 |
| |||
| CNE: Pediatric Asthma
This activity is co-provided by AHC Media LLC and RN. AHC Media LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This activity has been approved for 1.0 nursing contact hour using a 60-minute contact hour. Provider approved by the California Board of Registered Nursing, Provider # 14749, for 1.0 Contact Hour. After reading the article you should be able to:
 Click this button if you've already read the article and wish to take the test immediately. You will be transferred to the AHC Media LLC site. Should you need any assistance with the test-taking process, call (800) 888-3902. Originally Posted July 2008 By NANCY BANASIAK, MSN, APRN, BC, PNP; ANJENEAN BOLSTER, MSN, CPNP NANCY BANASIAK, an assistant professor at Yale University School of Nursing in New Haven, CT, is a pediatric nurse practitioner in Pediatric Primary Care at Yale-New Haven Hospital. ANJENEAN B. BOLSTER is a pediatric nurse practitioner with North Dallas Pediatric in Texas. The authors have no financial relationships to disclose. EDITOR: Martha K. Raymond, RN, BSN.Asthma is the most prevalent chronic illness facing children in the U.S. Typically affecting more boys than girls,1 it's estimated that approximately nine million children—about 13%—under 18 years of age have asthma.2 Collectively, children with asthma miss an estimated 14 million days of school each year,3 making it one of the most frequent reasons for school absenteeism. Furthermore, in 2004 alone, the healthcare costs associated with asthma were estimated to be $16.1 billion, with direct costs accounting for $11.5 billion.4 These costs are further increased when parents and caregivers must miss work to care for children suffering from exacerbations, ranging from moderate to severe. In 2002, asthma caused approximately 4,261 deaths, 170 of which were children under 18 years of age.4 The morbidity rates related to asthma have risen over the years, accounting for more than 10 million outpatient visits, 2 million emergency department visits, and 500,000 hospitalizations—44% of which were for children.1,3,4 Because of morbidity and mortality rates related to asthma, and their prevalence based on ethnic differences, it's imperative that healthcare providers have an understanding of the pathophysiology, assessment, diagnosis, and management of this disorder so it can be controlled in children before they become adults. Inside look at asthmaAsthma develops due to a complex interaction of intrinsic pulmonary cell-mediators and neural pathways leading to chronic inflammation, structural changes, and hyperresponsiveness of bronchial tubes. This cascade of events contributes to smooth muscle contraction, increased pulmonary vascular permeability, basement membrane thickening, and excessive mucus production. As a consequence, respiratory airway passages narrow, impeding respiration. Lower airways are constantly inflamed to varying degrees, even when a patient isn't experiencing asthma symptoms.5 During an asthma exacerbation, baseline status deteriorates due to an exaggerated inflammatory response related to a higher number of, and more active, inflammatory cells.6 Lung tissue responds by increasing inflammation, edema, bronchiole constriction, and producing mucous plugs. This hyperresponsiveness can be provoked by exposure to bronchiole-irritating stimuli called triggers. Common triggers are allergens and irritants including animal dander, dust mites, cockroaches, pollen, cigarette or wood smoke, exercise, viruses, and dry hot or cold air. These provoking stimuli further narrow the inflamed airways and lead to decreases in oxygenated blood delivered to the body. In response, the patient experiences dyspnea, chest tightness, coughing, and wheezing, especially at night and in the early morning.7 However, a hallmark symptom of asthma in children is nighttime cough. Exercise- or activity-related shortness of breath and recurrent cough are other signs.8 Symptoms are relieved spontaneously, through control of airway triggers, or with medications. Initial AssessmentAn acute asthma episode is suspected based on the exclusion of alternatives, even in patients with histories of asthma and exacerbations. Acute asthma mimics several conditions including heart disease, vocal cord dysfunction, acute bronchitis, bronchiolitis, or the presence of a foreign body in the bronchial passages. A table of conditions is in this article.8 Information gathered during the initial asthma assessment serves as baseline data, determining a patient's respiratory status and severity of the attack. To assess respiratory failure, you can use observational skills to estimate severity through noting patient's skin color; level of consciousness; ability to lie down and to speak; use of accessory respiratory muscles; the presence of clavicular, sternal, and costal