Content on Pediatric Asthma

Submitted to Mrs. Rupinder Kaur Lecturer Submitted by Anu George MSc Nsg. 1st year

Introduction Asthma is the most common chronic condition of childhood. Asthma is a chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, particularly at night and/or early in the morning. This clinical picture is caused by repeated immediate hypersensitivity and late phase reactions in the lung that give rise to the triad of intermittent and reversible airway obstruction, chronic bronchial inflammation with esnophils, and bronchial smooth muscle hypertrophy and hyperreactivity. Because asthma is a heterogenous disease triggered by a variety of inciting agents, there is no universally accepted classification scheme. About 70% of cases are said to be extrinsic or atopic and are due to IgE and TH2 (type 2 helper T) cell mediated immune response to environmental antigens. In the remaining 30% asthma is intrinsic or nonatopic and is trigerred by non-immune stimuli such as aspirin, pulmonary infections especially those caused by viruses; cold; psychological stress, exercise and inhaled irritants. Prevalence The prevalence of asthma varies from 5 -20 %. Etiology Despite the fact that pediatric asthma has become an important public health problem, the major determinants of childhood asthma are still unknown. Familial / genetic role for etiology is the most important factor. The most important etiologic factor of asthma is genetic predisposition to type 1 hypersensitivity (atopy). Environmental factors are also important and the most preventable predisposing factors. The common environmental triggers are cigarette smoke, animal proteins, pet related biological matter and dust mite. Environmental agents work in synergy with viral infections to alter reactivity of the airways. Pathophysiology

Classical triad: 1. Bronchial smooth muscle hypertrophy and hyperreactivity 2. Chronic bronchial inflammation with esnophils, and 3. Intermittent and reversible airway obstruction Hyperresponsiveness or hyperreactivity is the characteristic feature in asthma. This refers to the ease with which airways narrow in response to various nonallergic and nonsensitizing stimuli, including inhaled chemical mediators (e.g., histamine, methacholine) and natural physical stimuli (e.g. exercise, hyperventilation of cold air). It is likely that airway insult from chronic hyperresponsiveness early in life may lead to chronic changes in both lung structure and function. Airway inflammation is a major contributor to the pathology of asthma. The inflammatory process includes infiltration of airways by eosinophils, activation of T cells and production of cytokines as well as other mediators involved in inflammation, an increase in mast cell numbers, and desquamation of airway epithelium. Chronic inflammatory process causes remodeling of the airways with mucosal thickening and smooth muscle hypertrophy even in mild asthmatics. Inflammation causes an associated increase in the existing airway hyperresponsiveness to a variety of stimuli. Airway obstruction is due to narrowing of bronchioles and causes increased airway resistance, resulting in low forced expiratory volumes and flow rates. Obstruction causes premature closure of airways and air trapping. The blockage of airways from secretions and wall thickening causes atelectasis which leads V/ Q mismatch and the various changes in blood gases. Air trapping leads to hyperinflation and raised intrathoracic pressure, which in turn causes increase in work of breathing and may cause airleaks (pneumothorax, pneumomediastinum, subcutaneous emphysema). Increased intrathoracic pressure may cause hypotension by reducing venous return. Hypotension can cause hypoxia and decreased tissue perfusion and also affect the compliance. Precipitating factors: 1. Allergens food, animal, mold, spores, pollens, insects, infective agents and drugs.

2. Irritants paint odors, sprays, perfumes, smoke, cold air, cold water and cough. 3. Weather changes 4. Infection viral, fungal (aspergillosis), bacterial (B. Pertussis), and parasitic (Toxocara, ascariasis) 5. Exercise (70 % of all asthmatics) 6. Emotional factors 7. Gastroeosophageal reflux (Nocturnal Symptoms) 8. Allergic rhinitis 9. Sinusitis (Nocturnal symptoms) Clinical Features Classical presentation of recurrent prolonged cough , often with breathlessness or wheeze , suggests asthma. Demonstration of a favorable clinical response to bronchodilators and, when measurable, bronchodilation by Pulmonary function test confirms the diagnosis. A positive family history for allergic diseases or asthma, although not essential, tends to support a suspected diagnosis of asthma. The main symptoms and signs in asthma are cough, wheeze, tachypnea, dyspnea, and prolonged expiration. Other findings include anxiety, use of accessory muscles, monosyllabic speech, diaphoresis, fatigue, pulsus paradoxicus, cyanosis, hyperinflation, tachycardia, abdominal pain and vomiting. The symptoms may come up acutely (exposure to aero-allergen) or insidiously (following viral infections). Asthma is mainly diagnosed by history and physical examination. The diagnosis and estimation of asthma severity in smaller children depends on the history and response to therapy. In older children direct history and as well as more objective assessment is possible.

