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Management Of Asthma In Children

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Question:

Discuss about the Management of Asthma in Children.
 
 

Answer:

Introduction:

Asthma is a common chronic disease in most of industrialised nations and is predominant in children of family with historyatopy.  (André& Andrew, 2013; Andrew, 2015).The associated symptoms of asthma are aggravated by various factors including viral infections, exposure to allergens and poor quality of air (Bekmezien et al, 2013). In the present scenario Amelia Taylor has been presented to ED with history of asthma, although her mother denies any. Medical history reveals treating child for same in past few months and discussing management plan with parents (care takers). The child is presented with rhinorrhoea and is responding with only yes or no due to anxiety and improper breathing pattern due to bilateral expiratorywheezes which is noted on auscultation. With this information on the patient two primary concerns (priority problems) are

  • Ineffective breathing pattern (Problem 1)
  • Management of Asthma (Problem 2)

The need for prioritising the above has been dealt in detail below.

Ineffective breathing pattern (Problem 1):

Asthma is characterised by difficulty in breathing because of respiratory tract infections, allergic reactions and bronchospasm. Bronchospasm result due to allergic reactions which elicit production of IgE mediated antibodies triggering early phase of reaction. This induces rise in activation of airway mast cells and macrophages which release pro-inflammatory mediators such as eicosanoids, ROS and histamine which induce smooth muscle contraction, mucus secretion and vasodilatation which results in accumulation of mucus thereby blocking the airway (Britto et al, 2014; Danielle et al, 2017; Federico &Kanwalijeet, 2013; Ronit& Susanna, 2011)

 

Pathophysiology of Asthma:

  • Airway narrowing is associated always with bronchial hyper responsiveness leading to mucosal oedema and mucus plugs
  • Wheezing and cough will increase in night or early morning making difficult to breath (Susan et al, 2013)
  • Cytokine imbalance with T helper type 2 cells promotes IgE synthesis leading to allergic reactions leading to asthma (Andrew &Sejal, 2010)
  • Studies reveals infection with mycobacterium, hepatitis reduces risk of asthma. An increased use of fish in diet also reduces risk of asthma (Susan, 2017)
  • Asthma is differentiating into mild and severe depending on oxygen saturation, wheezing and cough. A nonspecific respiratory disease can also present similar symptoms but a well trained professional and nurse can differentiate between two easily (Susan et al, 2013)

Epidemiology:

  • Asthma is leading cause for hospitalization in Canadian children
  • The prevalence of asthma is 10 times more in developed countries in comparision to developing countries
  • Asthma is leading cause for school absenteeism in children of USA
  • The prevalence of asthma is more in blacks and hispanics in comparison to others
  • Rapid urbanization is paving way for increased number of asthma cases

From the given details and history it is evident that the child is suffering from too much cough and breathlessness in night and has been aided by ventolin and paracetomol to ease the situation in morning without any positive results. This may be due to the bronchospasm in which airways are constricted and filled with mucus due to allergic reactions. The child still suffers from breathlessness and anxiety with oxygen saturation<90%. She is also presented with cough (at night) lasting for more than a week worsened by cold weather and running nose. This is one of the common symptom associated with asthma. Differential counting of blood components will enumerate rise in level of eosinophil’s and IgE antibodies (Sills et al, 2011; Ullmann et al, 2013; Zemek et al, 2012).  As it’s well documented in medical history of patient, she has wheezing problem and unable to speak fluently which is an associated symptom in case of asthma

