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COPD and Asthma Characteristics, Causes, Symptoms and Treatments
- 1. COPD Characterized by: â«progressive airflow â«limitations into & out of the lungs â«Elevated AWresistance â«IRREVERSIBLE LUNG DISTENTION â«ABG IMBALANCE
- 2. Causes of COPD â«SMOKING(80 â 90%), 2nd hand smoke â«3 Eâs
- 4. 3 Primary symptoms and other manifestations: â«1. Sputum production â«2. chronic cough â«3. dyspnea (on exertion) â«4. weight loss â«5. use of accessory muscles
- 5. Laboratory Data â«1. ABG analysis â«2. chest x-ray: â«CONGESTION (in bronchitis) â«HYPERINFLATION (in emphysema)
- 6. Nursing Diagnoses â« Impaired gas exchange rt airflow obstruction from collapsed alveoli & narrow bronchioles â« Ineffective breathing pattern RT increased mucous & air trapping â« Activity intolerance RT fatigue & hypoxemia â« Nutrition imbalance less than body requirements RT increased energy expenditures from breathing difficulties
- 7. INTERVENTIONS â«AIRWAY!!! 1.Position 2.Admin Bronchodilators 3.Breathing & blowing exercises Ex. Incentive spirometry (deep inhalation & prolonged expiration)
- 10. OVERVIEW â«CHRONIC BRONCHITIS đĄȘinflammed bronchioles â«Aka âblue bloaterâ â«đĄȘobese, cyanotic
- 11. OVERVIEW â«EMPHYSEMA â«đĄȘ overdistented alveoli â«Aka âPINK PUFFERâ â«đĄȘthin, ruddy, barrel chest
- 12. OVERVIEW â«ASTHMA â«đĄȘinflammed air passages â«đĄȘwhitish sputum â«đĄȘ wheezing
- 13. GENERAL INTERVENTIONS (A-F) â«A â minophylline (Methylxantines â CNS & smooth muscles) â«Theophylline Signs of Toxicity: 1.Vomiting 2.hyperactivity 3.Insomnia 4.Agitation 5.Tachycardia (> 200 bpm)
- 14. B - ronchodilators (beta-adrenergics â Airway & smooth muscles) Types: (oral, inhaled, per neb) Metered-Dose Inhaler Dry powder inhaler Nebule Assignment: at least 5 pictures of different types of Bronchodilators ( long bond paper)
- 16. MDI â«Shake â«Tilt head back & breathe out slowly â«Press â inhale slowly & deeply (3 â 5 secs) â«Hold breath ( 8 â 10 secs) â«1 â 2 mins for the 2nd dose â«w/out spacer: 1 â 2â away (mouth) â«w/ spacer/ holding chamber: lips around the mouth piece â«Admin bronchodilator then corticosteroids ( wait for 5 mins)
- 17. SIDE EFFECTS â«Tachycardia â«Palpitations â«Dysrrhythmias â«Hyperglycemia â«h/a â«dizziness
- 20. C-hest physiotherapy â«Percussion & vibration over the thorax đĄȘ loosen secretions BEST TIME: â«AM â«1 HR Before, 2 hrs after eating STOP: PAIN Post care: ______
- 22. D- elivery of OXYGEN â«@ 1 â 3 â«LPM (1 â 2 LPM) â«Stimulus to breathe is a low arterial P02 â«đĄȘ RESPIRATORY DISTRESS â«pH= 7.35-7.45 â«P02 = 85 â 100 mmHg â«PC02= 35 â 45 mmHg â«HC03= 22-26mEqs/L
- 23. Evaluation of Oxygen (P02) âź100 = more than adequate 02 âź85 â 100 = adequate 02 âź78 â 84 = mild hypoxemia âź60 â 77 = moderate hypoxemia âź40 â 59 = severe âź< 40 = very sever hypoxemia
- 24. Venturi mask
- 25. E- xpectorants â«Water - expectorant of choice â«Mucus secreting drugs đĄȘSymptom relief only â«AVOID â ANTITUSSIVE (to depress cough)
- 26. F-ORCED FLUIDS
- 30. Chronic bronchitis involves inflammation and swelling of the lining of the airways that leads to narrowing and obstruction of the airways.
- 31. The inflammation also stimulates production of mucus (sputum) by GOBLET CELLS, which can cause further obstruction of the airways.
