ASTHMA

Laurine Gajkowski

Overview

Asthma is a common chronic inflammatory disorder of the large and small airways. Varying degrees of airflow obstruction occur due to bronchial muscle constriction, edema of the tracheobronchial mucosa, and increased mucous secretions. Susceptible children have intermittent respiratory symptoms, such as wheezing, dyspnea, and cough, especially at night. In the United States, 6.3 million children or 8.6% of those younger than 18 years have a diagnosis of asthma (Clarke, Ward, & Schiller, 2016). It poses a burden on the affected children, the parents, and the community. Children with asthma can experience a decreased quality of life because of impairment of daily activities, emergency department visits, and school absences (Miadich, Everhart, Borschuk, Winter, & Fiese, 2015). Childhood asthma is associated with high rates of school absenteeism (Cicutto, Gleason, & Szefler, 2014), and exacerbations or “flare-ups” of symptoms are the leading cause of pediatric hospital admissions in the United States (Sylvester & George, 2014). Nurses provide acute care to these children in hospitals when the level of respiratory compromise is too severe to be managed at home. Nursing interventions in outpatient settings such as schools and clinics are aimed at assisting the child and family to assume responsibility for asthma management.

Background

According to Global Initiative for Asthma (GINA), asthma is characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA, 2016). Asthma is a complex disease caused by an interplay of many genetic and environmental factors. “Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma” (NAEPP, 2007, p. 11). Other risk factors include intrauterine exposures (cigarette smoke, inadequate nutrition, and stress), prematurity, viral respiratory infections in early childhood, early antibiotic use, obesity, acetaminophen use, emotional stress, and air pollution (Woodruff, Bhakta, & Fahy, 2016). A hygiene hypothesis suggests that the increasing prevalence of allergies and asthma may be related to modern society’s emphasis on cleanliness, which leads to reduced early exposure to pathogens in children. There have been many theories about possible primary prevention strategies for the development of asthma, but none of them has been proven by existing evidence (Beasley, Semprini, & Mitchell, 2015).

The prevalence and severity of asthma are highest in certain vulnerable populations. According to the National Health Interview Survey, “For children under 18age 15 years, the sex-adjusted percentage by race and ethnicity (of children) who had an asthma episode in the past 12 months was 3.7% for Hispanic children, 3.5% for non-Hispanic White children, and 9.1% for non-Hispanic Black children” (Clarke et al., 2016, p. 99). This variability in prevalence, morbidity, and mortality may be attributable to many factors, including access to culturally competent health care, exposure to inflammatory agents such as air pollution in urban environments, coping with psychosocial stress, and exposure to substandard housing problems such as mold and roaches (Gruber et al., 2016).

Ongoing research in genetics and immunology is increasing our knowledge about the development of asthma. Once a child has developed this condition, ongoing inflammatory exposures seem to increase the risk of exacerbations and lead to progressive loss of pulmonary function. A range of indoor and outdoor allergens, as well as viral infections, food, medicine (beta-blockers, aspirin, or other nonsteroidal anti-inflammatory drugs [NSAIDs]), exercise, psychological stress, and weather changes may trigger a child’s asthma symptoms. Common indoor triggers include secondhand smoke, dust mites, mold, rodents, cockroaches, fragrances, chemical particulate matter, and pet dander. Common outdoor allergens include ozone, pollen, and air pollution (U.S. Environmental Protection Agency [EPA], Indoor Environments Division, Office of Air and Radiation, 2015).

Initially, the diagnosis of asthma is based on the child’s physical examination, history of respiratory symptoms, and pulmonary function test (spirometry). The most common spirometry measurement is the child’s forced expiratory volume in 1 second (FEV₁), and it is reported as a percentage of the predicted value for the child’s height and age. This measurement can demonstrate impaired airflow and airway hyper-responsiveness. The child’s clinical response to inhaled and oral medications is also considered in classifying the child’s asthma severity. The “Classification of Asthma Severity in Children” was written in the 2007 National Asthma Education and Prevention Program (NAEPP) by the National Heart, Lung, and Blood Institute of the National Institutes of Health (2007). Symptom-based definitions are used to classify the severity as “intermittent,” “mild persistent,” “moderate persistent,” or “severe persistent.” A child classified with the mildest form, “intermittent asthma,” has symptoms 2 or fewer days per week, has no nighttime awakenings, requires use of a rescue inhaler 2 or fewer days per week for symptom control, and has a normal FEV₁ between exacerbations. In contrast, a child with the most severe form, “severe persistent asthma,” has symptoms throughout the day, nighttime awakenings every night, uses a rescue inhaler several times daily, has extremely limited activity, uses oral corticosteroids two or more times per year, and has an FEV₁ fewer than 60% predicted.

