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Brad King, RRT

HESC 3310
Lesson Plan
Slide 1:
Foundation and Prevention of Asthma Exacerbations
Slide 2:
Question: In your own words, define triggers.
Response: Triggers are things that can cause asthma symptoms, an episode or attack or make
asthma worse. Those who have asthma may react to just one trigger or may find that several
things act as triggers.
Key Point: There are many allergens and irritants that can cause an asthma sufferer to have an
asthma attack or flare-up. Symptoms of an asthma attack can at first be very mild and then
become suddenly very severe. It can quickly become deadly if the person cannot eradicate
themselves from the trigger or if they do not have their asthma medication. Recurrent exposure
to the same trigger may lead to a strong sensitivity to that trigger which may cause a more severe
reaction or asthma attack the next time the person is around the same trigger. Each person with
asthma is not the same, and each person does not react the same to a specific trigger. Often, by
reducing contact or exposure to a known asthma trigger can reduce asthma symptoms and reduce
the severity of the asthma attack.
Slide 3:
Learning objectives: At the summation of this lesson the health care provider will be able to
define Asthma, describe the four main symptoms of an asthma attack, distinguish between
irritants, allergens, and physical condition that trigger an asthma attack, and finally be able
identify and give examples of triggers found in the home, outdoor environment, food allergens,
drug and chemical reactions, and occupational triggers.
Slide 4:

Brad King, RRT


HESC 3310
Lesson Plan
Question: In your own words, how would you define Asthma?
Does anyone know someone with Asthma? How well is their asthma controlled, or does asthma
control the way they live?
Slide 5:
Key Point: As a healthcare professional, it is our responsibility to educate our patients on disease
processes in order reduce the rate of morbidity and mortality. We must treat every patient
interaction as an opportunity to enlighten individuals on the disorder they possess to improve
awareness and patient outcomes.
Slide 6:
GAS CONDUCTING SYSTEM: The trachea is the beginning of the conduction system that
allows air to enter the lungs. This system is also referred as the tracheobronchial tree.
The trachea extends through the neck to the mediastinum where it divides into two mainstem
bronchi. The average adult trachea is 2-2.5 cm in diameter and 10-12 cm long and is supported
by c-shaped cartilage rings. The trachea ends at the carina where it divides into the right and left
mainstem bronchi. The mainstem bronchi each divide into lobar bronchi leading to each lobe.
The lobar branch off into segmental bronchi and then into sub segmental bronchi. These
divisions continue until the smallest conducting airways, the bronchioles, are reached.
The last level of the conducting system is the terminal bronchioles which lead to the respiratory
bronchioles.
Checkpoint: Identify the Trachea, carina, mainstem bronchi, lobar bronchi, sub-segmental
bronchi, bronchioles.
GAS EXCHANGE SYSTEM: The respiratory bronchioles conduct air and also have areas that
participate in gas exchange. Gas exchange refers to the movement of O2 from the alveoli to the

Brad King, RRT


HESC 3310
Lesson Plan
blood and CO2 from the blood into the alveoli. The respiratory bronchioles lead to the alveolar
ducts which end in clusters of alveoli where the majority of gas exchange takes place. This area
is also referred to as the terminal respiratory unit.
Checkpoint: Identify the respiratory bronchioles, alveolar ducts, alveolar sacs, alveoli.
Slide 7:
There are 3 tissue layers in the wall of the airway.
Mucosa: The mucosa has an epithelial lining. The main cell type in this layer is pseudostratified,
ciliated columnar epithelium. Beneath these cells are basal cells. Basal cells include cilia and
goblet cells. Goblet cells are responsible for secreting mucus. Cilia are responsible for clearing
and defending the conducting airways.
Submucosa: The submucosa layer contains the bronchial glands which are the major source of
respiratory tract secretions. An increase in the number of bronchial glands results in an increase
in secretion production. This layer also contains mast cells. When these mast cells are stimulated
they excrete mediators such as histamine and leukotriene's. Histamine causes constriction of the
bronchial smooth muscle leading to bronchospasm and SOB. Leukotrienes are
bronchoconstrictors and they also promote inflammation by attracting and activating eosinophils.
Adventitia: The adventitia is a layer of connective tissue that surrounds the airways. It is
scattered with blood vessels, nerves, lymphatic vessels and adipose tissue.
Checkpoint: Identify and describe the three tissue layers in the wall of the airways.
Slide 8:
Key Point: 3 primary changes occur in the airway during an asthma attack.
Bronchial smooth muscle constriction: The smooth muscle constricts in response to a stimulus
such as dust, cold air, smoke, animal dander, etc.