  • In this present patient scenario, the nurse first has to provide care for easing the breath which can be aided by administration of bronchodilators along with humid oxygen.
  • After comforting with breathing, nurse has to document the vitals and basic information and has to review the medical history for recent medication and past complications.
  • As it is always said, a nurse should have thorough knowledge about the clinical condition before making decision. The child is suffering from severe type of asthma as given by classification of asthma (increase breathlessness, oxygen saturation<90%)
  • In this case patient is child with less than 5 years of age which makes tougher to strict to medication and due to patient’s past experience in hospital she is in anxiety which is correlating factor with respect to asthma
  • The nurse once recorded with heart rate, respiration rate, bp and other vitals, they have to be continuously monitored at regular intervals so that any significant variation (deviating from normal) is taken care discussing the situation with health professionals
  • The child initially has been prescribed with salbutamol puffs (bronchodilators) until further review, during which vital such as heart rate has to be continuously observed since salbutamol has been found to have adverse effect on cardiac function
  • Since the patient vomited soon after consuming prednisolone, hydrocortisone has been administered through IV to reduce inflammations and allergic reactions if any
  • Since the patients age is less than 5, use of spirometer test may not be advised and if the patient is asymptomatic spirometer can’t be employed for testing
  • Analyse the peak flow monitor value to suspect severity of asthma
  • If asthma is mild can go for chemotherapy to regulate further worsening of situation and if situation is severe then immediate actions are need to tae care of patient
  • A nurse with thorough knowledge of asthma will look into eosinophil count or IgE level in blood with any explanation for the variation (if any)
  • Chronic obstructive pulmonary disorder (COPD) also presents some of the features presented by asthma, well trained nurse can differentiate between both
  • On the evidence based practising, any increase and decrease in heart rate, bp, respiration rate must be immediately taken care to avoid further worsening of the situation
  • Nurse has to demonstrate comprehensive skill in both physical and mental health, ethnic and cultural dimensions
  • A nurse to client (patient) relation should be based on trust and mutual understanding and in the meantime nurse should not interfere with cultural or ethnic belief and should not impose any of her decisions to follow without discussing with patient or care taker
  • Nurse will provide holistic treatment to patient with proper discussion with care taker and health professionals regarding the uses and adverse effects of the medication being administered.
 

Management of Asthma (Problem 2):

  • Asthma similar to diabetes mellitus can’t be cured but can be managed to increase the quality of life of patient.
  • Management of asthma requires strict dedication towards medication or pharmacotherapy failing which may increase the severity of disease worsening the condition (Campbell, 2011; Fleming et al, 2013).
  • Patient and the care takers should be advisedon used of medicationsand devises such as nebulisers, spacers and metered dose of inhalers
  • Patients condition should be discussed with care takers along with the precautions to be taken and do’s and don’ts with respect to asthma

In the present scenario, patient is a child of 4 years of age with anxiety and fears for hospitalisation because of previous bad experience. The care takers should be well educated in this case so that they can keep an eye on medications and devices used by the child and they also can assist in the severe cases or if the diseased condition get worse. Although medical history with previous admission of the patient clearly indicates the discussions and plan to be taken with respect to disease, patients mother fails to memorise it claiming she never had such problems.

Regular check-up and follow up to the hospital will avoid readmission to hospital due to disease severity. Improved living style and getting less exposed to allergens will favour the recovery. In this condition patient is suffering from running nose with light fever, which can be attributed to allergic reactions caused by hay leading to hay fever. In the present scenario the child has been diagnosed for asthma for past 6 months and her care taker fails to manage the condition properly which resulted in worsening condition with rhinorrhoea and a frequent moist cough. The condition was elevated by the cold weather and wheezing and patient mother ignorant of underlying causes and her past medical history (Antoinette et al, 2015; Britto et al, 2014; Fitzgerald, 2011; Ortiz-Alvarez&Mikrogianakis, 2012).

