ASTHMA Also see Chapter 28 for a complete discussion of asthma.

In 1997, the National Heart, Lung, and Blood Institute defined asthma as a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells, eosinophils, lymphocytes, neutrophils, and epithelial cells. In susceptible children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and early morning. These episodes are associated with variable airflow obstruction that is commonly reversible spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli. Airway inflammation is found in patients with mild, moderate, and severe asthma. Use of anti-inflammatory medications, especially inhaled steroids, is the most effective therapy presently available. Asthma is the most common chronic disease of childhood. Symptoms typically begin before age 4 and vary over time. Mild asthma during childhood may resolve spontaneously or it may develop into a progressive illness, especially in those with severe disease. A significant number of those who believe they have outgrown their asthma experience asthma symptoms later in life. Etiology and pathophysiology are the same as in adults (see page 993), and presentation may be gradual or sudden.

Cough Variant Asthma Cough variant asthma is typically seen in children, where cough (especially at night) is the principal symptom. The child may never wheeze. Although the symptoms are chronic and commonly mild in many children, severe exacerbations (attacks) may arise, even resulting in respiratory failure and death. Exercise-Induced Asthma Exercise-induced bronchospasm refers to symptoms of cough, shortness of breath, chest pain, tightness, wheezing, and endurance problems during or after vigorous activity. Typically, symptoms begin during exercise and peak 5 to 10 minutes after stopping; they may resolve spontaneously within 20 to 30 minutes. Diagnosis is confirmed by documenting a decrease in peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1), before and after exercise and at 5-minute intervals for 20 to 30 minutes. Treatment options include the use of longacting beta-2 agonists, short-acting beta-2 agonists, cromolyn, or nedocromil. P.1439 A warm- up period of 6 to 20 minutes prior to exercise is beneficial. Factors that Increase Risk of Asthma Death 1. Adolescence. 2. Previous exacerbation requiring hospitalization within the last

3.

4.

5. 6. 7.

8.

9. 10. 11.

year, history of intensive care unit (ICU) admission, history of intubation for asthma. Hospitalization two or more times within the year, three or more emergency department (ED) visits in the last year. Hospitalized or ED visit within the past month. Use of two canisters per month of short-acting inhaled beta-2 agonist. Current use of steroids; recent withdrawal from oral steroids. Poor perception of airflow obstruction or its severity. Low socioeconomic status, poor access to health care, and urban residence. History of depression, psychological problems, or psychiatric disease. Sensitivity to Alternaria (outdoor mold). Illicit drug use. Comorbidity: such as cardiovascular disease.

Management The Stepwise Approach to Managing Asthma, developed by the Expert Panel 2 report, identifies classifications of asthma according to symptoms and suggests pharmacologic options for the control of asthma. Medications may be stepped up or down depending on the patient's response to therapy. See Table 44-2, page 1440, for the recommended management of asthma for

infants and children age 5 and under. See page 996 for the management of older children with asthma. TABLE 44-2 Stepwise Approach for Managing Infants and Young Children (Ages 5 Years and Younger) with Acute or Chronic Asthma CLASSIFY SEVERITY: CLINICAL FEATURES BEFORE TREATMENT OR MEDICATIONS REQUIRED ADEQUATE TO MAINTAIN LONG-TERM CONTROL CONTROL Sym Daily Medications ptom s/da y

Step 3 Daily Preferred treatment: Moderate >1 persisten night Low-dose inhaled t /wee corticosteroids and long-acting k inhaled beta2-agonists OR Medium-dose inhaled corticosteroids

corticosteroids and maintain control with high-dose inhaled corticosteroids.)

receptor antagonist or theophylline. >2/w Preferred treatment: eek but < Low-dose inhaled 1 corticosteroids (with /day nebulizer or meteredStep 2 > 2 dose inhaler [MDI] with Mild night holding chamber with or persisten s/mo without face mask or t nth dry powder inhaler).

Alternative treatment:
Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline. Step 1 Mild intermitt ent 2 days /wee k

Alternative treatment (listed alphabetically):

Cromolyn (nebulizer is preferred or MDI with holding chamber) or leukotriene receptor antagonist. No daily medication needed.

