Question 1. What is asthma?

Asthma is a common and chronic inflammatory disorder of the airways and it can affect both adults and children of all ages (Price et al. 2004).

During an exacerbation of asthma, bronchoconstriction causes obstruction in the airways and therefore limits airflow. The obstruction in the airway is partially or completely reversible and this occurs either spontaneously or due to therapeutic interventions. The smooth muscle goes into spasm; there is also increased mucus secretion and cellular infiltration of the airway walls mainly by eosinophils, which leads to epithelial damage (Scullion 2005).

The tightness George felt in his chest was as a direct result of his airways narrowing and spasm of the smooth muscle, probably as a result of the exposure to the farmyard animals.

Reflect upon the scenario: apply Roper et al. (2009) model of care.

Activity of living: breathing.

In A&E, due to low Sp02 88% the doctor prescribed nebulized 5 mg Salbutamol. It was administered by a member of the nursing team in accordance with Nursing and Midwifery Council guidelines (NMC 2018). Doses prescribed were based on the https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma/ (2003, revised July 2019). George’s condition did not improve and he was beginning to feel agitated and frightened because of his breathing difficulties. He was reassured by the doctors and nurses. After 20 minutes he was reassessed by the medical team. The same prescribed dose of bronchodilator was administered again on two further occasions, unfortunately with no obvious improvement. George was also commenced on an oral steroid (prednisolone 30 mg). It was decided at this point that he needed to be admitted to the paediatric medical ward.

Question 2. Discuss the importance of monitoring vital signs

Activity of living: maintaining a safe environment.

On admission to the acute medical ward, George was tachypnoeic (respiratory rate: 52) and tachycardic (heart rate: 128). George was using his accessory muscles. Use of accessory muscles is indicated by nasal flaring, sternal recession and over-inflation of the chest wall. These symptoms are due to the respiratory system having to compensate for the narrowing of the airways.

George was pale, his oxygen saturations (SaO₂) were 88% in room air. Normal oxygen saturations are usually >95%, a reading of <93% will require oxygen (O₂) therapy.

SaO₂ is the percentage of Hb absorbed with the O₂ and measured in the arterial blood. SpO₂, meanwhile, is the process used for measuring pulse oximetry. Pulse oximetry, when performed correctly, is accurate to within plus or minus 3% of SpO₂ at higher ranges, but reflects SaO₂ less accurately when SpO₂ falls below 80% (Jubran 1999).

As part of good practice, paediatric nurses must assess the child holistically and not just rely on monitors, for example observing vital signs, monitoring patient’s use of accessory muscles, shortness of breath and skin colour. Signs of pallor or cyanosis as well as low SpO₂ are all indicators that O₂ therapy may have to be prescribed and administered. In George’s case two litres O₂ therapy was commenced via nasal specs, resulting in his SpO₂ rising from 88% to 95%.

When attaching the saturation probe to an infant’s/child’s thumb or toe, the light sensor needs to be attached directly opposite the probe to give a true reading (Booker 2008). It is also worth noting that nail varnish can interfere with SpO₂ readings and therefore needs to be removed where applicable (Booker 2007a).

Peak expiratory flow is generally used in the over five years age bracket not however used in acute exacerbations. More commonly air flow limitation is assessed using spirometry in an outpatient setting. Spirometry testing in children >5 years assesses airway obstruction. It is rarely useful during exacerbations of asthma, except where air leaks are suspected. However, it is useful when a diagnosis other than asthma is suspected (Townshend et al. 2007a).

Question 3. What are the risk and trigger factors of asthma?

It is important for medical and nursing staff to take a detailed history of symptoms during any consultation in a hospital ward/outpatients or a GP surgery.

In George’s case he had a higher probability of developing asthma compared to his peers. Family history included George’s sister, Daisy, who was known to suffer from asthma and eczema. Both parents were smokers and George had had a previous history of bronchiolitis and recurrent episodic viral induced wheeze episodes.

