How to write a nursing paper on the pharmacological Effects of Asthma Medications in the Management of Asthma

Noncommunicable diseases like heart disease, cancer, diabetes, and asthma are a major threat to the lives of many people today. These illnesses account for almost 70% of all deaths worldwide and contribute to premature death (Bidder, 2019). The majority of these diseases are caused by risk factors like tobacco use, physical inactivity, and unhealthy diets. Because of their burden on the affected individuals, families, and the community, it is important to understand the disease process and treatment approaches available. Asthma is a non-communicable disease that is associated with airway inflammation and hyper-responsiveness to several stimuli. The focus of this discussion is to describe the disease process, pathophysiology, and pharmacological agents available to manage the disease.

Asthma Disease Process

Asthma is a chronic condition that affects the airways causing inflammation and narrowing of air passages. According to reports from international health organizations, asthma affects more than 300 million people globally and it leads to more than 250000 deaths annually (Asthma and Allergy Foundation of America (AAFA), 2019). In the United States, the burden of the disease continues to rise with a significant increase in mortality and morbidity. For instance, 25 million Americans live with the disease and it poses a great threat to the cost of living, especially for those with low income (AAFA, 2019). Although the disease is very common in children, many adults die from Asthma as a result of poor management and treatment.

Asthma is a highly heterogeneous condition characterized by different underlying disease processes called asthma phenotypes (Rothe et al., 2018). These phenotypes are crucial in classifying patients and determining outcomes during treatment. The first category is early-onset asthma which occurs during childhood. This type of asthma is caused by a family history of allergic disease and manifests upon exposure to allergens (Rothe et al., 2018). The second category is adult-onset asthma which occurs after a series of infections like chronic sinusitis and prolonged exposure to allergens. Exacerbations of asthma among adults are associated with peripheral eosinophilia and different responses to medication may be observed. Other phenotypes include neutrophilic asthma, asthma with fixed airway inflammation, and asthma with obesity.

Asthma has a range of severity, from mild, occasional wheeze to acute life-threatening airway closure. The Asthma disease process can be classified into four categories including intermittent, mild persistent, moderate persistent, and severe persistent asthma (Bidder, 2019). Intermittent asthma symptoms occur no more than two days a week. Mild persistent asthma symptoms occur for more than two days a week, but not necessarily every day while moderate persistent asthma symptoms occur daily. Severe persistent asthma symptoms occur daily and greatly affect or limit functioning and physical activity. The disease is very common in childhood leading to hospitalization and increased healthcare costs. According to the Centers for Disease Control and Prevention (CDC), the US government spends more than $80 billion per year on asthma management and treatment. The disease causes a significant effect on the economy because it is associated with over 10 million missed workdays.

Pathophysiology of Asthma

Asthma is a chronic respiratory disease that is associated with airway inflammation and hyperresponsiveness (Bidder, 2019). The pathophysiology of the disease is complex because it is associated with a series of immune responses that lead to the manifestation of symptoms. However, the key factor in the development of the disease is an inflammatory response that involves key players like inflammatory cells, inflammatory mediators, and airway changes (Bush, 2019). Various scholars have established the role of Th1 and Th2 lymphocytes in triggering an inflammatory response that causes airway changes (Rothe et al., 2018). The involvement of immunoglobulin E (IgE) and cells of the immune system like leukotrienes, mast cells, cytokines, histamines, and prostaglandins causes inflammation, bronchoconstriction, and airway hyperresponsiveness.

Airway inflammation is the first physiologic response observed in patients with asthma and it can be either acute, subacute, or chronic. It is established that the loss of normal balance between Th1 and Th2 lymphocytes leads to airway inflammation (Rothe et al., 2018). For instance, Th2 cytokines mediate allergic airway inflammation whereby mediators of the immune response like macrophages and epithelial cells are released to cause inflammation. These cells also trigger the release of IgE that actively mediates responses to allergies in patients with asthma. The second feature observed after airway inflammation is bronchoconstriction, airway edema, and mucous secretin that lead to airway obstruction (Bush, 2019). This response is a result of IgE release and activation of dependent mediators that narrow the bronchioles and cause edema.

The last mechanism of the asthma disease process is bronchial hyperresponsiveness which serves to compensate for airflow obstruction. Acute hyperresponsiveness is thought to result from acute inflammatory changes such as mucus hypersecretion, airway wall edema, and plasma leakage (Bush, 2019). During treatment, acute airway hyperresponsiveness responds well to inhaled corticosteroid therapy. Chronic airway hyperresponsiveness is caused by airway wall remodelings such as fibrosis, smooth muscle hyperplasia/hypertrophy, and airway nerve hyperalgesia (Bush, 2019). This category does not respond well to corticosteroid therapy when administered for many years. These changes in the airway lead to the manifestation of symptoms of asthma including wheezing, chest tightness, shortness of breath, sleeping difficulties, and frequent asthmatic attacks (Rothe et al., 2018). Asthma triggers include exercise, chronic sinusitis, tobacco smoking, obesity, viral respiratory tract infections, environmental allergens, and the use of medications like beta-blockers.

Pharmacological Agents for Asthma Treatment

The management of asthma uses a stepwise approach that depends on the severity of the disease and response to treatment. For example, step 1 treatment usually involves the use of low-dose inhaled corticosteroid and formoterol. The second step involves treatment with daily low-dose inhaled corticosteroid plus as-needed short-acting beta 2 agonists. During step 3, the management of the disease is through medications like low-dose inhaled corticosteroids and long-acting beta 2 agonists plus as-needed short-acting beta 2 agonists. Step four represents a more severe form of the disease and management is done using medium-dose inhaled corticosteroids. The last step involves management of the disease using high-dose inhaled corticosteroids and long-acting beta 2 agonists plus long-acting muscarinic antagonist/anti-IgE. Because of the variations of the disease presentation, there are many classes of medications used to manage asthma.

