Continuing professional development

Understanding childhood asthma and the development of the respiratory tract

NCYP8 Crawford D (2011) Understanding childhood asthma and the development of the respiratory tract. Nursing Ctiildren and Young People. 23, 7, 25-34. Date of acceptance: May 18 2011.

Summary
Asthma is a chronic and acute condition that causes inflammation of the airways in response to allergens such as viral infections and pollen. This article reviews the developmental anatomy and physiology of the respiratory tract, and considers asthma diagnosis, treatment and management. This article is intended for the student or the junior registered nurse, however the experienced mentor may find it useful as a framework to help them support the learning needs of mentees. ASTHMA IS A leading chronic disease among children in most industrialised countries (Bacharier ef al 2008). It is a condition that is linked to high morbidity and a risk of death. The condition runs in families, particularly those with eczema and other allergies (Bacharier ei al 2008). The symptoms are unpleasant and can affect the quality of a child's life, their daily activities, how they see themselves (Hey 2008), and their selfconfidence (Vuillermin ef al 2010). Absences from school can affect a child's achievement and restrict their future education and career options. Unskilled and non-professional workers tend to be paid less than graduates. This could, in turn, limit the resources they have available for their own families. Understanding this point is important as there is a high correlation between disability, disease and poverty (Burchardt 2006, Preston 2006, Disability Alliance 2010). Although there is evidence that the prevalence of asthma is now tapering off slightly (Malik ef ai 2010), the incidence of childhood asthma has increased in the past 50 years. The reasons for this are unclear, however a number of lifestyle factors are incriminated, such as exposure to tobacco smoke, diet, domestic hygiene, and environmental factors such as pollution and early life infections. In childhood, asthma tends to be more common in boys than in girls (Malik ef ai 2010) so there may be a hormonal facet or gender influence. About one million children in the UK have a known diagnosis of asthma (National Institute for Health and Clinical Excellence (NICE) 2007) which NURSING CHILDREN AND YOUNG PEOPLE could indicate that every classroom has two children with asthma (NICE 2007). All schools should have policies for dealing with children with asthma and children's nurses should be effective in supporting the development of these (Anderton and Broady 1999). As care pathways change, managing asthma is going to be as important to children's nurses who work in the community as it is to those working in the acute sector. There is evidence that home visits are valuable to children with asthma (Bracken ef al 2009) and that specialist asthma nurses reduce comorbidity (McKean and Furness 2009). In addition, GPs believe that children's nurse-led asthma services benefit surgeries (Frost and Daly 2010). Children's nurses have a role in enhancing compliance with therapy and improving the understanding of the condition, which has been acknowledged to be poor, particularly in adolescence (Edgecombe ef a/ 2010).

Doreen Crawford is senior lecturer. De Montfort University, Leicester, and consultant editor Nursing Children and Young People

Keywords
Anatomy, asthma management, embryology, inhaler therapy, nebulisers, respiratory system and disorders, spacer devices This artide has been subject to open peer review and checked using antiplagiarism software. For related articles visit our online archive and search using the keywords

Aims and learning outcomes

The aim of this article is to increase children's nurses' awareness of asthma and enhance their confidence when dealing with children who present with the condition. By reading this article and completing the time out activities the reader will have a greater understanding of: The and The The underpinning of the developmental anatomy physiology of the child's airways. disease asthma. management of asthma.

The impact asthma can have on the child. September 2011 | Volume 23 I Number 713?

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Embryology
The embryo's blueprint comes from the genetic contribution of the parents. Asthma is increasingly being understood as a complex interaction between a child's genes and the child's environmental factors (Chung 2011). Although it is not uncommon for an asthmatic parent to express guilt for passing the disease on to their child, the children's nurse - while acknowledging that genes play a part - can emphasise the complexity of the condition. This may help to ensure that parents do not blame themselves or each other. The children's nurse could point out that genetics is a lottery: during the early embryonic phase the disc of specialising cells, which forms layers of tissue, are switched on and off by the genes of both parents; it would be impossible for the parents to influence the genetics of their child. In the future there may be techniques in genetic engineering which will identify children who are more at risk of the disease, improve its management and possibly eradicate the condition. The tissues that give rise to the respiratory system are the endoderm and the mesoderm (Figure 1), Rudimentary formation commences about the fourth week of gestation. Although the baby's respiratory system will not carry out its primary physiological function until after it is born, the respiratory tract, diaphragm and lungs do form early in the embryonic period. When considering the development of the respiratory system it is important to set if in context with the development of other systems. For example, the proximity of the developing trachea to the oesophagus of the upper gastrointestinal system and the dual role of the oropharynx. Because of the interconnectivity of the air entry points with the face and their role in
Transverse section of trilaminar emb