- 32. Chronic bronchitis usually is defined clinically as a daily cough with production of sputum for three months, two years in a row.
- 33. â«Obstruction of the airways, especially with mucus, increases the likelihood of bacterial lung infections.
- 34. PATHOPHYSIOLOGY SMOKING Irritation of AW Hypersecretion of mucus mucus â secreting glands & goblets cells (increase in number) mucus production mucus plug persistent cough
- 35. (Chronic) Inflammation bronchial walls thickened bronchial lumen narrows Adjacent alveoli may be damaged & fibrosed altered alveoli (macrophage function) Susceptible to respiratory infection
- 36. Inflammation Release of chemical mediators (BRADYKININ, HISTAMINE, PROSTAGLANDIN) Increased capillary permeability fluid/ cellular exudation edema of mucous membrane hypersecretion of mucus Persistent cough
- 37. S/Sx: â«Persistent bout of cough â«Thick, gelatinous sputum â«Wheeze & dyspnea â«Cyanotic nailbed â«SOB â«Tachypnea â«Acidosis â«Hypercapnia
- 38. Diagnostic Tests â«Chest roentgenography â«PFT- via SPIROMETRY â to evaluate airflow obstruction â«ABG analysis â«TIDAL VOLUME - the volume of air moved into and out of the lungs during quiet breathing
- 39. PFT
- 41. Exacerbation â«RETAINED SECRETIONS: 1. Chronic bronchial obstruction 2. Air trapping 3. Hypoxemia 4. CO2 retention 5. Localized infection đĄȘEMPHYSEMA đĄȘRSHF or COR PULMONALE
- 42. What treatment is available for COPD? The goals of COPD treatment are: 1. to prevent further deterioration in lung function; 2. to alleviate symptoms; 3. to improve performance of daily activities and quality of life.
- 43. The treatment strategies include: â« 1.quitting cigarette smoking; 2. bronchodilators 3.vaccination against flu influenza3.vaccination against flu influenza and pneumonia; 4.regular oxygen supplementation; and 5. pulmonary rehabilitation
- 45. EMPHYSEMA
- 46. EMPHYSEMA
- 47. PATHOPHYSIOLOGY SMOKING/ HEREDITY/AGING DISEQUILIBRIUM (ELASTASE & ANTI ELASTASE) DESTRUCTION OF ELASTIC RECOIL RETENTION OF CO2 OVERDISTENTION OF THE ALVEOLI
- 48. Hypercapnia Impaired diffusion of 02 Hypoxemia
- 49. alveolar walls maybe destroyed ____ dead space ___ pulmonary bed size ___Pulmonary capillary bed sizeđĄȘ ___ blood pressure in pulmonary artery
- 50. TYPES OF EMPHYSEMA 1.PAN LOBULAR (PANACINAR)- destruction of respiratory bronchiole, alveolar duct, alveoli đĄȘ Typically â HYPERINFLATED (HYPEREXTENDED CHEST) đĄȘ s/sx: đĄȘ 1. barrel chest đĄȘ 2. marked dyspnea on exertion đĄȘ 3. weight loss
- 53. 2. CENTRILOBULAR (CENTROACINAR)- center of the secondary lobule, preserving the peripheral of the acinus s/sx: V/Q mismatch
- 54. Late s/sx: 1. chronic hypoxemia 2. hypercapnia 3. Polycythemia Others: weight loss, easy fatigability, pursed-lip breathing, digital clubbing âPINK PUFFERSâ
- 57. V/Q MISMATCH â«ALVEOLI O2 cO2 O2 O2 CO2 CO2 CO2 CO2 cO2 O2 O2 O2 CO2 CO2 CO2 CO2 O2 O2 CO2 CO2 CO2 CO2 VENTILATION- PULMONARY ARTERY PERFUSION- PULMONARY VEIN
- 58. V/Q = 4L/5L/MIN â«VENTILATION= REFERS TO THE AMT OF AIR IN THE ALVEOLI â«Q- PERFUSION=REFERS TO THE AMT OF BLD IN THE CAPILLARIES â«V = ALVEOLI RECEIVES AIR @ THE RATE OF 4L/MIN â«Q = CAPILLARIES SUPPLY THE RATE OF 5L/MIN
- 60. EMPHYSEMA
- 61. Diagnostic tests â«1. PFT 2. chest x-ray â«3. ABG analysis â«4. Alpha antitrypsin assay - ___