retractions; and nasal flaring.9 If the patient's respiratory status is unstable and respiratory failure seems imminent, initiate supplemental oxygen and an inhaled beta2-agonist bronchodilator known as a rescue medication. Additional signs of respiratory failure are in this article. If the child is not experiencing respiratory failure, you can start a thorough assessment. This includes questions pertaining to the patient's history of symptoms and your clinical observations.10 Ask about the onset and duration of the exacerbation, symptoms experienced, and any therapeutic interventions used up to the point of seeking assistance. Was the child exposed to anything that could have triggered the attack or exacerbated symptoms? Could his cultural background predispose him to this disorder? (As a group, African-Americans are three times more likely to be hospitalized from asthma and three times more likely to die from it. And Puerto Ricans, more than other Hispanic subgroups, tend to suffer from this condition.)1 Next, determine the extent of the attack by auscultating the lung fields, noting air movement and presence of abnormal breath sounds. These criteria for diagnosis will vary among patients, and in the same person over time. After determining the symptoms are indeed related to asthma, the disorder can be classified as intermittent, mild persistent, moderate persistent, or severe persistent, based on severity. Components of severity are nighttime awakenings, use of short-acting beta2-agonists, interference with normal activity, and lung function. Accurate classification is critical because it determines a patient's treatment goals and pharmacological needs. Children need to be monitored more frequently than adults, due to growth and change in lung function. Therefore, they may manifest different symptoms over time. After initial classification, assessment of control is used to adjust therapy.8 Detailed information on classification and established guidelines for healthcare providers for the diagnosis and management of patients with asthma can be found on the National Heart, Lung, and Blood Institute (NHLBI) Web site, http://www.nhlbi.nih.gov/guidelines/asthma/04_sec3_comp.pdf. If a child's asthma isn't controlled, he can experience an exacerbation. In general, more frequent and intense exacerbations requiring urgent hospitalization, unscheduled care, or ICU admission indicate greater underlying disease severity.8 As soon as there's a confirmation of an acute attack, pharmacological treatment approved by an appropriate prescriber should start. Pharmacological managementAt the outset of treatment, administer an inhaled beta2-agonist, oxygen, and a short course of oral steroids. Use oxygen only if the patient's oxygen saturation falls below 90%, or if the peak expiratory flow (PEF) is less than 50% of expected. Inhaled beta2-agonists should be given to all patients regardless of the severity of their exacerbation. The intent of using these bronchodilators is to treat the acute symptoms, provide prompt relief from airway obstruction, and prevent the symptoms from escalating.8 To control exacerbations, up to three treatments of a short-acting beta2-agonist are given at 20-minute intervals over one hour. For mild exacerbations, which can be treated in an outpatient setting, medication generally is administered via either nebulizer or metered dose inhaler (MDI) with spacer attachment. For nebulization, a 5-mg/ml nebulizer solution of albuterol (Ventolin, Proventil, and others) is given via facemask with oxygen at the flow rate of 6–8 L/min. The minimum dose should be 2.5 mg, or 0.15 mg/kg of body weight. The alternative is to use an MDI with a spacer attachment and give two to three puffs of albuterol at 90 mcg/puff. Generally, this therapy can be administered every one to four hours for a duration of six to 12 hours. Provided there's clear improvement, additions to this regimen aren't necessary to attain treatment goals. However, if there's no improvement after the initial treatment, the exacerbation is classified as moderate or severe, and a steroid should be given in conjunction with the bronchodilator. A moderate or severe exacerbation should be treated immediately with a combination of a bronchodilator and an oral steroid, such as prednisone, prednisolone, or methylprednisolone.8 Steroids, known as controller medicines, reduce airway inflammation and hyperresponsiveness.11 The recommended child dose for an oral steroid such as prednisolone is a loading dose of 2 mg/kg of body weight, then 1-2 mg/kg of body weight divided into two daily doses at a maximum dose of 60 mg/day.8 Also, an inhaled beta2-agonist should be given every four hours as needed for wheezing. If the child is experiencing a severe exacerbation, oxygen administration should be considered to keep saturation above 90%. This regimen