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Restricted Airway Problem

Asthma is a very common problem in children of Amelia’s age. It is evident from the case description that, Amelia exhibiting asthma signs and symptoms like tachypnea (increased respiratory rate), hypoxia (decreased oxygen saturation), coughing, wheezing and rhinorrhea. These symptoms can be alleviated by administering anti-inflammatory and bronchodilator medications. Hence, in case of Amelia, anti-inflammatory drug like prednisolone and bronchodilator drug like salbutamol are prescribed. For the maintenance of normal oxygen saturation level in the blood, supplemental oxygen is provided to Amelia. Two significant problems associated with asthma are identified in Amelia. These problems are restricted airway and inflamed airway. These asthma related problems occurred in Amelia due to series of events like allergy due to allergens and dust, inflammation, secretion of inflammatory markers, bronchoconstriction due to mediators release and difficulty in breathing. In this essay, signs and symptoms of Amelia are correlated with the restricted airway and inflamed airway. In addition to this, possible interventions for these two problems are discussed.         

Restricted airway problem is the most prominent problem associated with asthma patients like Amelia. Asthma mainly occurs due to exposure to allergens. Due to these allergens, there is initiation of IgE dependent immune mechanism. This immune mechanism leads the release of immune and inflammatory mediators like histamine, leucotrines and prostaglandins. Due to effect of these mediators, there is contraction of airway smooth muscle which leads to the bronchoconstriction. Thus, inflammation of respiratory tract is the prominent reason of restricted airway. This restricted airway lead to the difficulty in breathing, inadequate airway clearance, augmented breathing rate and low oxygen saturation level (Kim et al., 2012)

There is increased breathing rate in Amelia. Normal breathing rate for the children of Amelia’s age should be between 20 – 30 breaths per minute.  Nevertheless, in case of Amelia, breathing rate is measured to 34 breaths per minute. In children of Amelia’s age oxygen saturation level should be between 95 – 100 %.  However, measured oxygen saturation level in Amelia is 90 %. Amelia is exhibiting moist cough which is a productive cough because in this type of cough there is expulsion of phlegm from the lungs and airways. This expulsion of phlegm is useful in the removal of infective agents and foreign particles from the lungs and airways. Rhinorrhea is also evident in Amelia. Rhinorrhea is marked with the accumulation of substantial amount of mucus in the nasal cavity.  Inflammatory markers exaggerate accumulation of mucus in the nasal cavity (Patadia et al., 2014). Rhinorrhea accompanied by restricted airway, leads to the insufficient airway clearance. This results in the insufficient breathing in Amelia. As a result of insufficient breathing, less amount of oxygen gets exchanged at the alveoli-capillary interface. This results in the less amount of oxygen availability in the blood and less supply of oxygen to the end users like tissues and organs. Due to availability of less amount of oxygen in the blood, there is possibility of faster breathing to fulfill the requirement of deficient amount of oxygen. In case of Amelia also, faster breathing rate is observed (Kim et al., 2012; Mims, 2015).

Sitting Up Posture Intervention

Sitting posture is the useful intervention for the restricted airway. This intervention would be useful in facilitating easy breathing in Amelia. Sitting up posture can increase surface area of lungs for exchange of gases like O2 and Co2 by stretching and widening of lungs. As a result, lungs become flexible and there is expansion of chest to receive more amount of air in the lungs.   

This intervention would be useful in improving respiratory function in Amelia. In this intervention, there is no requirement of physical activity and it can be done in comfortable position (Kim et al., 2012).

Sitting posture can be provided by using pillow which can support back of Amelia. However, care should be taken that more number of pillows should not be used because it may lead to sink in pillows. This sink may lead to restricted chest movement. Sleep position in Amelia can be prevented by slight movement of the leg on the bed. Amelia can sit on the edge of the bed or in armchair to achieve this sitting posture. Sitting posture can also be achieved by using table and inclining hands towards front side. Amelia should give attention towards other parts while sitting like heels, ankles, sacrum and elbows because these are the pressure points in the body. Adjustment of inclination against the wall and resting head on the raised arm can be useful in achieving maximum expansion of chest. It is evident from the literature that sitting posture intervention in addition to the regular asthma management progrmmae is useful in improving oxygen saturation level, breathing rate and overall respiratory function. However, implementation of this programme is not an easy task in children because children are dynamic and always seek to slide on the bed (Melam et al., 2014)