- 62. Management â«Bronchodilator â«Avoid narcotics, sedatives, tranquilizers â«Fluids â«Postural drainage â«Pursed-lip breathing â«Corticosteroids
- 63. GENERAL MANAGEMENT FOR COPD CASES â«1. exacerbation â«2. oxygen therapy â«3. surgical management â«Bullectomy â«Lung volume reduction surgery (LVRS)
- 64. BULLECTOMY
- 67. LUNG VOLUME REDUCTION SURGERY (LVRS)
- 68. â«4. pulmonary rehabilitation â educational, psychosocial, behavioral, physical
- 70. â«5. patient education â«A. Breathing exercises â«Diaphragmatic â«Pursed-lip â«B. inspiratory muscle training â«C. activity pacing â«D. physical conditioning â«E. 02 â«F. Nutritional â«G. Coping Measures
- 73. ASTHMA ( Page 1116) â«Is a chronic inflammatory disease of the airways characterized by episodic exacerbations of acute inflammation of the airways â«- symptom free periods & acute exacerbation
- 74. 3 MAIN PROBLEMS â«1. BRONCHOSPASM â«2. EDEMA OF THE MUCOUS MEMBRANES â«3. HYPERSECRETION OF MUCUS
- 75. etiology â«Triggers â cause the release of inflammatory mediators from the bronchial mast cells, macrophages, & epithelial cells â«- can be allergenic, pharmacological, environmental, air pollution â related, occupational, infectious, exercise â related
- 77. Allergens â«Animal dander (from the skin, hair, or feathers of animals) â«Dust mites (contained in house dust) â«Cockroaches â«Pollen from trees and grass â«Mold (indoor and outdoor)
- 78. Irritants â«Cigarette smoke â«Air pollution â«Cold air or changes in weather â«Strong odors from painting or cooking â«Scented products â«Strong emotional expression (including crying or laughing hard) and stress
- 79. Others â« Medicines such as aspirin and beta-blockers, penicillin â« Sulfites in food (dried fruit) or beverages (wine) â« A condition called gastroesophageal reflux disease that causes heartburn and can worsen asthma symptoms, especially at night â« Irritants or allergens that you may be exposed to at your work, such as special chemicals or dusts â« Infections
- 83. Cyclic adenosine monophosphate (CAMP) -maintains balance between ALPHA- ADRENERGIC RECEPTORS & BETA- ADRENERGIC RECEPTORS ____________ receptors đĄȘbronchoconstriction ______ receptors đĄȘbronchodilation -- for relaxation of smooth muscles cAMP - __________
- 84. â« Allergy (Extrinsic) â« Inflammation (Intrinsic) â« Release of chemical mediators by mast cells â« â« Histamine, Bradykinin, â« Prostaglandin,Leukotrienes â« â« Bronchospasm/Broncoconstriction â« Edema of mucous membrane â« Hypersecretion of mucus
- 85. â«Narrowing of airways â«Increased work in breathing â« Tends to sit up â«Restlessness â«Tachypnea/dyspnea â«Tachycardia â«Chest pain â«Flaring of alae nasi
- 87. â«Exhaustion â«Slow, shallow respiration (hypoventilation) â«Retention of carbon dioxide (air trapping) Hypoxia â«Respiratory acidosis
- 89. SIGNS AND SYMPTOMS: â« Dyspnea â« coughing â« wheezing â« chest tightness possible mucus production â« Signs of progressing exacerbation â« Diaphoresis â« Tachycardia â« Widened pulse pressure â« Hypoxemia â« Cyanosis
- 91. Classification of Severity of Asthma (Adult) table 33 -7, page 1119 â«I. MILD INTERMITTENT â«Symptoms <2 days/ wk â«< 2 nights/ mo â«2. MILD PERSISTENT â«> 2 wks but < 1 x in a day â«> 2 nights/ mo
- 92. â«3. MODERATE PERSISTENT â Daily â«> 1 night/ wk â«4. SEVERE PERSISTENT â«Continual â«Frequent (night)