Step 4 Severe persisten t

Sym ptom s/nig ht

Conti Preferred treatment: nual Freq High-dose inhaled uent corticosteroids and Long-acting inhaled beta2agonists and, if needed, Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg/day) (Make repeat attempts to reduce systemic

If needed (particularly in patients with recurring severe exacerbations):

Preferred treatment:

Medium-dose inhaled corticosteroids and long-acting beta2agonists Quick Relief All patients

2 night s/mo nth

Alternative treatment:
Medium-dose inhaled corticosteroids and either leukotriene

Bronchodilator as needed for symptoms. Intensity of treatment will depend on severity of exacerbation. Preferred

treatment: Short-acting inhaled beta2-agonists by nebulizer or face mask and space/holding chamber Alternative treatment: Oral beta2agonists With viral respiratory infection: Bronchodilator every 46 hours up to 24 hours (longer with physician consult); in general, repeat no more than once every 6 weeks. Consider systemic corticosteroid if exacerbation is severe or patient has history of previous severe exacerbations. Use of short-acting beta2-agonists more than 2 times per week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term-control therapy.

http://www.nhlbi.nih.gov/guideline/asthma . Acute Exacerbation 1. Be alert for severe asthma exacerbation. In a severe exacerbation, the child is short of breath, audibly wheezing with a prolonged expiratory phase, restless, apprehensive, anxious, and diaphoretic; color may be pale or flushed. Lips may be dark red or cyanotic. Cyanosis of the lips and nail beds is an ominous sign. There are signs of respiratory distress, such as nasal flaring, use of accessory muscles, retractions, hypoxemia, and respiratory alkalosis progressing to respiratory acidosis. Also seen are tachypnea, tachycardia, one- to twoword dyspnea (speaking in short phrases), and decreased level of consciousness. A young child will assume tripod position; an older child will sit upright with his shoulders hunched. 2. The goals of emergency management are to quickly reverse airflow obstruction, to reduce the likelihood of recurrence, and to correct hypoxemia. 3. Assess PEF rate or FEV1 upon arrival; assess degree of respiratory distress or fatigue. 4. Obtain an oxygen saturation level of 91% or greater (for infants, 95% or greater) and monitor closely.

5. Obtain arterial or capillary blood gas levels in infants with an oxygen saturation of less than 90% and in a child with moderate to severe respiratory distress. If necessary, deliver humidified oxygen via nasal cannula, hood, or face mask. Maintain oxygen tension greater than 64 mm Hg but less than 100 mm Hg to prevent oxygen narcosis. 6. Obtain a brief history and physical and focus on prior treatment and possible triggers of the episode, such as respiratory infection or lack of medication. 7. Administer a short-acting inhaled beta-2 agonist, such as albuterol, every 20 to 30 minutes for three treatments. Repeat assessment after the first and third dose of the medication (see Table 44-3, page 1441). TABLE 44-3 Drug Dosages for Asthma Exacerbations in Emergency Medical Care or Hospital CHILD DOSE (CHILD 12 YEARS OF COMMENT MEDICATION AGE) S Short-Acting Inhaled Beta2Agonists Albuterol Nebulizer 0.15 mg/kg Only solution (minimum selective 5 mg/mL, 2.5 dose 2.5 beta2-

National Asthma Education and Prevention Program Guidelines for the diagnosis and management of asthmaUpdate on selected topics 2002. Available:

mg/3 mL, mg) every agonists 1.25 mg/3 mL, 20 minutes are 0.63 mg/3 mL for 3 recommend doses, then ed. For 0.150.3 optimal mg/kg up delivery, to 10 mg dilute every 14 aerosols to hours as minimum of needed, or 3 mL at gas 0.5 flow of mg/kg/hour 68 by L/minute. continuous nebulizatio n. Metered-dose 48 As inhaler (MDI) puffs every effective 90 mcg/puff 20 minutes as for 3 nebulized doses, then therapy if every 14 patient is hours able to inhalation coordinate. maneuver. Use spacer or holding chamber.

on a milligram basis. MDI See 370 mcg/puff albuterol dose.

mix with other drugs. Has not been studied in severe asthma exacerbati ons.