maintaining homeostasis, it is recommended that the reader also reviews the embryological development of the sensory system and the skeletal system (Box 1), The sensory system influences some of the triggers in asthma and the muscular skeletal system can be developed with exercise and physiotherapy making the thoracic cage accessory muscles stronger, and this can influence the course of an asthmatic attack. The respiratory system begins at the nasal cavity and consists of a conducting portion and a respiratory portion. The conducting portion includes the nasal cavity, pharynx, larynx, trachea, bronchi and bronchioles. The respiratory portion consists of the respiratory bronchioles, alveolar ducts, alveolar sacs and the alveoli. The respiratory tract matures, develops and grows with the child and the adult anatomical framework and configuration is not in place until the age of seven to eight years (MacGregor 2008), As childhood is a period of rapid growth in the lungs and the immune system, developmental factors should be considered in the pathogenesis of childhood asthma (Chung 2011)

Anatomy
The shape and size of the head, the large occiput of the infant's head and the relatively short neck can result in neck flexion which may compromise the airway of the infant when consciousness is impaired or when the infant is exhausted and sick. Whether infants are obligatory nose breathers, or not, is controversial, but the nostril size is small and can get narrowed or blocked with mucus and crusted secretions. The relatively large size of the infant's tongue in proportion to the rest of the oral cavity can result in potential obstruction of the airway (Stoelting and Miller 2007), The larynx is higher in the neck at the level of C3-4 than in an adult (C4-5), and the infant's epiglottis enters the anterior pharyngeal wall at a 45 angle and projects more posteriorly than in the older child (Figure 2, page 29). The shape of the epiglottis is different from in the adult and resembles more of an uppercase omega (Q) - from the Greek alphabet (Stoelting and Miller 2007), The size and shape of the larynx is different, the cricoid ring is a complete ring of cartilage and the narrowest point of the upper airway compared to the vocal cords in the adolescent and young person (Stoelting and Miller 2007), The trachea is short in the infant, approximately 4 to 5cm from cricoid to carina. It is narrow and soft (Dixon ef al 2009), The airways are smaller and less developed than in adolescents. This means a relatively small obstruction can compromise the airway radius causing a significant increase In respiratory effort. This is important when considering children with asthma because a small amount of mucus or oedema can seriously reduce the
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Ectoderm Mesoderm Endoderm

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ibryological and fetal development of the respiratory system Gestational age Embryonic period: 26 to 52 days Development The lung begins to appear as ventral pouches from the foregut. The foregut divides into a dorsal portion, which becomes the oesophagus, and a ventral portion, which becomes the trachea and the early lung buds. Development continues with some divisions, giving shape to the left and right bronchial tree. Pseudoglandular period: Day 52 to 16 weeks gestation Formation of the major conducting airways and terminal bronchioles. The diaphragm is formed between eight and ten weeks of gestation. Life is not possible if the fetus is born at this stage as there is no possibility of gas exchange. However, damage can be done to the future airways at this stage and there is a high correlation between maternal smoking, future respiratory infections and predisposition to asthma. Canalicular period: Weeks 17 to 24-(- gestation Development of the respiratory bronchioles. Each bronchiole ends with two or three terminal sacs or primitive alveoli. At 24 weeks' gestation the fetus is regarded as viable, although infants born then require considerable supportive technology to sustain them. Supportive technology can cause damage, such as a ventilator lung. Despite considerable medical and nursing efforts, many infants born at this early stage will die or survive to develop complex needs, including pulmonary insufficiency and predisposition to respiratory illness, especially asthma (McCormick ei a/ 2011). Increased vascularisation of the lung occurs. Elastic fibres develop; smooth muscle and true alveoli are present at 34 weeks' gestation. Infants born at this stage are likely to do well and less likely to have complex needs. They are less likely to require aggressive support to sustain them. Although they are susceptible to seasonal epidemics such as respiratory syncytial virus (RSV) (Escobar ef a/2010). Further development of the terminal sacs and formation of the walls of true alveoli. Columnar cells develop and differentiate in the alveoli into type 1 and II. Type 1 cells provide the alveolar surface area for gas exchange and type II cells secrete surfactant, necessary to lower the alveolar surface tension and sustain lung inflation. Towards term the immune system starts to mature. Prematurity and exposure to supplemental oxygen during the neonatal period predisposes to RSV infection and these have independent associations with the development of recurrent wheezing in the third year of lite (Escobar ei al 2010),

Saccular period Weeks 28 to 36 gestation

Alveolar period Weeks 36 to term

(Adapted from Dixon e! ai 2009)

working diameter of the airway. In addition, airway remodelling with the increase in smooth muscle mass has been shown to be an early finding in childhood asthma (Tillie-Leblond ef a/ 2008), Hyperplasia and hypertrophy contribute to the increase in smooth muscle mass. This can be related to clinical severity and predictive of greater airflow obstruction (Bai 2010). Now do time out 1,

Age of viability
What is regarded as the age of viability and why is it not possible to sustain life before this? Why is it important to take a full antenatal history when an infant or young child is admitted with wheezing?

