthma Cold and exercise has been known to trigger asthma attacks, especially those with extremely reactive airways (Cantero-Recasens, et.al., 2010). For those whose trigger is exercise, the attack usually comes after the exercise, not during. Bacterial and viral agents including changes in the weather have also been considered as stressors and therefore, also triggers for the disease. The trigger may also be worse at night (Cantero-Recasens, et.al., 2010). This may be known as nocturnal asthma. Tobacco smoke exposure as well as pollutants has also been defined as triggers for asthma. 3.3 Use of drugs Some drugs have also been considered as triggers for asthma patients. Some of these medications are aspirin, beta blockers, interleukin-2, and nitrofurantoin (Kowalski, et.al., 2011). Aspirin-triggered asthma is observed with bronchoconstriction, nasal congestion, and redness in the skin after intake of aspirin. This is considered a systemic allergic reaction (Kowalski, et.al., 2011). In Australia, it has been known to occur in about 10.5% of the population, mostly among women. Its initial onset is at about 30 years. For those with a history of obstructive diseases, beta blockers must be avoided as they can prompt major bronchospasms among patients (Kowalski, et.al., 2011). 3.4 Family history of allergy Those having a family history of atopy, including maternal atophy are considered a major risk factor in the manifestation of wheezes, atopy, as well as asthma among children (Lloyd, 2010). Genes associated with atopy as well as airway sensitivity are inherited and contribute to the manifestation of asthma. 4.0 Signs & Symptoms 4.1 Symptoms Those with asthma describe their attacks to include wheezing, coughing at night, coughing induced by coughing, persistent rhinitis, and a persistence of these symptoms upon exposure to environmental triggers (Scholtens, et.al., 2009). For mild asthma attacks, patients may feel breathlessness as the season changes, difficulty in breathing upon exertion, persistent nasal congestion, and coughing (Scholtens, et.al., 2009). For acute severe asthma attacks, patients usually indicate tachypnea, tachycardia, and difficulty talking in one breath. 4.2 Signs For mild asthma attacks, the symptoms are often minimal. The wheezing may often be seen at the expiratory stage of the forced breathing. Nasal polyps may sometimes be observed among those having a previous history of allergies (Caudri, et.al., 2009). Among atopic individuals is often associated with atopic dermatitis. Upon the assessment of the respiratory system, wheezing is the often observed. The higher manifestation of asthma is indicated with physical findings including the expansion of the chest (Caudri, et.al., 2009). This result is often seen among children, sometimes related to children having hunched shoulders and deformed chest. In emergency cases, the wheezing may not be present due to the total blockage of the airflow. Other symptoms include tachycardia, cyanosis, difficulties in speaking, use of accessory muscles during respiration, irregular heart rhythm, and hypotension (Salo, et.al., 2009). Based on the elements mentioned above, asthma attacks can manifest. These elements are indicated below: (Allergywise, 2010) 5.0 Diagnosis The diagnosis of this disease calls for an evaluation of the patient’s history for airway hyperresponsiveness and obstruction of the airways (Sembajwe, et.al., 2010). The obstruction of the airways must be considered isolated cases and other possible diagnoses must be eliminated. Reversibility is considered to be an elevation of ? 12 % increase from baseline FEV1 or ? 10% rise in the FEV1 following inhalation with temporary duration of action (Sembajwe, et.al., 2010). A rise above 400 ml in FEV1 strongly may indicate asthma. Spirometry is crucial in diagnosing asthma because it is the most objective and accurate tool in assessing limitations in the airflow (Maio, et.al., 2010). It also assists in eliminating other possible lung disorders. For infants and children, their diagnosis and assessment can be carried out under the clinical setting (Maio, et.al., 2010). Other assessments may be carried out to assist in the diagnostic process (Dhar and Ghoshal, 2010). This includes peak expiratory flow rate as well as non-invasive measures for inflammation like the sputum eosinophil count and released concentrations of nitric oxide. 6.0 Management There are four variables in the management of asthma. These include disease monitoring, disease education, avoiding exposure to triggers, and drug therapy (Lougheed, 2010). 6.1 Acute attacks Acute attacks must be managed the soonest time possible. This process may be carried out in the patient’s home (Coffman, et.al., 2009). Patients must be instructed to recognize their triggers and be instructed as to possible plans in managing an acute attack. Under emergency conditions, in the hospital setting, the management would include the administration of oxygen, the use of bronchodilators, as well as the administration of corticosteroids (Power, et.al., 2012). The hypoxaemic patients suffering severe asthma must then be administered oxygen. The oxygen saturation being targeted is 95%. For hospitals and ambulances, the oxygen must be administered in the nebulization of beta agonists. With hypercapnea there is a threat to the life of the patient (Power, et.al., 2012). Sustained nebulization may be more helpful instead of bolus. The severe attacks may call for IV magnesium sulphate as well as HELIOX therapy. Aminophylline administered intravenously has not been seen as beneficial and has been related to various side effects (Ebben, et.al., 2013). With ipratropium bromide, alongside beta2 agonist agents during nebulisation greater bronchodilation may be observed (Chowdhury and Dal Pan, 2010). Thus, during acute severe attacks, a 0.5 mg ipratropium is given every 4 to 6 hours. Infants have a higher risk of suffering from respiratory failure. As such, they must be hospitalized as soon as possible (Chowdhury and Dal Pan, 2010). Infections caused by viruses can cause wheezing and must be resolved through the administration of antibiotics. 