Clinical Aspects

The typical presentation of a child during an acute asthma episode is ill and uncomfortable, with rapid, labored respirations and a fatigued look from an 19ongoing struggle to breathe. Coughing, nasal flaring, intercostal retractions, and accessory muscle use may be observed along with complaints of chest tightness. The expiratory phase is prolonged. On auscultation, wheezing is heard on expiration and/or inspiration unless the episode is so severe that a “silent chest” develops because of extremely poor air exchange. The child prefers to sit in an upright position, leaning forward in the tripod position. If the episode progresses to hypoxia, the child becomes wide-eyed, agitated, and confused or suddenly quiet as ventilation becomes ineffective. Episodes that fail to respond to medications, oxygen therapy, and hydration (acute severe asthma, also called status asthmaticus) can lead to death from respiratory failure, so the child must be immediately moved to and treated in the intensive care unit.

ASSESSMENT

The pediatric nurse begins with a respiratory assessment that includes color, respiratory rate, heart rate, level of consciousness, quality of breath sounds, ability to speak in sentences rather than single words, presence of abnormal findings that indicate impaired gas exchange (wheezing, nasal flaring, retractions, grunting, accessory muscle use, head bobbing), and pulse oximetry measurement. The pediatric nurse must compare the child’s heart and respiratory rate to the normal ranges based on the child’s age. Tachypnea, tachycardia, and SpO₂ fewer than 92% indicate hypoxemia. In addition to a respiratory assessment, the nurse must determine the child’s fluid status based on the child’s weight, intake and output, and skin turgor. Once the child’s condition is stable, the nurse can assess the child’s developmental and psychosocial concerns, as well as the family’s home asthma management history, using the Childhood Asthma Control Test (C-ACT) and the GINA (2016).

NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS

During the acute phase of an asthma exacerbation, the pediatric nurse focuses on the child’s risk for respiratory failure. Nursing interventions that eliminate the risk for respiratory failure include ongoing monitoring of breathing, supporting respiratory functioning (positioning, oxygen administration, hydration), and medication administration. Two categories of medications are commonly used to treat asthma: control and quick relief. Control medications are used on a daily basis to prevent an exacerbation. These include inhaled long-acting beta₂-agonists (LABAs), inhaled corticosteroids (ICSs), oral leukotriene receptor antagonists (LTRAs), and others. Quick-relief medications are used when needed for asthma flare-ups. These include inhaled short-acting beta₂-agonists (SABAs), oral corticosteroids, and inhaled anticholinergics. These medications are ordered according to the child’s asthma-severity classification. Nursing care often follows a standardized asthma care pathway that outlines a sequence for assessments and interventions to be used for hospitalized children. Studies have shown that the use of clinical pathways has decreased the patient length of stay and lowered the cost of treatment. Unfortunately, pathway use has not been shown to reduce 20hospital readmission rates (Sylvester & George, 2014). Support of parental participation in the hospitalized child’s care is often essential for the child’s overall sense of well-being.

At every health encounter, asthma education for self-management is a priority. Each member of the interprofessional team, including the bedside nurse, hospitalist, respiratory therapist, primary care provider, asthma specialist, and school nurse, develops a partnership with the patient and family. Supportive, open communication among all team members helps to build trust and alleviate misconceptions. Parents may be instructed to keep a symptom diary to help identify triggers. Asthma control is achieved through avoidance of triggers, adherence to prescribed controller and maintenance therapy, and the family’s ability to recognize symptoms and respond appropriately to them. Families may need help to view asthma management from a prevention perspective instead of viewing it from a crisis perspective (Archibald, Caine, Ali, Hartling, & Scott, 2015). Any child diagnosed with asthma should be provided with an individualized written asthma action plan that spells out specific guidelines for daily management when the child is symptom free (green zone), when the child’s symptoms begin to increase (yellow zone), and when emergency care is indicated (red zone; GINA, 2016). The pediatric nurse ensures that the child and/or caregivers have a clear understanding of their Asthma Home Management Plan. When caring for a child, it is especially important to educate about the correct use of inhaler devices and give the child an opportunity to perform a return demonstration. Parents need information about ways to reduce allergens at home, such as encasing the child’s mattress and pillow to control dust mites, or reducing molds by lowering humidity.

OUTCOMES

The expected outcome of quality nursing care for the child asthma patient is successful self-management through avoidance of triggers, early recognition and treatment with rescue medications, and compliance with an individualized asthma action plan that maintains daily control of symptoms.

Summary

Because there is no cure for asthma, the care of children with asthma should focus on successful home management to control symptoms. Nurses must be knowledgeable about the pathophysiology of asthma, prevention and management of exacerbations, and principles of health-maintenance education, and play a critical role in providing comprehensive family-centered asthma education that promotes a sense of shared responsibility.

Archibald, M. M., Caine, V., Ali, S., Hartling, L., & Scott, S. D. (2015). What is left unsaid: An interpretive description of the information needs of parents of children with asthma. Research in Nursing & Health, 38(1), 19–28. doi:10.1002/nur.21635

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