 


During the present hospitalisation, nurse has to intervene to educate patient and her care taker regarding the management of asthma by increasing health literacy of her mother. She has to be educated with use of the spacers and nebulisers in case of difficulty in breathing for her child, and also to maintain the strict regime of over the medication which helps in further complications. The nurse should intervene with things and food to avoid, management of the asthma outside hospital by giving suitable precautions. Although pharmacotherapy doesn’t cure the illness it assists it managing the disease with reduced complications. If the conditions of asthma are not shown continuously for more than three months then step down can be considered (Fleming et al, 2012; Kathleen et al, 2016; Sills et al, 2011; Ullmann, 2013)

The literature has well documented the fact that tobacco smoke exaggerates asthma, by making child a passive smoker, the smooth muscle of trachea contract creating further inconvenience to child. If any in home is a smoker, nurse should ask them to practise strictly outside home or to avoid. Further child and care take has to be educated regarding the complications associated with the change in weather such as cold and foggy conditions which are not suitable for the patient. The food allergens or any other household mould allergens has to be checked along with allergy to pets.Regular check-ups and follow up must be strictly maintained to assess the level of severity underlying with disease. Continuous follow helps in managing illness more effectively and if the condition has not improved or medication has shown any adverse effects, then the nurse can discuss with health professional for further treatment. The asthma if not managed properly then may consider step up 1 step and alternate diagnosis can be considered if any of adverse effects have been visualised. The condition of the patient should be assessed for every 2-6 weeks for any benefits. If the condition is still not controlled then short course of corticosteroids can be considered with follow up for every two weeks to assess disease severity (Andrew &Sejal, 2010; Jacqui, 2016, Kathleen et al, 2016; Zemek et al, 2012)

Since the patient in this case is child (<4 years) she has to avoid comorbidities such as obesity, rhino-sinusitis, dysfunctional breathing, and psychosocial problems which results in elevating asthma conditions. Nurse can intervene with multifaceted treatment if the disease severity increases.

 

Challenges in paediatric evidence based practise:

  • Need for developing a system where the errors are reported without blame which assists in reducing number of errors in future aspects
  • To provide better education and training for the nurses to reduce the errors
  • Bridging the gap between scientific evidence for practise and application of same in clinical care of the patients
  • Management of pain very much difficult and which vary the dosage calculation
  • Care for the patient is provided in complex system where time is limited which affects decision making ability of the nurses. Thorough knowledge and training on same will reduce number of errors and increase capacity of nurse to make quick decision depending on the best evidence available at that time
  • In the difficult situations, nurses has to practise based on the best evidence available along with discussion with patients care taker and their preferences. This evidence based practise of nursing maximises the clinical outcome especially with concern to paediatric patients and their families.
  • Improving communication between the groups of same hospital or between institutions will enhance the understanding and management of the disease in severe conditions.

Conclusion:

The child has been presented with the problem of breathlessness along with the complications associated with the asthma. Immediate care for the patient to be provided for easing breathlessness aided by Salbutamol 6 puffs via spacer and oral dose of prednisolone to reduce inflammation and allergic reactions if any. The child has asthma complication for past six months and even after the nurse has discussed with the care taker (mother) and asked for proper management plan of the same, her mother fails and claims her child has no previous symptoms of asthma (The symptoms, medication and discussion has been well documented in the medical history).

The condition is worsened by her rhinorrhoea and a frequent moist cough with anxiety and fear to get hospitalised due to past bad experience. The immediate care although provided through bronchodilators further the nurse has to intervene with the patient on easing many of associated complications such as management of disease, do’s and don’ts.

The patient and her mother has to be educated for the complications associated with asthma and precautions to minimise the complications. Also, along with this parents and child has to be made well acquainted with use of strict regime of the medications and use of devices such as inhalers and spacers under difficult conditions.  A thorough increase in health literacy of the patient and her care taker will reduce further complications and readmission to the hospital for the severity of the same disease.

 

References:

André, S.,& Andrew, C.M. (2013). Outpatient Management of Asthma in Children. Clinical Medicine Insights: Pediatrics, 7, 13–24. doi: 10.4137/CMPed.S7867

Andrew, B. (2015). Diagnosis and management of asthma in children, clinical review, BMJ, 350:h996 doi: 10.1136/bmj.h996.