Brad King, RRT


HESC 3310
Lesson Plan
Mucosal inflammation: The mucosa is infiltrated with eosinophils and other inflammatory cells
such as lymphocytes and mast cells, causing the tissue layer to become swollen or inflamed.
Hypersecretion of mucus: The number of goblet cells increases and the bronchial glands enlarge
resulting in excessive mucus secreted into the airways. This can lead to mucus plugging.
Slide 9:
Airway remodeling: If asthma is left untreated or poorly managed, recurrent episodes can lead to
permanent changes in the lung structure referred to as airway thickening or airway remodeling.
This occurs when scar tissue permanently replaces the normal airway tissue resulting in
obstruction that may not respond to treatment and eventual irreversible loss of lung function.
Slide 10:
Acute asthma: Acute asthma is defined as short term. If the patient develops and asthma attack
that lasts for days, even weeks, then he/she is described as having acute asthma.
Chronic asthma: If a patient has had asthma for years, he/she is described as having chronic
asthma.
Status asthmaticus: Status asthmaticus is defined as a severe asthma attack that does not respond
to conventional therapy. This condition can lead to respiratory failure and cardiac arrest.
Exercise induced asthma: EIA should be considered in all patients with asthma. a history of
dyspnea, cough, chest tightness or pain, wheezing or stamina problems during exercise suggests
exercise induced bronchospasm. Treatment usually begins with use of a SABA at least 15-20
minutes before the patient exercises.
Nocturnal asthma: Nocturnal asthma refers to asthma symptoms that occur during sleep.
Nocturnal asthma results in loss of sleep, leading to daytime sleepiness and irritability and can
make it more difficult to control daytime asthma symptoms.

Brad King, RRT


HESC 3310
Lesson Plan
Slide 11
Shortness of breath (dyspnea): An asthma sufferer may not notice this on a daily basis. When the
airways are narrow it is hard to get air in and out of the lungs.
Chest tightness: It is a signal that air is not being completely exhaled before the next breath is
inhaled. This leads to air trapped in the chest causing the chest to expand excessively.
Coughing: Asthma patients may cough to remove excess mucus from the lungs or it may be a
reaction to inflamed airways.
Wheezing: Air flowing through narrowed airways produces a high pitched, whistle noise known
as wheezing. If the air cannot get through the narrow airways, wheezing will not be produced.
This may be referred to as silent asthma and should be considered a serious situation. Many other
ailments may cause a patient to wheeze, such as CF, vascular rings around the trachea and
esophagus, congenital heart disease, bronchitis, pneumonia, bronchiolitis, and vocal chord
dysfunction. Be sure to clarify that not all patients will have ALL of these symptoms. They may
only display one or two of the symptoms.
Slide 12:
Irritant: An irritant is a substance that irritates the lungs and causes asthma symptoms.
Allergen: An allergen is a substance that causes an allergic reaction creating airway inflammation
and symptoms.
Key Point: Identify what triggers an asthma episode and work to avoid it or eliminate it entirely.
Slide 13:
Slide 14:
Smoking: Tobacco smoke is the number one source of indoor pollution. Patients with asthma
who smoke experience an increase in the decline of their lung function, increase in asthma