- 93. DIAGNOSTIC TESTS: â«History (Family, environmental, occupational) â«Sputum and blood tests â«ABG and Pulse oximertry â«Chest x-ray
- 94. Levels of Asthma I. Mild intermittent <2 days/wk;<2nights/mo II. Mild Persistent >2 wks but <1/day; >2 nights/ mo III. Moderate Persistent Daily; > 1 night/wk IV. Severe Persistent Continuous; freq @ night
- 95. COMPLICATIONS: â Status asthmaticus â Respiratory failure â Pneumonia â Atelectasis
- 96. Treatment â«A. LONG ACTING CONTROL MEDICATIONS B. QUICK RELIEF MEDICATIONS
- 97. A. LONG ACTING CONTROL MEDICATIONS 1. Corticosteroids-for mild, moderate, severe asthma 2. Mast cell stabilizers-as prophylaxis 3. Long acting beta2-adrenergic agonist- inhibit release of chemical mediators & increase CAMP 4. Methylxantines- may anti-inflammatory effect 5. Leukotriene modifiers 6. Combination Agent
- 98. B. QUICK RELIEF MEDICATIONS â âRESCUE MEDSâ 1. Short acting beta-adrenergic bronchodilators 2. Anticholinergics
- 99. A typical breathing treatment for cystic fibrosis, using a mask nebulizer and the ThAIRapy Vest
- 100. PEAK FLOW METER
- 102. PEAK FLOW METER PG. 1123 â«- measures the highest airflow during a forced expiration(3 times & record the highest reading) â«Monitors severity of asthma & how it is controlled â« REFER: PATIENT PLAYBOOK â USE OF PEF (PEAK EXPIRATORY FLOW)
- 103. PEF (PEAK EXPIRATORY FLOW) â«- LEVEL INTERPRETATIO N GREEN YELLOW RED
- 104. â«GREEN ZONE: DOING WELL (GOOD ASTHMA CONTROL) â« No cough, wheeze, chest tightness, or SOB during the day/night â« Can do usual activities â« Peak flow: more than - (80% or more of my best peak flow) My best peak flow is: __ â«Take these long â term control medicines each day
- 105. â« YELLOW ZONE: ASTHMA IS GETTING WORSE/ CAUTION â« Cough, wheeze, chest tightness, or SOB or â« Waking at night due to asthma, or â« Can do some, but not all usual activities â« Peak flow: __ to __ (50% - 80% of my best peak flow) â«Add quick- relief medicine and your green- zone medicines (Goal: Return to Green Zone)
- 106. â«RED ZONE: MEDICAL ALERT/ HEALTH CARE ALERT! â« Very SOB or â« Quick relief meds have not helped, or â« Cannot do usual activities, or â« Symptoms are same or get worse after 24 hours in Yellow zone â« Peak Flow: Less than __ (50% or less of my best peak flow) â« Take this medicine: â« ______________ â« ______________ â« Then call your Doctor NOW
- 107. â«DANGER SIGNS: â«Trouble walking & talking due to SOB â«Lips or fingernails are blue â«Take 4 or 6 puff of your quick relief meds AND â«Go to to the hospital NOW!
- 108. Teachings â« Allergen control â« Avoid extreme temperature â« Avoid crowds â« Instruct to identify early s/sx of acute asthma attack â« Adequate rest, sleep & diet â« Encourage cough effectively â« Immunization-_____&____
- 109. Ventilator Alarms HIGH PRESSURE ALARM -secretions in AW -ET is displaced -ET is obstructed- KINK đĄȘPt. coughs, gags or bites the ET đĄȘIs anxious or fights the ventilation
- 110. Low Pressure Alarm đĄȘDisconnection or Leak in ventilator đĄȘPt. stops spontaneous breathing
- 111. STATUS ASTHMATICUS â«LIFE THREATENING! â«Severe persistent asthma that does not respond to conventional therapy â«Attacks can last > 24 hours â«Can occur quickly đĄȘ ASPHYXIATION
- 113. Signs & symptoms â«SOB, cough, wheeze â«Cannot do usual activities â«Unable to speak in full sentences â«Change in LOC â«Quick relief meds have not helped