Bitolterol

Nebulizer solution
2 mg/mL

See Has not albuterol been dose; studied in thought to severe be one-half asthma as potent exacerbati as albuterol ons. Do not

Levalbuterol (R-albuterol) Nebulizer 0.075 0.63 mg of solution mg/kg levalbutero 0.63 mg/3 mL, (minimum l is 1.25 mg/3 mL dose 1.25 equivalent mg) every to 1.25 mg 20 minutes of racemic for 3 albuterol doses, then for both 0.0750.1efficacy 5 mg/kg up and to 5 mg adverse every 14 effects. hours as needed, or 0.25 mg/kg/hour by continuous nebulizatio n. Pirbuterol MDI See Has not 200 mcg/puff albuterol been dose; studied in thought to severe be one-half asthma as potent exacerbati

as albuterol ons. on a milligram basis. Systemic (Injected) Beta2-Agonists Epinephrine 1:1000 (1 0.01 mg/kg No proven mg/mL) up to 0.3- advantage 0.5 mg of subcutaneo systemic usly every therapy 20 minutes over for 3 aerosol. doses. Terbutaline 1 mg/mL 0.01 mg/kg No proven subcutaneo advantage usly every of 20 minutes systemic for 3 doses therapy then every over 2-6 hours aerosol. as needed. Anticholinergics Ipratropium bromide Nebulizer 0.25 mg May mix in solution every 20 same 0.25 mg/mL minutes for nebulizer 3 doses, with then every albuterol. 24 Should not hours. be used as first-line therapy; should be added to beta2agonist

therapy. MDI 48 Dose 18 mcg/puff puffs as delivered needed. from MDI is low and has not been studied in asthma exacerbati on. Ipratropium with albuterol Nebulizer 1.5 mL Contains solution every 20 EDTA to Each 3 mL vial minutes for prevent contains 0.5 mg 3 doses, discolorati ipratropium then every on. This bromide and 2 to 4 additive 2.5 mg hours. does not albuterol induce bronchospa sm. MDI 48 puff Each puff as needed. contains 18 mcg ipratropium bromide and 90 mcg of albuterol Systemic Corticosteroids (Dosages and comments apply to all three corticosteroids) Prednisone 1 mg/kg For Methylprednis every 6 outpatient olone hours for burst Prednisolone 48 hours use then 12 4060

mg/kg/day mg in single (maximum = or 2 60 mg/day) divided in 2 divided doses for doses until adults peak (children: expiratory 12 flow is 70% mg/kg/day, of maximum predicted 60 mg/day) or personal for 310 best. days. National Asthma Education and Prevention Program Guidelines for the diagnosis and management of asthmaUpdate on selected topics 2002. Available: http://www.nhlbi.nih.gov/guideline/ast hma . 8Administer corticosteroids, oral or I.V. as prescribed. o Steroids are recommended early in the episode for infants. Monitor oxygen saturation levels, and maintain at greater than 95%. Assess the infant's level of airway obstruction and signs of serious respiratory distress by observing for the use of accessory muscles, paradoxical breathing, cyanosis, respiratory rate greater than 60/minute, oxygen saturation level of 91% or less. Notify

health care provider and monitor closely. 8. Obtain arterial blood gas (ABG) levels for patients with severe distress, suspected hypoventilation, or FEV1 or PEF at 30% or less of predicted after treatment. 9. Children in severe status asthmaticus unresponsive to the above therapy may require: o Intubation and mechanical ventilation with 100% oxygen for impending or actual respiratory distress, decreased mental alertness, increased fatigue, or partial pressure of arterial carbon dioxide (PaCO2) greater than or equal to 42 mm Hg. o Nebulized beta-2 agonist, hourly or continuously. o Anticholinergic such as ipratropium. o I.V. corticosteroid therapy. o Admission to ICU. o Pharmacologic paralysis to ventilate effectively. o Cardiopulmonary monitoring of the child's response to treatment. o Placement of an arterial line for blood monitoring. 10. Therapies not recommended for treating an exacerbation, based on the 1997 National Heart, Lung, and Blood Institute Expert Panel Report:

Subcutaneous beta-2 agonist provides no advantage over inhaled medication. Theophylline or aminophylline is not recommended in the ED. It does not provide additional benefit to short-acting beta-2 agonists; it may produce adverse effects. Chest physical therapy (CPT) and mucolytics. Antibiotics are not recommended for asthma treatment. However, antibiotics may be needed in patients with fever, purulent sputum, and evidence of bacterial pneumonia. Anxiolytic and hypnotic drugs are contraindicated. Aggressive hydration is not recommended in older children. Assess fluid status; make corrections as needed for infants and young children to decrease risk of dehydration.