Brad King, RRT


HESC 3310
Lesson Plan
severity and they are less responsive to steroid therapy. These patient have more frequent
exacerbations and hospital admissions.
Dust and dust mites: Dust is the product of normal breakdown of materials. Common
components of dust include animal dander, insect remains, human hair and skin, tobacco ash,
material fibers, dust mites, spices, ect. Dust mites live in dark, warm, humid environments. This
includes common sources such as mattresses, rugs, towels, pillows, drapery, and stuffed toys.
Animal dander: Dander comes from common pets such as cats, dogs, horses, and also from other
sources such as hamsters, mice, rats, and cockroaches. If a patient is sensitive to cats then they
are sensitive to all species of cats and the same goes for dogs. Cat allergens can linger in an area
for years and be carried on clothing.
Molds: Mold is defined as a growth of minute fungi forming on vegetable or animal matter
associated with decay and dampness. Only a few molds produce allergens that can trigger and
asthma episode, including; Alternaria, Cladosporium, Aspergillus.
Slide 15:
Question: A 45-year-old woman calls a health care provider after experiencing an exacerbation of
her asthma. The health care provider asks the patient to describe what precipitated her symptoms.
She states I was outside doing spring weeding in my flower garden when I started coughing and
wheezing. I had to stop working and use my inhaler. the health care provider should inform the
patient that her symptoms are most likely caused by
A. Ragweed exposure
B. Industrial pollution
C. Allergic rhinitis
D. Aspergillus fumigatus

Brad King, RRT


HESC 3310
Lesson Plan
Answer: D. Aspergillus fumigatus
Slide 16:
These are the most difficult allergens to avoid. Seed bearing plants produce pollen that is carried
by the wind, insects, or animals. There are three classifications of plants that produce wind-borne
pollens:
Trees: These pollens are most often released between noon and 6pm. If the patients symptoms
worsen during the spring, tree pollen is most likely causing the problem.
Grasses: Most grasses release pollen from 7:30am throughout the day. If the grass is wet, the
release will be delayed until the moisture has evaporated. If the patients symptoms worsen
during the late spring to early summer, grass pollen is the most likely cause.
Weeds: Ragweed is most commonly the culprit in this category, it begins releasing pollen
between sunrise and 9am. If the patients symptoms worsen during the late summer to autumn,
ragweed is most likely causing the problem.
Pollen goes up in the atmosphere as the air warms during the day and then falls down as the air
cools after sunset. Most of it reaches the ground between 8-10pm. Patients who are sensitive to
outdoor allergens should try and stay indoors from midday to afternoon when pollen and spore
counts are the highest.
Slide 17:
Question: A 34-year-old female with well controlled severe persistent asthma visits the clinic.
She complains that when she goes outside in the afternoon to work in her garden, she frequently
has to use her albuterol inhaler for relief. This problem is most likely due to
A. Dander
B. Pollen

Brad King, RRT


HESC 3310
Lesson Plan
C. Pollution
D. cockroaches
Answer: B. Pollen
Slide 18:
Specific foods: Food allergens are most likely proteins found in the following: peanuts, fish,
shellfish, eggs, wheat, cows milk, tree nuts. Allergic reactions can develop within minutes to
hours after eating the food allergen. People react differently depending on what it is they are
allergic to.
MSG: MSG is a preservative used in many foods. It is rare for MSG to cause severe symptoms.
Tartrazine (yellow dye #5; FD&C yellow, #5)
This dye is used in many foods, medications and vitamins. Be sure to check labels before using
any cold or flu medications.
Sulfites: Found in: processed foods, shrimp, guacamole, wines and beers, soup mixes, canned
vegetables, trail mix, condiments. The most common reaction is difficulty breathing. Sulfites
have been known to trigger life-threating asthma symptoms, especially in patients with severe
persistent asthma. food labels may list sulfites as sulfur dioxide, potassium or sodium bisulfate,
potassium or sodium metabisulfite or sodium sulfite.
Slide 19:
Question: An individual with food allergies is having dinner with some business associates at a
local restaurant. He orders grilled chicken, broccoli, fresh bread, and wine. Which of these items
would most likely trigger an asthma attack?
A. Grilled Chicken
B. Broccoli

