Asthma Outline1

Chronic Exam One: 5 QuestionsWong: pgs. 851-63L. Jones

Asthma: Reactive Airway Disease

Definition

Asthma is defined as an airway obstruction or narrowing that is characterized by bronchial irritability after exposure to stimuli

Another definition: A chronic inflammatory disorder of the airways in which many cells (mast cells, eosinophils, and T lymphocytes) may play a role. In susceptible children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, especially at night or in the early morning. These asthma episodes are associated with airflow limitation or obstruction that is reversible either spontaneously or with treatment.

 Asthma is classified as intermittent or chronic

Asthma is the most common chronic disease of childhood and the primary cause of school absences

Also responsible for a major proportion of pedi admissions to emergency departments and hospitals

Etiology

The reason some children’s airways are more reactive than others is unclear

Genetic predisposition plays a role

Episodes can be triggered by a variety of stimuli-e.g. virus, cold, other stimuli

Common Asthma Triggers

Environmental factors-e.g. smoke, fireplaces, deodorants, etc.

Allergy-trees, shrubs, dustmites, dust, perfumes, tobacco smoke

Exercise-E.g. exercise induced asthma—often induced by breathing in large amounts of cool, dry air.

Infection-viral, bacterial, etc.

Emotions-can be exacerbated by emotions

Endocrine factors—e.g. hormones, thyroid disease

Infants: Strong relationship between viral infections and asthma

Risk Factors

Age

Heredity

Gender

Children of young mothers under 20

Smoking

Ethnicity

Previous life-threatening attacks

Lack of access to medical care

Psychologic & Psychosocial problems

Pathophysiology

Bronchospasm resulting from constriction of bronchial smooth muscle-when exposed to an irritant—IgE released and attach to mast cells—then release of histamine

Inflammation and edema of the mucous membranes

Accumulation of tenacious secretions-esp. with kids—lots of mucous.

Diagnostic Evaluation

Clinical manifestations—1st attack is usually between 3-8 years old

History

Physical examination

Laboratory tests: PFT and Skin Testing

  • PFT=pulmonary function text: degree of lung disease and response to therapy is measured with PFT
  • Skin Testing= may or may not help identify allergens
  • PEFR= peak expiratory flow rate—helps diagnose using three zones. Based on child’s personal best (rate of flow over a 2-3 week period of recording results)
  • Green= 80-100% of personal best—signals all clear. Asthma is under reasonable good control. No symptoms are present and the routine treatment plan for maintaining control can be followed.
  • Yellow= 50-79%--signals caution. Asthma is not well controlled. An acute exacerbation may be present. Maintenance therapy may need to be increased. Call the practitioner if the child stays in this zone
  • Red= Below 50% of personal best signals a medical alert. Severe airway narrowing may be occurring. A short-acting bronchodilator should be administered. Notify the practitioner if the peak expiratory flow rate (PEFR) does not return immediately and stay in yellow or green zones.

Clinical Manifestations

Wheezing-can hear this with or without a stethoscope

Tachypnea-rapid respirations

Prolonged expiratory phase-

Cough

Shortness of breath

Lips a deep, dark red color

May progress to cyanosis of nail beds and/or circumoral cyanosis

Restlessness

Barrel chest/Elevated shoulders-using accessory muscles to breathe

Allergic shiner-dark circles under eyes

Hyperresonance on percussion b/c of air filled lungs

Wheezes throughout lung fields

Crackles

Severe Asthma

Status asthmaticus= severe asthma attack requiring hospitalization

Medical emergency

Can result in respiratory failure

Hospitalization

Tx:

  • Bronchospasm relieved by giving inhaled aerosolized short-acting Beta2 agonists either intermittently or continuously along with corticosteroids.
  • For the child not responding to either of those therapies, subcutaneious epinephrine or terbutaline is administered.

Therapeutic Management

1st line of defense=Metered dose inhaler. Need a spacer for children with inhalers!!

Allergen control

Bronchodilators-Albuterol nebulizers

Corticosteroids

Drug Therapy

Long-term control medications – preventor medicines

Quick-relief medications – rescue medications

Humidified O2

NPO status

Medications: especially Nebulized bronchodilators/e.b. Albuterol

Possibly have to intubate

Possible antibiotics to treat underlying infection

Ascultate breath sounds—if no breath sounds= worsening asthma b/c there is no O2 moving in and out.

Long-Term Management

Goal is to minimize symptoms

Prevent acute asthma episodes

Avoid side effects of therapy

Prevention meds for long term treatment/management

Rescue meds for acute exacerbations

Nursing Management

Assessment-teach metered dose inhalers and difference between rescue and long term drugs. Also important to teach what to do to prevent attacks.

Education of child and family

Nursing Diagnoses

Impaired gas exchange R/T airway inflammation, spasms of smooth muscles of the airways, accumulation of mucous

Knowledge deficit: Child/Family

Fear: Child

Fluid volume deficit

Activity intolerance

Compromised family coping

Extra Notes

Prognosis varies widely—some lose symptoms at puberty

Exercise Induced Asthma usually stops 20-30 minutes after exercise is discontinued. One of the best exercises for EIA children is swimming as the children are breathing in humidified air and exhaling underwater prolongs expiration.

Non-steroidal anti-inflammatory= preventor meds e.g. Cromolyn sodium (an NSAID for asthma)

For acute treatment: Beta Adrenergic agonists (Albuterol, metaproterenol and terbutaline)