The number and size of the alveoli continue to increase until approximately eight years of age. As the number of alveoli increase the respiratory surface area available tor gas exchange increases correspondingly. As the child grows and matures so do the number of collateral ventilatory channels. This means that the alveoli can be aerated via these connections even when the terminal bronchiole, which directly supplies them, are narrowed or blocked. This is important as the lungs can shunt air about and the gas exchange units do not need to be directly connected to a main airway. The channels of Martin are interbronchiolar connections. The canals of Lambert connect closely adjacent bronchioles and alveoli, and the pores of Kohn facilitate interalveolar connections (Dixon ef al 2009). These communications between the lower airways are thought to develop after infancy and up to six years of age. Until these pathways September 2011 | Volume 23 | Number 7

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develop, young children are at increased risk of atelectasis and hyperinflation which can be associated with asthma and infection (Dixon ef al 2009) The position of the ribs and the shape of the thorax do much to ease the work of breathing in the mature individual. In infants the ribs lie horizontally and the shape of the thorax is circular. This changes and by approximately six years of age the thorax is ellipsoidal in shape. In infancy the chest wall is thin with little muscle to stabilise it and, as a result, is highly compliant. To compensate for this instability infants use their abdominal muscles to assist with breathing. A child's diaphragm is flatter in shape making each contraction less efficient than that of the more mature young person. Appreciating the developmental differences in a child's anatomy and physiology underlines the fact that children are not small adults. A nurse who is aware of the detail of a child's respiratory system will understand that the younger the child, the poorer their functional reserves. The asthmatic child can get into respiratory difficulties quickly, and will need intervention and help sooner. Although most children will grow out of their asthma, some studies have suggested that decreased lung function can occur early. Although it may not change further with ageing (Chung 2011), it may have an impact on the child's growth and development. Now do time out 2. In contrast, the swollen narrowed airways of the asthmatic child having an attack causes airway turbulence and an audible wheeze. The respiratory system serves a vital function in maintaining metabolic homeostasis. Oxygen is needed to support normal metabolism and, as part of that process, carbon dioxide - a waste gas - is produced. This gas exchange is performed in the lungs, via the interface between alveoli and capillary. It is important to regulate the levels of oxygen and carbon dioxide in the blood because changes in the concentration of blood carbon dioxide affects the child's pH. The body chemistry works best in a narrowly defined pH of 7.35-7.45 (Dixon ef al 2009). Centres in the brain regulate the rate and depth of respiration and a fall in pH which results in a more acidotic internal environment will trigger a breath, which will help eliminate carbon dioxide. As carbon dioxide is continually produced it needs to be eliminated constantly so the cycle of breathing in health is regular and not interrupted (Tortora and Derrickson 2009). The asthmatic child may present with an altered blood gas depending on the severity and duration of the attack. When the attack begins, the natural response to a sensation of being short of breath is to become frightened. This can lead to hyperventilation. Because more air is being shifted in and out of the lungs more CO^ is washed out and the CO^ level will initially drop, while the pH may rise (respiratory alkalosis). The situation can deteriorate if the asthma attack is not managed well. Because asthma causes bronchospasm and obstruction the patient cannot exhale completely which can result in air trapping and hyperinflation. To maintain ventilation, the child will need to work hard to breathe and maintain his or her blood gas. Eventually the child will begin to tire and start breathing less. The CO^ will start to rise and the pH will drop (respiratory acidosis). With respiratory insufficiency the 0^ will drop (hypoxemia).

Anatomical differences
List at least five differences in the anatomy of the young child compared to that of the adolescent. Using the information provided, how can asthma change the airways, breathing and homeostasis of the child?