Salbutamol is used as bronchodilator for Amelia because she has restricted airway. Mechanism of action of salbutamol is β2 adrenergic agonist. Salbutamol produces long duration effect and it inhibits release of mast cells. It is also helpful in the drainage of mucus in the airways. Effectiveness of salbutamol in case of Amelia should be evaluated prior to 2 hours post administration. Arterial blood gas (ABG) analysis and pulmonary function test (PFT) can be used to evaluate effectiveness of salbutamol in case of Amelia. Nurse should perform ABG and PFT in Amelia prior to administration and post administration. Based on the post administration data, dose level and frequency of administration should be adjusted accordingly. Salbutamol is prone to produce central nervous system (CNS) stimulation in children of Amelia’s age. CNS stimulation effects comprises of hyperactivity, excitement, nervousness and insomnia. Hence, nurse should monitor these symptoms in Amelia during its administration. Other symptoms like fine tremor in figures, tachycardia, dizziness, vertigo and gastrointestinal tract (GI) symptoms should also be monitored in Amelia. It is very important to give proper training for use and maintenance of salbutamol inhaler to Amelia and her parents. Eye contact of salbutamol inhaler should be avoided. Instruction should be given to Amelia and her parents about the frequency of inhalations of salbutamol. They should not increase or decrease frequency of salbutamol inhalations without consultation of doctor (van Buul and Taube, 2015; Neininger et al., 2015).   

Salbutamol

Asthma predominantly occurs due to respiratory tract inflammation. This inflamed airway is the second problem identified in Amelia. In asthma, body reacts to allergens and it produces inflammation in the airways. Inflammation of airways produces its effects in the form of swollen and narrowed airways and release of varied inflammatory mediators like inflammatory cells and cytokines. Inflammatory cell which plays important role in the pathogenesis of asthma are Th2 lymphocytes, mast cells, eosinophils, dendritic cells, epithelial cells, macrophases and resident cells of airway. Th2 lymphocytes produces cytokines like interleukin – 4 (IL-4), IL-5 and IL-13 which are responsible for the maintenance of inflammation in asthma (Kim et al., 2016). Progressive inflammation leads to the release of more amount of mucus and deposition of mucus plugs which leads to the occurrence of edema in the bronchial tubes. Mucus also gets deposited in the nasal cavity which is called as rhinorrhea. This rhinorrhea is also observed in case of Amelia. Rhinorrhea leads to other complications like limitation in air passage, low level of oxygen saturation and dyspnea. All these symptoms observed in Amelia. Mucus deposition is also responsible for moist cough in Amelia. Cough is useful for the expulsion of deposited mucus. Chronic and persistent inflammation can lead to the narrowing of the airways. Dust or cold air can exaggerate narrowing of the airways and cough. This narrowing of the airways leads to the difficulty in breathing, dyspnea and rapid breathing rate. Difficulty in passage of air through narrow airways leads to the forcibly passage of air through it. It gives whistling sound at the time of exhalation. This whistling sound is termed as wheezing. There isalso occurrence of wheezing in Amelia (Chawes, 2011).         

Hydrocrtisone can be prescribed in Amelia for reversing inflammation because Amelia is diagnosed with asthma and asthma is predominantly an inflammatory disease. Hydrocortisone can produce its effects by stabilizing leukocyte lysosomal memebranes and inhibiting release of allergic substances. Hydrocortisone can reduce antibody titers and suppress hyperactivity reactions in Amelia. By this, it can produce immunosuppression effect in Amelia. It reflects, hydrocortisone can produce both anti-inflammatory and immunosuppression effects in Amelia.  

Most widely used hydrocortisone like prednisolone can be effectively used in Amelia. It is very important to initiate prednisolone treatment for Amelia as early as possible. Prednisolone should be initiated in case of Amelia prior to 1 hour after the evidence of symptoms like cough and wheezing.  Recommended initial dose for children of Amelia’s age is 2 mg/kg. Not more than 50 mg prednisolone should be administered to Amelia per day. In succeeding days, 1 mg/kg twice a day prednisolone can be administered to Amelia (Zhang et al., 2014; Kravitz et al., 2011).

Nurse should monitor for overuse of prednisolone in case persistent symptoms because prednisolone is having few adverse effects. There should be monitoring of blood pressure, weight, fluid and electrolyte balance and glucose level in Amelia. As prednisolone has immunosuppression property, there should be monitoring of platelet count and white blood cells differential count in Amelia. As prednisolone has hypocalcemia property, there should be monitoring of chest pain and fractures of long bones in Amelia. High protein, calcium and vitamin D rich food should be incorporated in the diet of Amelia. Immunosuppression increases chances of infection, hence nurse should perform tests for infection in Amelia. Mood changes and depression should be assessed in Amelia because long term use of prednisolone produces behavioral and psychological symptoms. According to 2015- Global Initiative for Asthma (GINA), inhalation is the preferred route for the administration of hydrocortisone in patients with asthma. Hence, it is administered through inhalation route in Amelia (Olin and Wechsler, 2014).               