should be continued until the goals for exacerbation treatment have been met and maintained, without any intervention, for one hour. However, if no improvement is noted after three beta2-agonist treatments and the administration of oral steroids, the patient should be transferred to the emergency department for further evaluation. Control future attacksWhen the child's respiratory status is stable, gather a more detailed history. Ask about current medications, and inquire about his drug regimen. Also, find out if the patient uses a peak flow meter, and if so, what's his best value. The patient and his parents also should be asked about previous exacerbations, including the number of emergency department visits and hospital admissions. If the child has been admitted to the hospital, determine if he was in theintensive care unit and ventilated due to an asthma exacerbation. After the treatment goals have been met, it is crucial that nurses instruct parents and caregivers in how to manage medications and control symptoms once the patient is discharged. Devise an action plan with goals to maximize lung function, reduce the number of activity-restricted days, eliminate asthma exacerbations, and increase patient and family knowledge. In addition to a written copy of the plan, provide educational information, a follow-up appointment within three days of the exacerbation, and details on how parents can contact the provider in case the child's condition deteriorates. Once home, the child and his parents continue therapy with a short-term treatment intensification, usually a systemic steroid along with a beta2-agonist. Albuterol or an equivalent should be given every four to six hours as needed for a prescribed number of days.8 If the child is of school age, include a second copy of the written plan so teachers, coaches, and the school nurse can be notified of the treatment regimen as well. At the follow-up appointment, monitor the response to treatment, and encourage continued patient compliance with the medication regimen. Review the correct use and purpose of medications, and stress the importance of taking them properly. Provide an educational review of information discussed during previous visits. A large percentage of children have repeat exacerbations and continue to be poorly controlled as outpatients, so clear and detailed explanation of care is imperative. Further follow-up is desirable every one to six months, depending on the severity of the child's disease. These visits are vital to perform a respiratory examination, monitor asthma signs and symptoms—wheezing, coughing, and shortness of breath—assess goals, determine patient follow-through, adjust treatment, address patient questions or concerns, review the appropriateness of the asthma action plan—which every patient should have9—and evaluate medication administration. The correct use of inhalers is critical and should be rechecked at every visit, along with peak flowmeter technique. Patient follow-up can be assessed and reinforced through phone contact initiated by the healthcare provider. Asthma at homePart of an asthma action plan is to teach the patient and family a care approach including pharmacological and nonpharmacological strategies for control. In medication management, the care plan should include the name and dosing instructions of all prescribed asthma medications, as well as criteria necessary for aggressively increasing inhaled medication use at home during an exacerbation. Nonpharmacological management includes teaching children and parents to identify, eliminate, or minimize contact with their particular triggers to prevent bronchiole hyperresponsiveness and associated symptoms. Documenting symptoms in a diary can assist some families in identifying triggers like dust, pollens, molds, dust mites, cockroaches, animal dander, smoke, strong odors, and dry hot or cold air.8 In addition, allergy testing by a physician specializing in allergies may determine asthma triggers. Besides environmental triggers, physical problems such as upper respiratory infections, sinus conditions, post-nasal drip, and gastroesophageal reflux disease can cause asthma. Asthma can also occur during exercise. Advise patients to get an annual influenza vaccination, especially if their exacerbations are triggered by viral illnesses. Encourage children to stay indoors when pollen counts are high, restrict animals inside the home, and eliminate exposure to cigarette smoke.8,12 Provide information on how to reduce mold spores, cockroach infestation, and the incidence of dust mites. Suggest patients encase pillows and mattresses in allergen covers, wash bedding in hot water weekly, and remove carpets, upholstered furniture, and plush animals from the bedroom. Keep stuffed toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and bleach. Placing pillows