Breathing
Although there is learned conscious override when children learn to control their breathing to enable speaking, swimming, singing and - in some children - breath-holding behaviour, breathing is automatic and the child is usually unaware of the process. In quiet, passive, normal breathing air enters through the child's nose, where it is warmed, moistened and filtered in the nasal cavity before travelling through the pharynx, larynx and into the trachea. From the trachea the airways divide into the left and right main bronchi and further divide into increasingly smaller diameter airways called bronchioles, which branch off and become microscopic and terminate in tiny, thin-walled sacs called alveoli (Tortora and Derrickson 2009). The structure and linings of the airways are relatively smooth and this encourages the flow of air over them so that breathing is relatively silent. September 2011 | Volume 23 | Number 7

Defining asthma
Asthma is a chronic condition that has periods of quiescence and exacerbation. It involves inflammation of the airways and airway reactivity causing a contraction of the bronchioles; this is called bronchospasm (Dixon ef al 2009) (Figure 3, page 30). It results from a complex chain of events involving a number of cells and pathophysiological mechanisms. Asthma could be regarded as an immune-inflammatory response condition where the normally protective and beneficial inflammatory reactions start to occur in the airways when there is no need for them to react, such as in response to infections, toxins, or inhaled substances, such as pollen or tobacco smoke. The NURSING CHILDREN AND YOUNG PEOPLE

inflammatory responses, which result in an attack, are triggered as a result of the action of cells such as B and T lymphocytes, mast cells, eosinophils, neutrophils, macrophages and the chemical mediators produced by cells. In an asthma attack the inflammation becomes persistent and a number of changes occur in the ainways. Oedema develops in bronchial tissue, mucus secretion increases; epithelial cells slough off the airway wall and mix with the mucus to form thick plugs, which can further block the airways. The smooth muscle contracts and, because of the diameter of a child's ainway, even small changes can limit the amount of air that can flow through the bronchioles. Frequent attacks can result in permanently narrowed airways. Asthma can affect children of all ages although it is hard to diagnose under the age of three (Amado and Portnoy 2006). Babies can wheeze but because not all wheezes are caused by asthma, parents might experience frustration that their infant is in and out of hospital with no diagnosis.

Vital signs
Define asthma to an anxious parent in layterms. Construct a tabie of the average and normal vital signs of heart rate an(d respiratory rate for the following, an infant aged three months, an infant just under a year, a toddler, a preschool child, a school-age child and a young person aged 14 (a suggested answer is on page 34). At what point would you consider each of these patients to have a tachycardia or be tachypnoeic?
lowest amount of medication to control symptoms while maintaining efficient respiratory function. Children should begin treatment at the stage most appropriate to the severity of their symptoms. When the child's condition improves, he or she should be maintained on the lowest step that controls their symptoms. The approach to asthma management allows treatment to be stepped up or down as required (British Thoracic Society, Scottish Intercollegiate Guidelines Network 2011) (Table 1, page 31). Relievers The first medicines used for children with mild intermittent asthma are treatments known as 'relievers' these are short-acting beta^ (^) agonists. They provide relief from distressing symptoms of asthma during an acute attack. In the UK they are usually colour-coded Figure 2

Asthma attack symptoms

The following are signs of respiratory distress, because of the altered anatomy of the ainways which results in a variable and reversible airflow obstruction:

Tachypnoea.
Use of accessory muscles (seen as nasal flare, head bobbing, shoulder fixing, abdominal breathing and in-drawing of the musculature of the thoracic cage). Continuous, high-pitched musical-like wheeze because of airway turbulence. Normally a troublesome cough. Also, there may be emotional distress and panic, including restlessness and breathlessness. Verbal and cognitively aware children might complain of a tight chest, and children may become uncommunicative because they do not have the breath to speak. Now do time out 3.

Sinus

Larynx Trachea Right lung

Diagnosis
Diagnosis can be difficult, particularly in infants and those under five years of age. Spirometry and the measurement of peak expiratory flow (PEF) are the lung-function tools most frequently used to measure airflow obstruction in older children. For practical reasons these methods are not used in children under the age of five. A diagnosis is based, instead, on clinical symptoms and observation of features prevalent in asthma during clinical examination.