6.1.1 Inhalers and nebulizers Inhalation is the best route for asthma attacks. Under these conditions, the drug is given at the primary site affected, with the systemic impact being managed (Thomas and Pavord, 2010). Metered dose inhalers, both pressurized and breath actuated, inhalers, and nebulisers are the preferred devices for delivery of the drugs. Patients are taught how to manage their interventions in order to ensure medication (Thomas and Pavord, 2010). Spacers are often used to manage drug delivery as well as distribution of drugs in the lungs. The pressurized and metered dose inhalers with spacers are recommended to manage mild and moderate attacks among children and adults (Krishnan, et.al., 2012). For those who cannot apply these methods, other options are based on the drug to be administered. 6.1.2 Bronchodilators in mild acute attacks Mild asthma attacks can easily be relieved with the use of short acting beta agonists. Where no relief is seen with these agonists, then a short course of oral systemic corticosteroids may be given (Pauwels, et.al., 2012). An elevated dose of beta2 agonist agent is considered the primary therapy for managing bronchoconstriction during acute asthma attacks (Pauwels, et.al., 2012). Beta2 agonists administered intravenously are not effective in managing related issues. 6.1.3 Corticosteroids administered during severe attacks Severe manifestation of symptoms of asthma is qualified with dyspnea when patient is resting and sometimes during peak expiratory rate. Such patients require hospitalization as well as oral systemic steroids allows for some relief in symptoms (Brehm, et.al., 2010). With the earlier administration of steroids during acute attacks, better outcomes are expected. These can be given orally via tablets or injected to the patient. Prednisolone 40-50 mg given or hydrocortisone given through IV 100 mg every 6 hours are mostly effective in managing symptoms (Brehm, et.al., 2010). Inhaled corticosteroids can also be initiated in the chronic management of asthma. 6.1.4 Emergency responders The emergency team of paramedics is often involved in the prehospital management of asthma patients. As such, they are called in to retrieve the history of the patient, evaluate the severity of the airway obstruction and to identify any possible life-threats to the patient (Bendall, et.al., 2012). These paramedics also indicate the status of the patient as soon as they reach the hospital, and on the way to the hospital, IV lines are usually established, and oxygenation is provided. As paramedics, they must also be aware of the medications provided for immediate relief (Bendall, et.al., 2012). Present updates include standing orders for various drugs like oral corticosteroids, ipratropium, as well as albuterol. 6.2 Chronic Asthma The education of the patient is also crucial in order to manage chronic asthma in order to manage symptoms and prevent complications (Rosenfeld, et.al., 2011). These patients are also taught to avoid triggers including medications which can lead to bronchospasm. Support must also be ensured for smokers who must quit smoking. The device for the delivery of the drug must also be taught to the patient and must be re-evaluated occasionally (Rosenfeld, et.al., 2011). Peak expiratory flow rates are a favorable tool in evaluating and monitoring asthma. Inhaled corticosteroids are also important in preventing asthma attacks. Controller drugs are also recommended in order to manage the chronicity of asthma (Andrade, et.al., 2010). These drugs include corticosteroids, long-acting beta2 agonists, as well as IgE antibodies. The objectives in treatment are set to ensure the management of symptoms and to manage medication side effects. In this case, night awakenings, acute attacks must be avoided; better tolerance for exercise must also be promoted (Andrade, et.al., 2010). In reaching these objectives, inhalational corticosteroids are important for adults and children more than 5 years of age. Majority of the medications for asthma are administered in doses equal to 400 mcg budesonide daily (Rosenfeld, et.al., 2011). Other drugs include beclomethasone dipropionate, fluticasone as well as triamcinolone. In instances of limited relief seen via inhaled corticosteroids, add-on therapy is indicated, not so much on the increase of dosage. 6.2.1 Corticosteroids alongside bronchodilators For children less than 5 years of age beta2 agonists at three times a week must be administered with caution. These interventions must be combined with corticosteroids and bronchodilators (Krishnan, et.al., 2012). Majority of the corticosteroids are generally appropriate twice a day. The long-term impact of maximum efficacy is indicated at twice a day use. Among adults, the use may include oral candidiasis to bone loss. For children, the failure in growth and the suppression of the adrenal glands is often expected (Krishnan, et.al., 2012). Washing of the mouth following drug intake can decrease the manifestation of oral fungal issues. Leukotriene receptor antagonists are favorable alternatives for inhaled corticosteroids in children below 5 years of age (Bibby, et.al., 2010). 7.0 Summary Based on the above discussion, asthma is considered a chronic illness having major health, social, and financial implications. It is acknowledged as a partly reversible airway obstructive disease with associated symptoms of inflammation. 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