Pediatric Asthma Past Course Notes PDF

 CONCEPTS The priority concept in this chapter is Gas Exchange The interrelated concepts in this chapter are Perfusion Inflammation Cellular Regulation  RESPIRATORY SYSTEM REVIEW Upper airway...

 CONCEPTS The priority concept in this chapter is Gas Exchange The interrelated concepts in this chapter are Perfusion Inflammation Cellular Regulation  RESPIRATORY SYSTEM REVIEW Upper airway Nares (or nostrils), pharynx (throat) Larynx is located between the pharynx and trachea and houses the vocal cords. Ciliated mucous membranes Tonsils Lower airway Trachea, bronchi, bronchioles and lung periphery (alveoli) Alveoli where gas exchange occurs RESPIRATORY SYSTEM DIAGRAM MECHANISM OF GAS EXCHANGE  DIFFERENCES IN PEDIATRIC AND ADULT RESPIRATORY SYSTEM Lack of or insufficient surfactant Smaller airways and undeveloped cartilage Obligatory nose breather (infant) Less well-developed intercostal muscles Brief periods of apnea common (newborn) Faster respiratory rate; increased metabolic needs Eustachian tubes relatively horizontal Tonsillar tissue enlargement More flexible larynx, susceptible to spasm Abdominal breathers  ASTHMA: INCIDENCE AND PREVALENCE Can occur at any age Highest between 10-17 years of age Leading cause of acute and chronic illness in children Most frequent admitting diagnosis in Childrens’ hospitals 8.3% of children in US have asthma Higher in African American population More common in urban than rural settings  ASTHMA-PATHO Chronic disease that occurs intermittently Genetic and environmental factors Result: Inflammation and airway tissue sensitivity A reversible obstructive airway disease characterized by Increased airway responsiveness to a variety of stimuli Bronchospasm resulting from constriction of bronchial smooth muscle (bronchoconstriction) Inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways (mucous production)  PATHO, CONT.. Immediate Reaction Allergens activate IgE receptors on mast cells Histamines, leukotrienes and prostaglandins released Causes bronchoconstriction Non allergic stimuli (cold air, exercise) also cause bronchoconstriction Late Reaction Eosinophils, basophils, neutrophils attracted to the respiratory tract Causes inflammation, edema, mucous production/plugging Get bronchoconstriction and hyperesponsive airways (can last weeks to months).  ASTHMA (PATHO) Pictured above is a normal bronchial tube and lumen compared to a  BRONCHIAL ASTHMA Pictured above: With bronchial asthma, the bronchiole is obstructed on expiration, particularly by muscle spasm, edema of the mucosa, and thick  ASTHMA ASSESSMENT-HISTORY Premature Family history Previous episodes of wheezing Cough, coughing at night, cough during or after exercise SOB Allergies (food, meds, etc..) Triggers Allergic rhinitis or eczema? Ever hospitalized for asthma? # of episodes in the last year?  RISK FACTORS Family history of asthma Previous severe lower respiratory infections Presence of allergy/allergic rhinitis (seasonal allergies) or atopy (eczema) Called Allergic triad… More common in boys Prematurity  ASTHMA TRIGGERS Variety of stimuli: Cold air/change in weather Smoke Allergens (pollen, dander, dust, mold, cockroach droppings) Viral /bacterial infections Stress Exercise Environmental pollutants (smoking, carpets) Foods Medications (aspirin, NSAIDs, beta blockers)  ASTHMA ASSESSMENT- SIGNS AND SYMPTOMS Vital signs (HR and RR) Color (circumoral…) Lung sounds-wheezing, aeration, stridor, cough, chest tightness Accessory muscles (retractions) Clavicular Sternal (supra and sub) Intercostal Neck muscles Abdomen Restless, apprehension, anxiety, diaphoresis Tripod position Difficulty talking, eating and walking Symptoms worse at night  ASTHMA ASSESSMENT-DIAGNOSTICS Laboratory assessment Pulse ox End tidal CO2 monitoring (carbon dioxide) ABG’s (arterial blood gas) Peak flow meter (daily) CXR Pulmonary function tests Diagnostic for asthma Forced vital capacity (FVC)-decreased Forced expiratory volume in first second (FEV1)- decreased Increased residual volume  ASTHMA DIAGNOSTICS, CONT. See allergic rhinitis (seasonal allergies), sinusitis and nasal polyps in asthmatic patients IgE skin testing for allergens (for specific allergens) Blood and sputum See eosinophils present  ASTHMA: ASSESSMENT: RECOGNIZE CUES Assessment: Noticing Key Features of Disease: Asthma Symptoms and Control Level Symptoms Controlled Partly Uncontrolled Controlled Daytime symptoms of wheezing, dyspnea, coughing present more than twice weekly Waking from night sleep with None of these 1-2 of these 3-4 of these symptoms of wheezing, dyspnea, coughing Relieved (rescue) drug needed more than twice weekly Number of times per week activity was limited or stopped by symptoms Adapted from Global Initiative for Asthma (GINA). 