Bronchi

Treatment and management

Because there is no cure the aim of managing asthma is to achieve control of the condition by using the
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Figure 3 Normal airway Airway in asthma attack Side effects Parents and professionals can be anxious over the long-term use of steroid therapy in children and the steroid load placed on a child with asthma can be a cause for concern. The effects of long-term exposure to steroids are not fully known (Sridhar and Widened blood vessels Blood vessels McKean 2006). They may be associated with slower growth and there are other side effects on the flora of the mouth, mood swings, heartburn or indigestion and on adrenal function. Oral steroid therapy, such as prednisolone, is given with caution with young children as a rescue therapy and only under the direction and review of a senior clinician. Contracted muscle Muscle Swelling and inflammation Long-acting ^ agonists (LABAs) These are an add-on therapy for children aged more than five years and can be used to improve symptom control. LABAs work by relaxing smooth muscles and are taken one or twice a day. As they do not have anti-inflammatory action they are used in conjunction with an inhaled steroid, such as salmeterol. Mucus Increased mucus blue, ^agonists are bronchodilators with a rapid onset of action, relaxing the smooth muscle of the bronchioles and relieving bronchospasm. They are administered by a metered dose inhaler (MDIs). Pocket-size breathactuated inhalers can be used for co-operative young people, but spacers and face masks need to be used with MDIs to deliver this medication into the airways of young children under the age of five, children with learning disabilities, and children with co-ordination problems such as cerebral palsy. Preventers For children who do not have their asthma sufficiently well controlled with a pro re nata (PRN) reliever, preventers can be tried. The effectiveness of these medicines builds up with time, when compliance is good these drugs reduce inflammation in the airways (Asthma UK 2010). Preventers decrease the distressing symptoms of asthma, improve lung function and reduce airway reactivity to triggers. In the UK, preventers can be colour-coded red, brown, beige, pink or orange. Example medications include beclometasone and budesonide (Asthma UK 2010). Leukotriene receptor antagonists Leukotrienes are a group of chemicals produced by mast cells, which are important mediators of inflammation in the upper and the lower airways. They work by blocking the binding of leukotrienes to the receptors on bronchial smooth muscle. An example of this medication includes montelukast, which was first licensed in January 1998 for use in children aged more than six years and in January 2 0 0 1 the licence was extended to Include children aged two to five years. Theophylline The role of xanthines as an add on is controversial. There is marginal evidence that it has some good effect, but this needs to be balanced against not inconsiderable side effects (Seddon ef al 2006). Omalizumab This is an injectable monoclonal antibody that binds to IgE and is available and licensed for the treatment of severe asthma as an add on in adolescents and children over six years of age who have proven IgE-mediated allergic asthma. NICE guidance does not recommend it for children under 11 years of age (NICE 2010). It is a new generation of medicine, has a range of side effects, and should only be prescribed for patients over 12 years and the child should be monitored by senior doctors (NICE 2010).

Other treatments and add ons

Inhaled corticosteroids (ICS) Sometimes called glucocorticoids, these are another anti-inflammatory therapy for the treatment of a child's asthma symptoms. They help to reduce inflammation in the ainways. They are regarded as suitable for children under 12 years (NICE 2007). Although the effective dosage will vary from child to child, for most children they are effective at low doses.
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Assessment tools
There are a number of tools available to check the level of control a child has over their condition (see The Childhood Asthma Test in the resource box for an example). The Royal College of Physicians devised three questions which have been successfully
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Stepwise therapy for treating asthma in children and young people Steps 1-5 Step 1: mild intermittent asthma Step 2: regular preventer therapy Adolescents and young people aged 13 years and over Inhaled short-acting beta^ (p agonist as required. Add an inhaled steroid 200-800 micrograms (meg)* daily (400mcg is an appropriate starting dose for many patients). Start at dose of inhaled steroid that is appropriate to the severity of the disease. Children aged five to 12 years Children aged under five years Inhaled short-acting ^ agonist as required. Inhaled short-acting ^ agonist as required. Add Inhaled steroid 200-400mcg daily Use other preventer drug if inhaled steroid cannot be used, 200mcg is an appropriate starting dose for many patients. Start at dose of inhaled steroid appropriate to the severity of disease. Add inhaled steroid 200-400mcg daily or leukotriene receptor antagonist if an inhaled steroid cannot be used. Start at dose of inhaled steroid appropriate to the severity of the disease. Step 3: add-on therapy Add inhaled long-acting ^ agonist (LABA), Assess control of asthma: Good response to LABA - continue LABA, Benefit from LABA but control still inadequate - continue LABA and increase steroid dose to 800mcg/day - if not already on this dose. No response to LABA - stop LABA and increase inhaled steroid to 800mcg* daily. If control still inadequate, institute trial of other therapies, for example, leukotriene receptor antagonist or slow release theophylline. Step 4: persistent poor control Consider trials of; Increasing inhaled steroid up to 2,000mcg'day, Addition of a fourth drug, for example. leukotriene receptor antagonists. slow release theophylline, and oral j agonist bronchodilators. Step 5: continuous or frequent use of oral steroids Use a daily steroid tablet in the lowest dose providing optimal control. Maintain a high dose inhaled steroid at 2,000mcg/day, Consider other treatments to minimise the use of steroid tablets. Refer patients to a respiratory specialist.
'Example doses: some children will have medication individually prescribed. (Adapted from British Thoracic Society and Scottish Intercollegiate Guidelines Network 2 0 1 1 , and Scullion 2005)

Add inhaled LABA. Assess control of asthma: Good response to LABA - continue LABA, Benefit from LABA but control still inadequate - continue LABA and increase steroid dose to 400mcg/day (if patient is not already on this dose). No response to LABA - stop LABA and increase inhaled steroid to 400mcg daily. If control still inadequate, institute trial of other therapies, for example, leukotriene receptor antagonist or slow release theophylline.