Diagnosis 1. History: Cough (especially in night) Recurrent wheeze (absence does not rule out diagnosis) Recurrent dyspnea Recurrent chest tightness All above complaints are classically episodic, nocturnal, seasonal and exertional atopy. 2. Precipitating or aggravating with specific factors: Airborne chemicals or dusts Animals with fur or feathers Changes in weather Exercise House dust mites (mattresses, upholstery, carpets) Menses Nighttime Pollen Smoke (tobacco, wood) Strong emotional expression (laughing, crying) Viral infection 3. Reversibility and variability: Variations in PEFR during the day(>=20%) Reversible symptoms with treatment If all or some of above present, confirm diagnosis by spirometry and response to bronchodilator drugs. If response is good, asthma is most probable and assess severity and give appropriate medications. If response is not good consider other diagnosis or check compliance of anti asthma drugs.

Differential diagnosis History not consistent with asthma: Sudden onset of symptoms Coughing or wheezing with feedings Neonatal / early onset (less than 2-3 months) Neonatal requirement for ventilatory support Symptoms of stridor Vomiting / choking Signs not consistent with asthma: Clubbing (cystic fibrosis, bronchiectasis, Interstitial lung disease, congenital heart disease) Failure to thrive and vomiting Productive cough Stridor or choking Ability to speak or cry normally-( infant and young child) Investigations The investigations to be considered are chest xrays, sinus xrays, lung function tests, bronchial challenge tests, mantoux test, sweat test, immune function studies, ciliary studies and reflux studies. Along with these studies response to bronchodilator therapy should also be assessed. If response is good and other tests are negative then consider asthma alone or in association with other diseases. Spirometry: The findings in asthma are:

Increased total lung capacity, Functional residual capacity and residual volume. Decrease in vital capacity Decreased dynamic tests of air flow i.e. FEV1, FVC, Maximum expiratory flow between 25 75 % of vital capacity

Management The aim in management of acute asthma is: 1. Correct significant hypoxemia (O2, mechanical ventilation rarely needed) 2. Reverse airflow obstruction as rapidly as possible. 3. Reduce inflammation and risk of recurrence by intensifying therapy. The overall goal of asthma management is to prevent disability and to minimise physical and psychologic morbidity- to help the child to live as normal and happy a life as possible. This includes facilitating the childs social adjustments in thefamily, school and community and normal participation in recreational activities and sports. To accomplish these goals, efforts are directed towards recognising acute episodes early and implementing appropriate therapy, identifying and eliminating irritant and allergic factors from the childs environment, educating parents to the long term nature of the disease and how to manage exacerbations, and helping the child to deal constructively with the disease. Compliance to the prescribed regimen is essential to successful management. Allergen Control The goal of non-pharmacotherapy is prevention and reduction of the childs exposure to airborne allergens and irritants. Often, simply removing the offending environmental factors will decrease the frequency of asthma episodes. Drug Therapy Most children donot require continuous medication. The goal is to control the acute exacerbation; therefore early recognition and treatment at the onset are important. Several drugs are prescribed often in combination, to reverse or prevent bronchospasm. Many of the medications are given by inhalation with a nebuliser or metered dose inhaler (MDI). Children who have difficulty in using the MDI can obtain effective relief with nebulisation.