Quick-Relief Medications

Quick-relief medications give fast relief for tight, narrowed airways and symptoms of wheezing and coughing observed in asthma patients. The first class of medication under this category is beta-2-adrenergic agonists. These drugs provide relief from symptoms by relaxing the smooth muscles of the bronchi. Short-acting beta-2 agonists (SABAs) are used for patients with exercise-induced asthma and include drugs like albuterol and levalbuterol. Advanced practice nurses should monitor patients for side effects like tachycardia, hyperglycemia, and tachyphylaxis that commonly occur with the use of SABAs.

The second class of medication for quick relief is anticholinergic agents. These drugs work by inhibiting the muscarinic cholinergic receptors reducing the intrinsic vagal tone of the airway (Gosens & Gross, 2018). Examples include Ipratropium and tiotropium drugs which can be combined with beta-2 agonists to achieve maximum effect. Advanced practice nurses should understand that ipratropium and tiotropium are the only approved anticholinergics for asthma treatment (Gosens & Gross, 2018). Ipratropium is a short-acting agent that provides quick relief to reversible airway obstruction in acute and chronic asthma while tiotropium is a long-acting form approved as an add-on therapy to inhaled corticosteroids.

The third category that can provide quick relief to asthma is systemic corticosteroids. These drugs provide faster relief of symptoms during moderate and severe exacerbations and speed up recovery. An example is methylprednisolone and prednisolone which are used to address issues with airway inflammation. The mechanism of action includes increased permeability of the capillaries brought about by polymorphonuclear leukocyte activity. Overall, the national guidelines for the management of asthma recommend SABAs as the first-line treatment for patients with mild asthma (Papi et al., 2020). These agents are recommended as rescue agents for rapid symptom relief because asthma is mainly related to bronchial smooth muscle contraction (bronchoconstriction) rather than a condition concomitantly caused by airway inflammation (Papi et al., 2020).

Long-Term Control Medications

Inhaled corticosteroids. Inhaled corticosteroids (ICS) are the mainstay treatment for controlling asthma exacerbations in patients with persistent asthma (Papi et al., 2020). These drugs relieve symptoms by suppressing inflammation and reducing airway hyperresponsiveness. Examples include beclomethasone, fluticasone, budesonide, mometasone, and ciclesonide. Advanced practice nurses should understand that patients with severe asthma have a poor response to corticosteroids and this requires high doses of medication (Papi et al., 2020). Additionally, the effectiveness of these drugs can be achieved in combination with inhaled beta-2 agonists.

Inhaled long-acting beta-2 agonists (LABAs). LABAs are bronchodilators used to treat acute bronchospasms in combination with ICs to prevent asthma symptoms (Rothe et al., 2018). Examples include salmeterol which acts by relaxing smooth bronchiole muscles and formoterol. Although these drugs are well-tolerated, high doses can lead to tremors and palpitations.

Immunomodulators are another class of drugs used for the long-term management of asthma, especially for those with frequent exposure to allergens. Examples include omalizumab, mepolizumab, and reslizumab. Long-term control of asthma can also be achieved by the use of leukotriene receptor antagonists like montelukast and zafirlukast. These drugs are mainly used as adjunctive therapy to ICS. Lastly, methylxanthines are a unique class of medication used for the management of severe acute asthma to achieve bronchodilation. An example is theophylline medication that is used together with ICs to achieve bronchodilation in asthma and patients with COPD. Overall, the anti-inflammatory relive strategy is more effective than other strategies in controlling asthma and reducing exacerbations (Papi et al., 2020). SABAs are the preferred options for rescue during asthmatic attacks because they dilate the bronchioles to ease breathing.

References

Asthma and Allergy Foundation of America. (2019). Asthma facts and figures. Retrieved from https://www.aafa.org/asthma-facts/

Bidder, T. M. (2019). Effective management of adult patients with asthma. Nursing standard (Royal College of Nursing (Great Britain): 1987), 34(8), 43-50. DOI: 10.7748/ns.2019.e11411

Centers for Disease Control and Prevention. (2020). Asthma: Data, statistics, and surveillance. https://www.cdc.gov/asthma/asthmadata.htm

Bush A. (2019). Pathophysiological Mechanisms of Asthma. Frontiers in Pediatrics, 7, 68. https://doi.org/10.3389/fped.2019.00068

Gosens, R., & Gross, N. (2018). The mode of action of anticholinergics in asthma. The European Respiratory Journal, 52(4), 1701247.

https://doi.org/10.1183/13993003.01247-2017

Papi, A., Blasi, F., Canonica, G. W., Morandi, L., Richeldi, L., & Rossi, A. (2020). Treatment strategies for asthma: Reshaping the concept of asthma management. Allergy, asthma, and clinical immunology : Official Journal of the Canadian Society of Allergy and Clinical Immunology, 16, 75. https://doi.org/10.1186/s13223-020-00472-8

Rothe, T., Spagnolo, P., Bridevaux, P. O., Clarenbach, C., Eich-Wanger, C., Meyer, F., … & Leuppi, J. D. (2018). Diagnosis and management of asthma–the Swiss Guidelines. Respiration, 95(5), 364-380. https://doi.org/10.1159/000486797