In children aged two to five years consider trial of leukotriene receptor antagonist. In children under two years consider proceeding to step four.

Consider trials of: Increase inhaled steroid up to 800mcg/day,

Referral to specialist respiratory paediatrician.

Use a daily steroid tablet in lowest dose providing optimal control. Maintain a high dose inhaled steroid at 800mcg/day, Refer patient to respiratory paediatrician.

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evaluated (Thomas ef al 2009), These can be modified for use with children during the assessment of a verbal and cognitive child whose asthma is being reviewed or paraphrased tor use with their parents. The three questions are: Has the child had difficulty sleeping because ot their asthma symptoms, for example, have the parents heard the child coughing? Has the child demonstrated their usual asthma symptoms during the day, tor example cough, wheeze, complained ot chest tightness or seemed short ot breath? Has asthma intertered with the child's usual daily activities, tor example playing or school? Now do time out 4, Technique Shake the inhaler well. It the child is old enough they can be involved with this preparation as a game. Their involvement will help to underscore the health message that instructions are only ettective it followed. Fit the inhaler into the opening at the end of the spacer, check the fit. With the child's consent, get down to the child's level, place the mask over the child's tace and check the seal around the nose and mouth. Press the inhaler once and breathe with the child, demonstrating five long slow breaths in and out ot the spacer. It children are very young and uncooperative an assistant or the parents might perform supportive holding. The use of therapeutic holding is controversial but a therapy can only be effective it administered. However, overly restraining a child can cause emotional distress that will create problems tor the future. There are professional dimensions to this practice and the reader is reterred to Jeffery (2010) for a balanced review and the Royal College of Nursing guidelines on restraint (2010). Remove the inhaler and shake again. This process is repeated for each dose of the medicine. Compliance This is improved if the administration ot medication can be built into a child's routine. Intants can have their drugs administered while sleeping, it they are awake they may need to be swaddled to prevent them squirming and knocking the inhaler and spacer away. If the intant or child is prescribed several puffs, it is ineffective to administer them all at one time. This is because a higher concentration of the drug may coalesce and result in droplets adhering to the side of the spacer, which may result in the child receiving less ot the drug. It is good practice, when possible, to wash the child's face and rinse the mouth, provide a drink or brush the teeth after administering medication to avoid deposits ot the drug lingering on the face or in the mouth, Nebulisers These are small plastic devices that can contain a prescribed drug in solution, which is then attached to a mouth piece or mask and a compressor which blows air or oxygen under pressure through the solution to make a fine mist which is then inhaled. There is evidence that multiple doses of relievers are as good as nebuiisers (Asthma UK 2009). Although nebulisers should ideally be used in hospital under medical supervision they are sometimes used in GPs' surgeries, hospital emergency departments and on wards. Now do time out 5.

Patient education
Any therapy is only as good as compliance and concordance with the products. Inhaler therapy has been central to the management ot children with asthma and has been recommended tor difterent age ranges by NICE since 2000 and 2002, Children's nurses play a key role in teaching children how to use their inhalers or nebulisers correctly. Spacers A spacer is trequently used tor intants, young children or those with additional needs. A spacer is a large plastic container, with a mouthpiece at one end and an opening tor the aerosol inhaler at the other. Spacers only work with an aerosol inhaler. They are usetui because they make the aerosols easier to apply and more ettective; more medicine is inhaled and the possibility of side effects is reduced. This equipment needs to be kept clean. Unless the child is immunecompromised, domestically clean is sufficient. This is achieved by washing the spacer in warm water with a small amount of household detergent, leaving it on a clean surface to air dry. Apply and check the fit of the face mask on the spacer it the child needs to use one. If the device is new to the parents and the child, a demonstration on teddy and a few test runs with a placebo will back up the printed information, diagrams and discussion. It is worth spending time in parent education as good habits learned early might aid compliance later.

Compare and contrast

Consider the usual dauy actixities of a well child, then compare and contrast those with the lifestyle of a child with chronic asthma. I A suggested answer is given on page 34.

Conclusion
This CPD has introduced the developmental origins of the respiratory systems and considered aspects of the normal growth and physiology of the airways.