Corticosteroids These are the most effective anti-inflammatory drugs for the treatment of asthmaand are highly effective in controlling symptoms. And reducing bronchial hyperactivity in chronic asthma. Corticosteroids may be administered parentrally, orally or as aerosol. Acute short term therapy is typically begun with high doses, which can be maintained for 5-10 days. adrenergic agonists (albuterol, metaproterenol, and terbutaline) are the drugs of choice for treatment of acute exacerbation and to prevent exercise induced asthma. They can be administered parentrally, orally or as aerosol. Salmetrol is a long acting bronchodilator that is used two times a day. Methylxanthines, principally theophylline, have been used for decades to relieve symptoms and prevent asthma. Status Asthmaticus Children who continue to display respiratory distress despite vigorous therapeutic measures, especially sympathomimetics, are considered to be in status asthmaticus. The condition may develop gradually or rapidly, often coincident with complicating conditions(eg; pneumonia) that can influence the duration and treatment of the attack. These children are acutely ill and require hospitalisation where PICU is available. Nursing Management Based on a thorough assessment, several nursing diagnosis are identified. The commonest ones are: 1. Ineffective airway clearance related to allergic response and inflammation in the bronchial tree. 2. High risk of injury (respiratory acidosis, electrolyte imbalance) r/t hypoventilation, dehydration. 3. Altered family process r/t emergency hospitalisation of the child 4. Activity intolerance r/t imbalance between oxygen supply and demand

5. High risk for suffocation r/t bronchospasm, mucus secretions, edema. Avoid allergens: the primary goal of asthma management is avidance of an exacerbation. Health education to the parents is very important. Parent education Parent education covers 1. Basic asthma facts - Taught to understand their asthma; to know how to recognize symptom patterns indicating that their asthma is getting out of control. This can prevent emergency room visits and hospitalizations 2. Roles of medications difference between quick relief and long term control 3. Skill needed for inhaler and spacer use 4. Environmental control measures and avoidance measures. 5. When and how to take rescue steps, written treatment plans. The parents are cautioned to avoid exposing a sensitive child excessive cold, wind or other extremes of weather, smoke, sprays or other irritants. Explain strategies to make home allergy-proof like avoid using carpets, stuffed animals, pets, sprays and aerosol pesticides and only do wet mopping and never go for dry dusting. Relieve Bronchospasm Parents and older children need to learn how to use the prescribed medications. They are taught to recognize early signs and symptoms of an impending attack so that it can be controlled before symptoms becomes distressing. Most children can recognise prodromal symptoms well before an attack so that preventive therapy can be implemented. Some objective signs that parents may observe include, rhinorrhea, cough, low grade fever, irritability, apathy, anxiety, sleep disturbance, and loss of appetite. Instructions for use of Inhaler 1. Shake the inhaler well

2. Remove the cap 3. Hold the inhaler in such a way that with the thumb rests on the top of the MDI 4. Expire fully 5. Along with the next inhalation press the inhaler with the thumb to release the aerosols 6. Hold this breath as long as you can 7. Repeat the procedure as prescribed Care of the MDI Separate the case and the medicine container to clean. Wash the case under running water. Use a scrub or soap if needed keep it dry. Keep the inhaler always ready for use. Support Child and Family The nurse working with children with asthma can provide them with support in a number of ways. Adaptation of affected children to the disease depends greatly on familys acceptance of the disorder and compliance with the therapy. There are periodic crises and the ever present threat of crisis, requiring parental vigilance, sleepless nights, frequent emergency trips to the hospital, and often overwhelming medical expenses. Throughout this stress, parents are expected and encouraged to promote as normal a life as possible for their children without neglecting the needs of siblings. Bibliography 1. Kliegman and et al; Nelson Textbook of Pediatrics; 18th edition; Vol.1; pages:953970 2. O.P Ghai; Ghai Essential Pediatrics; 5th edition; 356-7 3. Dr. C S Wagle; Principles And Practice Of Clinical Pediatrics; Pages: 4. Donna L Wong; Essentials of Pediatric Nursing; 5th edition; pages: 775-86.

5. www.google.com(pediatric asthma) 6. www.pediatriconcall.com 7. www.aaaai.com