A risk factor increases the probability of a person developing asthma, whereas a trigger factor may be the instigating factor during an exacerbation of asthma.

Risks: family history of asthma, atopy/allergy, gender (more common in males than females), birth history, passive smoking, certain foods, and recurrent respiratory infections.

Triggers: Non allergic – viruses, cold air, menarche, emotion, smoking, chemical odours, pollution, exercise, certain drugs. Allergic triggers – house dust mites, animal dander, pollens, moulds, food (Scullion 2005).

Both of George’s parents were smokers. Smoking during pregnancy increases the child’s risk of respiratory conditions by 35%. Also, children whose parents smoke face a 50% increased risk of developing asthma (Asthma UK 2005).

George’s sister Daisy also had a history of eczema. Atopic conditions such as eczema and rhinitis increase the probability of asthma (British Guideline on Management of Asthma 2019).

Daisy’s asthmatic symptoms became worse when playing outdoor sports. In George’s case his symptoms became worse once he was exposed to farmyard animals. Skin prick testing could confirm George’s allergens. If positive, George would then avoid known trigger factors. This would be completed at a future outpatient appointment. Bloods for specific IgE to aeroallergens and Eosinophil count can be requested during admission but it is not a routine test.

One reason why atopic asthma patients wheeze with viruses is due to the fact that they are born with smaller airway dimensions than those who do not wheeze (Townshend et al. 2007b).

Question 4. Explain the importance of asthma medication and education

George’s symptoms improved with the assistance of various medications:

1. Bronchodilators: open up the airways
   
2. Steroids (inhaled and oral): reduce airway inflammation
   
3. Montelukast: leukotriene receptor antagonist – non steroidal anti-inflammatory effect plus mild bronchodilation.

George’s respiratory symptoms initially did not improve with the aid of an MDI via spacer device. He was prescribed and administered bronchodilators via a nebuliser device which was attached to the O₂ mains by his bedside. Nebulisers are instruments designed to atomise liquid drugs into fine mists for inhalation into the lungs (Booker 2007a). Booker (2007a) also states that nebulisers require a driving gas flow rate of 6–8 litres. Nebulisation of normal volume of drug (2–4 ml) should be complete in about ten minutes. Realistically it may be necessary to reduce the time to around five minutes when administering nebulisers to infants. Toddlers often find the mist from nebulisers quite scary and generally do not like to be held for long periods.

The mist of the drug can only be delivered to the lungs once the patient has inhaled. Therefore the nebulised drug is wasted during exhalation (Booker 2007a). Since so much of the drug is wasted it is important to keep the nebuliser mask sealed to the child’s face and not wafting from a short distance from the face to ensure that maximum dose is administered.

Nebulised salbutamol 5 mg was prescribed hourly and reassessed thereafter. Due to poor response to the beta2 agonist, ipratropium bromide 0.25 mg (a B2 agonist) was added in. As George’s symptoms improved, the interval between bronchodilator nebuliser therapy was gradually stretched from one to four hourly. His mum noticed that George’s hands had started to shake.

Side effects of bronchodilators include fine tremor of the hands, tachycardia, and hypocalcaemia (BNF_C 2021–2022). Around 12% of the nebulised drug which leaves the chamber enters the lungs, but the majority of the drug stays in the apparatus (Rees 2005).

Once George’s symptoms improved and vital signs settled to within normal limits, that is, heart rate 98, respiratory rate 28, and SpO₂ 95% in room air he was changed to an MDI via a yellow spacer device. Aero chamber Plus generally fit all forms of MDIs. They are available in five different sizes:

• Orange: has mask attached, suitable for children <1 year.
  
• Yellow: has mask attached, suitable for children aged 1–5 years.
  
• Green: has mouthpiece attached, suitable for children aged 5+ years
  
• Purple: facemask attached, suitable for 5+ years children unable to use mouthpiece.
  
• Blue: has mouthpiece attached, suitable for children 12+ years and adults, also available with facemask.

Other medium to large spacers are available.