2018. Pocket Guide for asthma management and prevention.  CLASSIFICATIONS OF ASTHMA Intermittent Mild persistent Moderate persistent Severe persistent  THERAPEUTIC MANAGEMENT OF ASTHMA Goal: Improve airflow and gas exchange 4 Domains: Assessing, Collaboration, Avoidance and Meds Recognize early signs of an asthma episode Follow an asthma action plan Avoidance of triggers Administer medications and treatments Education for patient and family Close f/u and collaboration with PCP, parents, school, etc.  ASTHMA MEDICATIONS Drug therapy Rescue drugs (used to stop an attack) (ACUTE) SABA’s (short acting beta adrenergic agonists) Bronchodilators (MDI, nebulizer) Albuterol( ProAir HFA, Ventolin, Proventil) Levalbuterol (Xopenex) Terbutaline (Breatheair) Anticholinergics Ipratropium bromide (Atrovent) (kids 12 and older) Combined with a SABA (albuterol)..duo neb Corticosteroids (short term..5 to 7 days) PO (prednisone, prednisolone) IV (Solumedrol)  ASTHMA MEDS, CONT.. Control therapy drugs (LONG TERM..prevention) Daily use, prevention Anti-inflammatory agents (inhaled) Budesonide (Pulmicort), fluticasone (Flovent), beclomethasone (Qvar) LABA’s (long-acting beta 2 adrenergics) Salmeterol (Serevent) and formaterol (Foradil) Combo meds Symbicort (budesonide and formoterol) (ICS and LABA) Advair (fluticasone and salmeterol) (ICS and LABA) Leukotriene inhibitors Decreases action of leukotrienes Montelukast (Singular) Give as young as 1 year old (sprinkles/chewables) Anti IgE antibody Omalizumab (Zolair), Nucala SQ injection every 4 weeks For allergic type asthma  ASTHMA MEDS, CONT.. Xanthines Older drug Theophylline (Slo bid, Theodur) Relaxes bronchial smooth muscle, increase HR Need to monitor levels for toxicity Theophylline level  SIGNS AND SYMPTOMS (NEED FOR EMERGENCY TREATMENT) Worsening wheeze, cough, or shortness of breath No improvement after bronchodilator use Difficulty breathing Trouble with walking or talking Discontinuation of play Listlessness or weak cry Gray or blue lips or fingernails Poor aeration, minimal or no wheezing noted  STATUS ASTHMATICUS Severe, life-threatening, acute episode of airway obstruction Intensifies once it begins, often does not respond to common therapy Can develop pneumothorax and cardiac or respiratory arrest Treatment—IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen Prepare for emergency intubation ASTHMA ACTION PLAN  VA ASTHMA ACTION PLAN https://www.vdh.virginia.gov/content/uploads/sites/58 /2016/12/Asthma-Action-Plan-2019.pdf  ENVIRONMENTAL MODIFICATIONS Pollen and dust Wash sheets weekly in hot water No wool or down blankets Dust-proof covers on pillows and mattresses Replace carpet with wood or tile No drapes or blinds; use curtains or shades Air filters and cleaners, use air conditioner Household humidity at 40-50% Multilayer vacuum bags Clean with dust-attracting rags/towels  ENVIRONMENTAL MODIFICATIONS, CONT.. Mold Clean with mold inhibitor Dry shoes thoroughly Moisture remover in closets Avoid basements No rubber or inner-spring mattresses Use air conditioner Humidity below 35%, use a dehumidifier House ventilation Limit number of indoor plants  ENVIRONMENTAL MODIFICATIONS, CONT. Dander Keep pets outside, if possible House ventilation Air cleaners Dust covers on mattresses and pillow cases Frequent vacuuming Air purifier  EDUCATION/ PREVENTION OF ASTHMA Collaboration/communication between patient, parents, PCP’s and school nurses. Frequent visits to PCP/education ongoing. Know and avoid triggers Alter environment Use your peak flow! Know yourself! Take your medications! Seek medical help as soon as symptoms not responding to treatment. Don’t wait! Questions/Comments?