Brad King, RRT


HESC 3310
Lesson Plan
C. Fresh bread
D. Wine
Answer: D. Wine
Slide 20:
Aspirin/NSAIDS: This is not an allergic reaction so it cannot be identified with skin-prick testing.
The response to aspirin-like drugs takes a few minutes to two hours to progress. The diagnosis
can only be established by performing an aspirin challenge test. Once a patient develops aspirin
or NSAID hypersensitivity, it is present for life.
Non-Selective Beta Blockers: Non-selective beta blockers block both beta1 and beta2 receptors.
Beta2 receptors are responsible for the function of smooth muscle. Beta blockers are also called
beta-adrenergic blocking agents. Asthma patients should not take beta blockers. Taking these
drugs may make the airway contract and bring on an asthma attack. These drugs also worsen
asthma symptoms by blocking the receptor sites that cause bronchodilation.
Contraceptive pills: Pills that contain estrogen may make asthma worse. The asthma patient
should consider taking progesterone-only pills.
Omega3 oils: Studies have shown that there is little to no benefit for asthma patients taking these
supplements. Taken in high doses, Omega 3 oils can make asthma symptoms worse. Patients
sensitive to aspirin are most likely to be affected.
Slide 21:
Pets: Up to 30% of people with asthma are allergic to household animals, according to the
ACAAI. If you cant part with your pet, keep them out of your bedroom, bathe them once a
week, and wash your hands after petting them.

Brad King, RRT


HESC 3310
Lesson Plan
Smoke: Smoke irritates the linings of your airways, making you more susceptible to an asthma
attack. So dont let anyone smoke in your house or in your car, and try not to use wood-burning
stoves or fireplaces.
Dust Mites: Up to 90% of people with allergic asthma are sensitive to mites. Use a vacuum with
a HEPA filter, which traps small particles and buy allergen-resistant bedding. Or if you dont
want allergen-resistant bedding, be sure to wash regular bedding in hot water as often as
possible.
Mold: Keep the humidity in your house under 50% to avoid growing mold, which can trigger an
asthma attack, and fix leaky faucets and pipes as soon as you notice a problem.
Cold Air: Cold air can constrict airways, especially for people with asthma. When you are
outside in winter, be sure to cover your nose and mouth with a scarf.
Cockroaches and Mice: The problem isnt just them- it is also what they leave behind that can be
a problem. After calling in an exterminator, wash dishes right away after you eat and empty trash
often to prevent recurrences. Be aware of these triggers and stay away from them to prevent
yourself from having an asthma attack.
Slide 22:
Question: Based on the information provided, how would you diagnose this patient?
Answer: Acute asthma exacerbation.
Question: What is causing his tachypnea?
Answer: Several pathophysiologic mechanisms operating simultaneously may lead to an
increased RR rate. Stimulation of peripheral chemoreceptors (hypoxemia). Decreased lung
compliance and increased ventilatory rate. (hyperinflation). Anxiety.
Slide 23:

Brad King, RRT


HESC 3310
Lesson Plan
Question: How would you approach the patient and discuss eliminating asthma triggers?
Based on the information from this case study we have concluded that the patients asthma was
exacerbated by inhaling foreign substances while mowing the lawn. It is now the heath care
providers responsibility to educate the patient on how to eliminate from this occurring again in
the future by offering some tips to eliminate asthma triggers.
First you will want to educate the patient on asthma. Define asthma for the patient. Discuss the
symptoms associated with asthma. Explain what causes an asthma attack. Explain to the patient
that he may have pollen or mold allergy, and by inhaling these spores may be the source to his
asthma exacerbation. Explain the importance of eliminating the source by wearing a protective
mask or watering the lawn prior to mowing to prevent pollen or mold from becoming airborne.
You may also want to tell the patient to use his inhaler 20-30 minutes prior to mowing the lawn.