Inflamed Airway Problem

Education should be provided to Amelia and her parents about inflamed airway, its consequences and its management because it is highly possible that Amelia and her parents might not aware of this. Nurse should correct her for breathing and coughing. It includes deep breathing, sequential 2 - 3 times coughing, use of abdominal muscle for breathing and coughing and changing position during continuous coughing. Susceptibility to infection is more in patients with asthma. Hence, nurse should advise Amelia and her parents to maintain personal and environmental hygienic condition. For maintaining hygienic condition, Amelia should wash hands prior to eating and use gloves and facemasks (Klok et al., 2015; VanGarsse et al., 2015). Nurse should advise Amelia to protect herself from exaggeration of asthma conditions. This can be achieved by preventing exposure to dust and allergens. There is deposition of mucus in the inflamed airways of Amelia. Thinning of this mucus can be achieved by more consumption of the liquids and fluids. Hence, nurse should educate Amelia and her parents about more consumption of fluids. Persistent coughing and inhalation medications can change taste of food. Hence, Amelia may lose interest in eating food. Amelia and her parents should be taught with problem in eating. Nurse should educate Amelia and her parents about medications consumption and inhalation use (Young, 2011).                                          

Conclusion

It is evident that Amelia is suffering through Asthma and exhibiting respiratory system symptoms. Two problems related to the decline in the lung function are identified in Amelia. These problems are restricted airway and inflamed airway. Inflamed airway and restricted airway are the sequential processes with first occurrence of inflamed airway followed by restricted airway. Amplified response to allergens lead to inflamed airway and increased release and accumulation of inflammatory markers lead to restricted airway. Dyspnea in Amelia is due to inflamed airway and restricted airway. In case if restricted airway, sitting up posture and administration of salbutamol, are implemented. Sitting up posture facilitates easy breathing, while, salbutamol facilitates bronchodilation. In case of inflamed airway, administration of hydrocortisosne and education to Amelia and her parents, are the two interventions provided. Hydrocortisone cures inflammation of airways and education provide information about different aspects of cure of Asthma. In summary, recognition of the problem and implementation of intervention can be helpful in improving condition of Amelia.     

References

Bonini, M., & Usmani, O.S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Therapeutic Advances in Respiratory Disease, 9(6), 281-93.

Chawes, B.L. (2011). Upper and lower airway pathology in young children with allergic- and non-allergic rhinitis.  Danish Medical Bulletin, 58(5), B4278.

Kim, K., Byun, M., Lee, W., Cynn, H., Kwon, O., and Yi, C. (2012). Effects of breathing maneuver and sitting posture on muscle activity in inspiratory accessory muscles in patients with chronic obstructive pulmonary disease. Multidisciplinary Respiratory Medicine,  7(1), 9. doi.   10.1186/2049-6958-7-9.

Kim, H.Y., Umetsu, D.T., and Dekruyff, R.H. (2016). Innate lymphoid cells in asthma: Will they take your breath away? European Journal of Immunology, 46(4), 795-806.

Kravitz, J., Dominici, P., Ufberg, J., et al. (2011). Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Annals of Emergency Medicine, 58, 200-204.

Klok, T., Kaptein, A.A., and Brand, P.L. (2015). Non-adherence in children with asthma reviewed: The need for improvement of asthma care and medical education.

Pediatric Allergy and Immunology, 26(3), 197-205.

Melam, G.R., Buragadda, S., Alhusaini, A., Alghamdi, M.A., Alghamdi, M.S., and Kaushal, P. (2014).  Journal of Physical Therapy Science, 26(4),  591-593.

Mims, J.W. (2015). Asthma: definitions and pathophysiology. International Forum of Allergy & Rhinology, 5(l), S2-6.

Neininger, M.P., Kaune, A.,  Bertsche, A.,  Rink, J., et al., (2015). How to improve prescription of inhaled salbutamol by providing standardised feedback on administration: a controlled intervention pilot study with follow-up. BMC Health Services Research, 15, 40.

Olin, J..T, & Wechsler, M.E. (2014). Asthma: pathogenesis and novel drugs for treatment. British Medical Journal,  349, g5517. doi: 10.1136/bmj.g5517

Patadia, M.O., Murrill, L.L., Corey, J. (2014). Asthma: symptoms and presentation. Otolaryngologic Clinics of North America, 47(1), 23-32.

van Buul, A.R, & Taube, C.  (2015). Treatment of severe asthma: entering the era of targeted therapy. Expert Opinion on Biological Therapy, 15(12), 1713-25.

VanGarsse, A, Magie, R.D., and Bruhnding, A. (2015). Pediatric asthma for the primary care practitioner. Primary care, 42(1), 129-42.

Young, C. (2011). Patient education. Avoiding asthma triggers: a primer for patients. Journal of the American Osteopathic Association, 111(7), S30-2.

Zhang, L., Prietsch, S.O., and Ducharme, F.M. (2014). Inhaled corticosteroids in children with persistent asthma: effects on growth. Cochrane Database of Systematic Reviews, (7):CD009471. doi: 10.1002/14651858.

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