- 115. Risk of Death pg 1120 â« With hx of severe exacerbations â« Intubated â« Admission to ICU â« 2 or more hosp/yr â« 3 or more emergency â« Consume 2 or more MDI/mo â« Urban Residency â« Comorbid â« LOW SOCIOECONOMIC
- 116. BRONCHIOLECTASIS
- 117. BRONCHIECTASIS
- 118. BRONCHIOLECTASIS â«đĄȘ characterized by increased mucus formation & difficulty of breathing
- 119. May be: â« Localized or diffused â3 TYPES: 1. c________- mildest, slight widening of the respi passages; reversible 2. v_______- air sacs fail in portions of the passages 3. c______- most severe type involving ballooning or expansion of the air sacs
- 120. pathophysiology â« Etiology (viscious cycle of bacterial colonization) â« Inflammatory change â« Increased mucus production â« Scaring â« More bacterial colonization
- 121. â«Damage of mucociliary mechanism â«Damage bacterial clearance â« â«Stretching & enlargement of respiratory passages â«Scaring â«Bacteria build up (cycle)
- 122. â«(Notes) â«Etiology â«Impairment of bronchial clearance â«Bronchial secretions â«Stasis â«infection
- 123. â« Weakening & further destruction of bronchial walls â« Increased dilation â« atelectasis â« Inflammatory scarring â« Fibrosis â« Respiratory insufficiency â« V/Q mismatch â« Hypoxemia
- 124. â S/SX: â«Chronic cough â«Purulent sputum - ______ to _____ white fluid (infection) â«Hemoptysis â«Clubbing â«Repeated respiratory infections â«Hypoxemia, weight loss, dyspnea â«Definitive sign: ________
- 125. â DIAGNOSTIC TESTS 1. CT SCAN - _______ 2. X-RAY - 3. BRONCHOGRAM/ BRONCOSCOPY - 4. SPUTUM CULTURE 5. Auscultation -
- 127. TREATMENT/ GOALS: â«1. To promote effective airway clearance and remove secretions (bronchial drainage) â«2. To prevent or control infections â«3. to minimize further damage (complications)
- 128. â MEDICAL MANAGEMENT: 1. Postural drainage & CPT 2. Anti microbial therapy 3. Bronchodilators, steroid therapy 4. Vaccination 5. Surgical interventions/ lung resections A.Lobectomy B.Segmental Resection/ segmenectomy C.Pneumonectomy
- 130. NURSING MANAGEMENT Stop smoking! 1. Alleviate symptoms 2. Assist in secretion clearance 3. Balance rest and activity 4. Watch out for sx of infection â AVOID _____! 5. Nutritional support
- 131. CYSTIC FIBROSIS
- 134. â S/SX: â«1. RESPI S/SX: A. Coughing, wheezing,respiratory obstruction B. barrel chest, cyanosis, digital clubbing â«II. GI S/SX: A. Steatorrhea B. In newborns: MECONIUM ILEUS
- 135. â Other s/sx: â«Coughing with thick, sticky phlegm â«Freq. pneumonia, bronchitis â«Salty skin â«DHN (due to fluid shifting) â«Infertility
- 136. â DIAGNOSTIC 1. Sweat chloride test/ pilocarpine test NORMAL: A. Na:< 50 mq/l B. Cl: < 50 meq/l ABNORMAL: A. Na:> 90 meq/l B. Cl: > 60 meq/l Suggestive: Confirmatory:
- 138. â«2. x-ray, PFT â«3. sputum exam â«4. abdominal exam, stool analysis and Pancreatic function test - to asses GI involvement & presence of fats
- 139. â MANAGEMENT â«1. Control & prevent infection â«2. bronchodilators â«3. CPT â«4. mucolytic â«5. corticosteroids â«6. O2 â«7. lung transplant â«8. gene therapy
- 140. â HEALTH TEACHINGS â«Avoid crowds â«Assess s/sx of respiratory infection â«Fluid intake â prevent DHN â«Exercise freq â«Healthy diet â«end of life issue
- 141. ACTIVITY â«ÂŒ - USE 1 PAPER PER PAIR â«19 â 20 = +3 â«17 â 18 = +2 â«14 - 16 = +1 â«11 â 13 = + 1 â«0 â 10 = NONE