Antoinette, G., Barbara, K., Wendy, B., Diane, K.M., Susan, R., Lynne, M., Kathy C.E., Mullen, A., Karen, R., & Donald, A. (2015). National standards for asthma self-management education. Annals of Allergy Asthma &Immunology,114, 178-186. https://dx.doi.org/10.1016/j.anai.2014.12.014

Bekmezian, A., Fee, C., Bekmezian, S., Maselli, J.H., &Weber, E. (2013). Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma. Pediatric Emergency Care, 29, 1075–81.

Britto, M.T., Vockell, A.L., Munafo, J.K., Schoettker, P.J., Wimberg, J.A.,& Pruett, R.(2014). Improving outcomes for underserved adolescents with asthma. Pediatrics, 133, 418-427.

Campbell, J.D. (2011). Managed care opportunities for improving asthma care. American Journal of Managed Care, 17(3), 90-96.

Clinical Guideline for the Diagnosis, Evaluation and Management of Adults and Children with Asthma retrieved May 7, 2017,  from New York State Department of Health website, www.health.ny.gov

Danielle, K. M., Nadia, K.,&Courtney, M. R.(2017). Pediatric asthma severity score is associated with critical care interventions. Retrospective study, World Journal of ClinicalPediatrics, 8, 6(1),  34-39. DOI: 10.5409/wjcp.v6.i1.34

Federico, F, N., &Kanwaljeet, J. S. (2013). Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit. Journal ofPediatric Pharmacology and Therapeutics,18(2), 88–104

Fitzgerald, J. M. (2011). Targeting lung attacks,Thorax, 66, 365-366.

Fleming, L., Tsartsali, L., Wilson, N., Regamey, N., &Bush, A. (2013). Longitudinal relationship between sputum eosinophils and exhaled nitric oxide in children with asthma. American Journal of Respiratoryand Critical Care Medicine,188, 400-402.

Fleming, L., Wilson, N., Regamey, N., &Bush, A. (2012). Use of sputum eosinophil counts to guide management in children with severe asthma. Thorax,67, 193-198.

Jacqui, W. (2016). Processed meat is linked to asthma symptoms, study finds. BMJ,355, i6807 doi: 10.1136/bmj.i6807

Kathleen, B., Sabah, I., Su-Lin, S., Jennifer, F., James, C., &Paul, C. M. (2016). Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis. BMJ Quality Improvement Reports, 5:u216506.w5621. doi:10.1136/bmjquality.u216506.w5621

Ortiz-Alvarez, &Mikrogianakis, A. (2012). Canadian Paediatric Society, Acute Care Committee. Managing the paediatric patient with an acute asthma exacerbation. Paediatric Child Health, 17(5), 251-256.

Andrew, B., &Sejal, S. (2010). Management of severe asthma in children. Lancet. 376(9743), 814–825. doi:10.1016/S0140-6736(10)61054-9.

Ronit, H.,& Susanna, C. R. (2011).Pediatric asthma: natural history, assessment and treatment. Mt. Sinai Journal of Medicine, 78(5), 645–660. doi:10.1002/msj.20285.

Sills, M. R., Fairclough, D., Ranade, D., &Kahn, M. G.(2011). Emergency department crowding in associated with decreased quality of care for children with acute asthma. Annals of Emergency Medicine, 57, 191–200.

Susan, L., Janis, B., Smith, &Karen, C. (2013). Chapter 15. Paediatric Safety and Quality. Patient Safety and Quality: An Evidence-Based Handbook for Nurses,1, 405-434.

Susan, M. (2017). High dose fish oil supplements in late pregnancy reduce asthma in offspring, finds study. BMJ, 356:i6861 doi: 10.1136/bmj.i6861

Ullmann, N., Bossley, C. J., Fleming, L., Silvestri, M., Bush, A., &Saglani S. (2013). Blood eosinophil counts rarely reflect airway eosinophilia in children with severe asthma. Allergy, 68, 402-406.

Zemek, R., Plint, A.,& Osmond, M.H. (2012). Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency. Pediatrics,129, 671–80.

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