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It has reviewed asthma at a basic level for students and junior staff. It can also be used as a resource for mentors to enhance their awareness of the academic level of those they mentor. It has reviewed common therapy and it is hoped enthused the reader to engage with this opportunity to enhance their portfolio and to continue to seek more information to help develop and enhance their knowledge and skill base.

Practice profile
Now that you have read the article you might like to write a practice profile. Guidelines to help you are on page 36.

Clinical strategies
What communication strategies would you use when a breathless > oung person is admitted to the ward and suffers an acute asthma attack during the admission process? What would your priorities be during a follow-up home visit where an infant had been discharged from the emergency department, or a medical assessment unit following a period of breathlessness?

Resources
Asthma UK Materials to Help You and Your Patients. http://tiny.cc/4xynu British Guideline on the Management of Asthma National Ciinicai Guideline 101. http://tiny.cc/lqtdh The Childhood Asthma Test http://tiny.cc/z25zq Patient.co.uk Inhalers for Asthma. http://tiny.cc/08gau British Thoracic Society Nebuliser Treatment Best Practice Guideline, http://tiny.cc/ilp5b

Suggested answers to time out activities on page 34

References
Amado M. Portnoy J (2006) Diagnosing asthma in >ouiiK children. Current Opinion in Allergy and Clinical Immunology, (i, 2, 101-105. Anderton J. Broady J (1999) Improving schools' asthma policies and procediores. Nursing Standard. 14, (1, :i4-38. Asthma UK (2010) Schook and Earty Years. www.asthma.org. iik/how_we_help/schools_early_ years/index.html (Last accessed: .luly 8 2011.) Asthma UK (2009) Asthma Facte. www.as thma.org. iik/alLabout_asthma/factfUes/ index.html (Lastaccessed: July8 2011.) Bacharier L el a/(2008) Diagnosis and treatment of asthma in childhood: a PR.ACTALL consensus report. Allergy. G'i. 1, 5-34 Bal T (2010) Evidence for airway remodeling in chronic asthma. Carrent Opinion in Allergy and Clinical Immunology. 10.1.82-86. Bracken M et al (2009) The importance of nurse-led hoine \1sits in the assessment of children with problematic asthma. Archives of Disease in Childhood. 94, 10, 780-784. British Thoracic Society. Scottish Intercollegiate Guidelines Network (2011) Briti'ih Guideline on the Management of Asthma. BTS. London, SIGN, Edinburgh, wu-w.sigaac.uk/ guidelines/fuUtext/lOl BurchardI T (2006) Changing Weights and Measures: Disability and Child Poverty, www. cpag.org.uk/info/Povert>articles/Povertyl23/ disability.htm (Last accessed: July 8 2011.) Chung H (2011) Asthma in childh(xxl: a complex, heterogeneous disease. Korean .loumal of Paediatrics. 34. 1, 1-5. Disability Alliance (2010) Disability Alliance Response R67. ww-vv.disabiiit>alliancc.org/r67.htm (Last accessed: April 2011.) Dixon M et al (Eds) (2009) Nursing the High Dependency Child and Infant. Oxford. Wiley-Blackwell, Oxford. Edgecomhe K et al (2010) Health experiences of adolescents with uncontrolled seyere asthma. Archives of Disease in Childhood. 95,12.985-991. Escobar GJ ef al (2010) Recurrent wheezing in the third year of life among children bom at 32 weeks' gestation or later relationship to laboratory-confirmed, medically attended infection with respirator> s>iic>tial virus during the first year of life. Arclii\'es of Pdiatrie and Adolescent Medicine. 164,10, 915-922. Frost S. Daly W (2010) Nurse-led asthma services for children and young people: a survey of GPs' views. Paediatric Nursing. 22, 8, 32-36. Iley K (2008) The impact of asthma on children's lives: a social perspective. Primary Health Care. 17.8,25-29. Jeffcry K (2010) Supportive holding or restraint: terminology and practice. Paediatric Nursing. 22. 6. 24-28. MacGregor J (2008) Anatomy and Physiology of Children. Second edition. Routledge. London. McComnck MC et a;(2011) Prematurit>^ an overview and public health implications. Annual Review of Public Health. 32. .April 21, 367-379. Malik G et al (2010) Changing trends in asthma in 9-12 year olds between 1964 and 2009. Archives of Disease in Childhood. 96, 3. 227-231 McKean M. Furness J (2009) Paediatric respirator^' nursing posts in secondary care reduce asthma morbidity', but provision is variable. Archives of Disease in Childhood. 94, 8. (44. National Institute for Health and Clinical Excellence (2000) Guidance on the Use of Inhaler systems Devices) in Children under the Age of 5 Years with Chronic .Asthma. TAIO. NICE, Londoa National Institute for Health and Clinical Excellence (2002) Inhaler De\ices for Routine Treatment of Chronic Asthma in Older Children (aged 5-15 years). TAIIS. NICE Londoa National Institute for Heaith and Clinical Excellence (2007) Inhaled Corticosteroids for the Treatment of Chronic Asthma in Children under the Age of 2 years. TA l.il. NICE, London. National Institute for Health and Clinical Excellence (2010) Omaliiumab for the Treatment of Severe Permtent Allergic Asthma in Children aged 6to 11 Years. NICE. London. Preston G (Ed) (2006) A Route Out of Poverty? Disabled People, Work and Welfare Reform. Chapter 4. Living with a Disability: a Message from Disabled Parents. Child Poverty Action Ciroup, London. Royal College of Nursing (2010) Restrictive Physical Intervention and Therapeutic Holding for Children and Young People: Guidance for Nursing Staff. RCN, London. ScuUion J (2005) A proactive approach to asthma. Nursing Standard. 20 . 9, 57-6S. Seddon F et al (200(>) Oral xanthines as maintenance treatment for asthma in children. Cochrane TMabase of .Systemic Reviews Issue I. Sridhar A. McKean M (2006) Nedocromil sodium for chronic asthma in children Cochrane Database of Systematic Reviews. Issue 3. Stoelting R. Miller R (2007) Basics in Anaesthesia. Fifth edition. Elsevier Health Sciences, Philadelphia PA. TilUe-Lehlond 1 et a/(2008) Airway retnodelling is correlated with obstruction in children with severe asthma. Allergy. 63, 5. 533-541. Thomas M et al (2009) A.ssessing asthma control in routine clinical practice: u.se of the Royal College of Physicians '3 Questions'. Primary Care Respirator)' Journal. 18, 2, 83-88. Tortora G. Derrickson B (2009) Principles of .Anatomy and Physiology. Twelfth edition. Wiley Publishers, New York, NY. Vuillermin P e( af (2010) An.xiet> is more common in children with asthma. Archives of Disease in Childhood. 95. 8, 624-629.