- 142. 1. YPTAAHYNCE 11. LPAILMHEININO 2. BOLEYMECTOM 12. AXNERPTOCTE 3. IFLLA TCESH 13. STAANASETIEL 4. OMPNRESOICS 14. GROVEAPNHY 5. OCPNREPIALI 15. MHYXEIAPO 6. LMIYCEOBN 16. PXENTHORAUMO 7. PIRASRERYTO IAIDSCOS 17. OARCNETLBRIUL 8. TETCHORASIENS 18. RAUPLEL UFFOENSI 9. ORIONESSTIOPH 19. CHOBNTSIRI 10.SMEPIRRYOT 20. CMUISIOVSSIDO
- 143. END OF QUIZ!!! âș
- 144. 1. TACHYPNEA 11. AMINOPHILLINE 2. EMBOLECTOMY 12. EXPECTORANT 3. FLAIL CHEST 13. ANTIELASTASE 4. COMPRESSION 14. VENOGRAPHY 5. PILOCARPINE 15. HYPOXEMIA 6. BLEOMYCIN 16. PNEUMOTHORAX 7. RESPIRATORY ACIDOSIS 17. CENTRILOBULAR 8. THORACENTESIS 18. PLEURAL EFFUSION 9. IONTOPHORESIS 19. BRONCHITIS 10.SPIROMETRY 20. MUCOVISIDOSIS
- 145. QUIZ â BLOCK A
- 146. â«1. this is the enzyme that destroys the lung tissue during the inflammatory process
- 147. â«2. this is the enzyme that inhibits the action of proteolytic enzymes
- 148. â«3. Type of emphysema that affects the respiratory bronchiole, alveolar duct, & alveoli
- 149. â«4. The normal V/Q ratio
- 150. â«5. refers to the abnormal increase in the immature erythrocytes
- 151. â«6. medication in asthma which is commonly used as prophylaxis
- 152. â«7. â 9. what are the 3 main problems in asthma
- 153. â«10. type of asthma when the patientâs night attack is more than twice per month.
- 154. QUIZ
- 155. â«1. What is the major problem in emphysema
- 156. â«2. this is the enzyme that destroys the lung tissue
- 157. â«3. type of emphysema that affects the secondary lobule but not the peripheral acinus/ air sac
- 158. 4. This refers to the amount of blood in the cappilaries
- 159. 5. This refers to the abnormal increase in the number of immature erytrocytes
- 160. 6. This is a surgical procedure to treat COPD that involves removal of a portion of a diseased lung parenchyma allowing the functional lung to expand
- 161. â«7. ENZYME THAT PROTECTS THE LUNG TISSUE FROM INJURY
- 162. â«8. What is the ideal position of patients with COPD
- 163. 9. This is a management in COPD that involves vibration & percussion
- 164. â«10. EMPHYSEMA IS ALSO KNOWN AS
- 165. 11. What is normal therapeutic range of theophylline?
- 166. â«12. The patientâs heart rate is 130 bpm after taking salbutamol. What must the nurse do? â«A. Do nothing, it is expected â«B. Report to the physician, it is abnormal
- 167. â«13. The doctor orders a bronchodilator and steroids to be given at the hour. What must be given first?
- 168. â«14. This is the enzyme that facilitates the stretchability of the lung tissue
- 169. â«15. Hypertrophy of the right ventricle is AKA __________, which could lead to RSHF.
- 170. â«16-20. 5points â«Write a brief pathophysiology of chronic bronchitis.
- 171. QUIZ (ASTHMA)
- 172. â«1. RINSING THE MOUTH AFTER INHALING PREDDNISONE IS TO PREVENT WHAT CONDITION
- 173. â«2. TYPE OF BRONCHODILATOR GIVEN AS PROPHYLAXIS
- 174. â«3. THE PERSONAL BEST OF THE PT. IS 62% . WHAT COLOR ZONE IS THIS?
- 175. â«4. INTERPRET THE FINDINGS
- 176. â«5. IF THE PATIENT HAS NO COUGH, NO SOB, CAN DO ACTIVITIES. HE IS IN WHAT ZONE
- 177. â«6. EXAMPLE OF LEUOTRIENE MODIFIERS
- 178. â«HIGH OR LOW PRESSURE ALARM â«7. DISCONNECTION â«8. LEAK â«9. SECRETIONS IN THE ET
- 179. â«10. ONE RECOMMENDED VACCINE GIVEN IN ASTHMA
- 180. â«11. DOC OF STATUS ASTHMATICUS
- 181. â«12. ONE MANIFESTATION OF STAUS ASTHMATICUS
- 182. â«13 â 15: ENUMERATE RISK OF DEATH IN ASTHMA