1. Epidemiology
   1. Pros
      1. The death rate from Asthma has been on a steady decline sine 1995.
      2. Asthma is controllable in combination with preventative care and proper treatment.
      3. New pharmacologic treatments provides the ability to better control Asthma.
   2. Cons
      1. Asthma effects as many as one third adolescents in some countries.
      2. Prevalence rate in American is around 4-8%.
      3. Boys are more frequently effected that girls.
      4. Around 26 million people and 7 million children are effected by Asthma in America.
2. Pathophysiology
   1. Bronchoconstriction in the trachea, bronchi, and bronchioles.
      1. Airway walls dilate and leak secretions, oedema, adding to the overall narrowing and hyper-responsiveness of the airway.
         1. Unmyelinated afferent fibers in combination with peptide neurotransmitters can induce smooth muscle or bronchospasm.
            1. Mast cell degranulation leads to vasoactive mediators increasing vasodilation and capillary permeability while chemotactic mediators increase cellular infiltration with the over-production of neutrophils, eosinophils, and lymphocytes.
            2. An abnormal narrowing and hypersensitive, congested airway.
3. Outpatient Treatment
   1. Green Zone: Doing Well •No cough, wheeze, chest tightness, or shortness of breath during the day or night •Continue normal activities +Continue long-term control medications daily and any medications needed before activities. ---> What is your best peak flow reading?
      1. Yellow Zone: Asthma Is Getting Worse •Cough, wheeze, chest tightness, or shortness of breath, or •Waking at night due to asthma; You can do some but not all normal activities. --->Is Peak Flow between 50-79% of best peak flow? Continue to take all Green Zone medication and add quick relief medication: Short-acting beta2-agonist -->every 20 minutes up to an 1 hour/ two-four puffs. Use Nebulizer if available. If symptoms resolve, return to Green Zone. If they do not continue in Yellow Zone and call MD for possible use of oral steroid in addition to nebulizer and short-acting beta2-agonist.
         1. Red Zone: Medical Alert! •Very short of breath and Quick-relief medicines are not helping. •Cannot do normal activities. •Shortness of breath making it difficult to walk or talk. •Blue lips or fingernails. •In the Yellow Zone for over 24 hours with similar or worse symptoms. ---> Is peak flow less than 50% of your best? **Continue taking medications in Yellow Zone and CALL MD. ***Take 4-6 puffs of quick-acting medications ****Call 911 or go straight to the hospital if symptoms continue past 15 minutes and/or you have not reached your doctor.
4. Inpatient Treatment
   1. Oxygen
   2. Inhaled short-acting beta 2-agonist intermittently or continuously
   3. Corticosteroids - oral or intravenously
   4. Consider other therapies
   5. Monitor patient closely: SpO2,FEV1, PEF, and vitals.
   6. In extreme cases consider intubation
5. References
   1. American Lung Association, (2016). Asthma Action Plan. Lung Health & Diseases. Retrieved from http://www.lung.org/assets/documents/asthma/asthma-action-plan.pdf.
   2. American Lung Association, (2016). How is Asthma Diagnosed? Lung Health & Diseases. Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease lookup/asthma/diagnosing-treating-asthma/how-is-asthma-diagnosed.html
   3. American Lung Association, (2016). Learn about Asthma. Lung Health & Diseases. Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/learn-about-asthma/
   4. Pollart, S. (2011). Management of Acute Asthma Exacerbations. American Family Physician. 84(1):40-47. Retrieved from http://www.aafp.org/afp/2011/0701/p40.html
   5. Huether, S.E. & McCance, K. L. (2012). Understanding pathophysiology (Laureate custom ed.). St. Louis, MO: Mosby.
   6. McPhee, S. J., & Hammer, G. D. (2010). Pathophysiology of disease: An introduction to clinical medicine (Laureate Education, Inc., custom ed.). New York, NY: McGraw-Hill Medical.
   7. Zimbron, J. (2008). Mind maps—Dementia, endocarditis, and gastro-oesophageal reflux disease (GERD) [PDF]. Retrieved from http://MedMaps.co.uk
6. Clinical Presentation
   1. Minimal no signs or symptoms
      1. No cough
      2. No wheezing
      3. No chest tightness
      4. No shortness of breath at day or night
      5. Able to do all normal activities
   2. Worse signs and symptoms
      1. Cough
      2. Wheezing
      3. Chest tightness
      4. Shortness of Breath
      5. Waking at night with symptoms
      6. Able to do some normal activities
   3. Life threatening signs and symptoms
      1. Very short of breath
         1. Difficult to walk or talk
            1. Blue lips or fingernails
            2. Medications not working
            3. Unable to do activities
7. Diagnosis
   1. Confirmed by a worsening of symptoms: like wheezing, frequent cough, shortness of breath or chest tightness.
      1. Low Expiratory Flow Rates (i.e. Peak Flow)
      2. Identification of underlying triggers or infection
      3. Respiratory alkalosis and hypoxemia
      4. Respiratory Acidosis is a late diagnosis sign showing impending respiratory failure in acute asthma exacerbations.
      5. Pulsus Paradoxus - a consequence of lung hyperinflation
      6. Tachypnea & Tachycardia
      7. Hypercapnia