DRUG ALERT Anticholinergics such as ipratropium bromide (Atrovent), 0.25 mg for children, may be added to albuterol in nebulizer. It has been shown to improve bronchodilation in some patients, especially those with severe airflow obstruction. Long-Term Management As the child becomes stabilized, begin to develop a home and school management plan. Components of the plan should include: o The use of quick-relief medications (inhaled beta agonists); expected effect and side effects. o The use of long-term controllers (usually inhaled corticosteroids, leukotriene modifiers, mast cell stabilizers); desired effect and adverse effects. See page 996 for dosages of long-term medications. o Inhalation technique with nebulizer or multidose inhaler with spacer (see Figure 44-4). o Peak flow and symptom monitoring. o Use of PEF zone system if indicated (see below). o Identification of triggers (eg, mold, pollen, exercise, weather change, infection, allergen exposure, including cockroach and mouse allergen).

o o o o

o o

NURSING ALERT Absence of wheezing with decreased breath sounds and inability to blow a PEF indicates minimal air exchange. This situation requires immediate, swift attention to prevent respiratory failure. Respiratory failure tends to progress quickly and is difficult to reverse.

Environmental control by removal of suspected stimuli. Hydration, nutrition, rest, and exercise regimens. Emergency action plans. Plan a team conference involving the child, his parents, school nurse, and teacher if possible. Ideally, the plan should be clear and easy for the child and his family to follow, adapted to their lifestyle, and using the least amount of medications necessary to control and prevent the child's asthma symptoms. A written action plan should be submitted to the school, including information on selfmedication, identified triggers, steps in an emergency plan, and emergency contact information. A copy of this form can be found in Guidelines for the Diagnosis and Management of Asthma, available at http://www.nhlbi.nih.gov/guide lines/asthma. Stress that, without exception, no smoking should be permitted in the home or car of a child with asthma. Even if the child is out of the home, the residual odor will cause symptoms. Opening

windows or using sprays and air cleaners are not acceptable alternatives. Encourage the parents to pay particular attention to environmental control in the child's bedroom, including eliminationof dust, not allowing any pets, and avoidance of any strong smells or sprays. Obtain more information from The National Asthma Education Program, http://www.nhlbi.nih.gov/about /naepp/; The American Association of Allergy and Asthma, http://www.aaai.org; or the American Lung Association at http://www.lungusa.org.

Peak Expiratory Flow Monitoring and the Zone System Teach the family and child the importance of PEF monitoring at home (see Figure 44-5). It is one of the most important tools in asthma education. PEF monitoring, along with an asthma diary, is of paramount importance for newly diagnosed patients and those with labile or persistent symptoms. It assists the family with: o Identification of individual triggers.

Appreciation of varying degrees of airflow obstruction. o Recognition and treatment of early symptoms. o Active participation in asthma management plan. o Self-confidence and decisionmaking skills. o Compliance. A PEF meter measures the PEF rate that can be produced during a forced expiration. It measures airflow through the large airways; the result is effort dependent. PEF measurements can be initiated in children as young as age 5. Given time and practice, consistent readings will be produced. (See page 998 for directions on use of PEF meter.) A table of predicted PEF values should be included in the packaging of the home PEF meter. These values are based on age and height. A few patients may find their readings above or below the published values. Therefore, each child should establish his personal best PEF value. Ideally, this should be implemented during a time when the child is symptom-free. If PEF readings are consistently below predicted values, the health care provider should be contacted and additional medications may be necessary. Use of the PEF zone system along with a home asthma management plan assists families in the proper use of o

medications, and assists in decision making regarding the degree of airflow obstruction. After the personal best PEF value is identified, teach the patient that subsequent PEF measurements can be classified into three zones that will dictate a home management plan. o Green Zone = 80% to 100% of personal best. No asthma symptoms are present. Continue usual medications. o Yellow Zone = 50% to less than 79% of personal best. Signals caution. May be experiencing an asthma episode, or day-to-day control is suboptimal. Need to use short-acting inhaled beta-2 agonist, follow emergency plan, and contact health care provider for further instructions. o Red Zone = less than 50% of personal best value. This zone signals danger. Must take a short-acting inhaled beta-2 agonist immediately and, if PEF does not return to yellow or green zone, contact health care provider or proceed to the ED immediately.