and stuffed animals in the clothes dryer for 20 minutes each week can reduce or kill dust mites and remove some of their allergens. Promote daily use of peak flow meters in asthma management to obtain an objective assessment of lung function.10 A decrease in lung function often can be detected with a peak flow meter before a patient ever experiences symptoms. This early recognition is important because it prompts intensification in pharmacological therapy and contact with the healthcare provider, which may prevent or diminish an exacerbation. To help keep your patient's asthma in control, reinforce patient-teaching at every meeting, ask thorough questions about symptoms, and inquire about new activities, or exposure to different environments. Above all, work together with your patient and his family to make sure they understand the importance of following the asthma action plan and continuing control medications, even when not experiencing symptoms. REFERENCES1. Asthma and Allergy Foundation of America. "Asthma Facts and Figures." (n.d.). http://www.aafa.org/display.cfm?id=8&sub=42. (16 Jun. 2008). 2. Centers for Disease Control. (2005). Summary health statistics for U.S. children: National health interview survey, 2003. 10 (223), 1-87. Atlanta, GA: U.S. Dept. of Health and Human Services. 3. Mannino, D. M., Homa, D. M., et al. (2002). Surveillance for asthma—United States, 1980-1999. Morbidity & Mortality Weekly Report Surveillance Summaries, 51 (1), 1. 4. American Lung Association. "Trends in asthma morbidity and mortality." 2005. http://www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/ASTHMA1.PDF. (1 Mar. 2006). 5. Holgate, S. T., Holloway, J., et al. (2004). Epithelial-mesenchymal communication in the pathogenesis of chronic asthma. Proceedings of the American Thoracic Society, 1 (2), 93. 6. Wang, L., McParland, B. E., & Pare, P. D. (2003). The functional consequences of structural changes in the airways: Implications for airway hyperresponsiveness in asthma. Chest, 123, 356S. 7. Courtney, A. U., McCarter, D. F., & Pollart, S. M. (2005). Childhood asthma: treatment update. American Family Physician, 71 (10), 1959. 8. National Heart, Lung, and Blood Institute. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma, (NIH Publication No. 07-4051). Washington, DC: U.S. Government Printing Office. 9. Higgins, J. C. (2003). The "crashing asthmatic." American Family Physician, 67 (5), 997. 10. Mintz, M. (2004). Asthma update: Part I. Diagnosis, monitoring, and prevention of disease progression. American Family Physician, 70 (5), 893. 11. Rowe, B. H., Edmonds, M.L., et al. (2004). Corticosteroid therapy for acute asthma. Respiratory Medicine, 98 (4), 275. 12. Rees, J. (2005). ABCs of asthma. Prevalence. BMJ, 331 (7514), 443. Differential DiagnosisAsthma often is associated with recurrent episodes of coughing and wheezing. However, other significant causes of airway obstruction must be considered in the initial diagnosis and if there's no response to initial therapy. Infants and Children Upper airway diseases
Large airway obstructions
Small airway obstructions
Other causes
Source: 1. National Heart, Lung, and Blood Institute. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (NIH Publication No. 07-4051). Washington, DC: U.S. Government Printing Office. Signs of impending respiratory failure include:
Source: 1. National Heart, Lung, and Blood Institute. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (NIH Publication No. 07-4051). Washington, DC: U.S. Government Printing Office. Unique pediatric respiratory physiologyChildren's physiology leads to challenges in respiratory assessment. Knowing the differences when compared to adults helps determine the severity of an airway obstruction. General guidelines use subjective and objective parameters to guide initial therapy. Greater airway resistance Upper Large tongue Nose breathing Smaller airway Pharyngeal muscle tone decreased Airway compliance increased Lower Smaller airway Airway compliance increased Less elastic recoil Respiratory muscles less efficient Less efficient diaphragm Higher rib cage compliance Lung volume decreased Less alveoli Fewer collateral channels of ventilation
Metabolism increased High O2 consumption Risk for apnea Breathing control immature Respiratory muscle endurance decreased Less fatigue-resistant type muscle fibers High respiratory rate Normals Age and Rate Awake in Children <2 months: <60/min 2–12 months: <50/min 1–5 years: <40/min 6–8 months: <30/min Sources: 1. Hammer, J. & Eber, E. (2005). The Peculiarities of Infant Respiratory Physiology. Prog Resp Res, 33, 2–7 2. National Heart, Lung, and Blood Institute. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma, (NIH Publication No. 07-4051). Washington, DC: U.S. Government Printing Office.
|
 
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