NURSING CHILDREN AND YOUNG PEOPLE

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Continuing professional development

Suggested answers to time out activities Time outs 1 and 2: answers can be found in the text and Box 1. Time outs 3 and 4: see tables below. Time out 5: Under normal, less acute, circumstances, children's nurses can enable successful and open communication by using strategies such as: making the overture, setting the context, questioning, active listening, summeirising, reflecting, paraphrasing and bringing the interaction to an acceptable closure. Good communication skills help to reassure the child, relieve anxiety, and make the child feel valued and importcint. The child with asthma may not have the breath or the energy to participate in a lengthy two-way interaction. Strategies that could be used include: closer observation and taking more cues from body language, keeping the questions closed so the child only has to say 'yes' or 'no', or phrasing them in such a way that the questions only require a short answer. Additionally, giving the child more time to answer, which alleviates the need to rush in to fill the pauses in the conversation, could be employed The children's nurse might consider providing the answer and asking the child to nod or shake the head if they agree. Computer keyboards could be used, or recourse to a pad of paper for children who are cognitively advanced. Another idea is to engage and agree simple signs. Asthma may make a child temporally aphasie because they are so breathless but that child still has communication needs and wants to be heard.

Time out 3

nal range values and indicators of concer Example range of heart rates depend on the age of the child, state of arousal and level of health and fitness Example range of respiratory rates depend on the age of the child, state of arousal and level of health and fitness (Breaths per minute) If tachypnoeic, the nurse should have a lower threshold of concern because children have lower respiratory rates when at rest or asleep

Age

(Beats per minute)

Three months Nearly a year old Toddler Preschool School child Young person

(Breaths per minute) More than 60 More than 60 More than 50 More than 40 More than 40 More than 40

90-160 80-130 80-110 70-100 60-100

60-90

30-40 25-40 20-30 18-28 16-26 15-20

*Weil-trained athletes may have very low heart rates

Time out 4 Normal child

}aily activities of a well child and a child with chronic asthma Chronic asthma and not well controlled Child has poor night's sleep. Disturbed when moved off high pillows, takes relievers. Paces activity, breathless in the shower. Is slow to eat because higher respiratory levels make chewing, swallowing and breathing difficult to co-ordinate. Has car ride to school with parent. Has no breath or energy to run in the playground or participate fully in games and sports. Unable to take a turn to clean out school hamster cage. Has allergy to fur and dander. Stands out as little as possible. Poor body image and lack of confidence. Eats packed lunch. In the past, has had allergic reactions to muesli bake, lentil curry, and kiwi fruit yogurt. This has made staff and parents anxious. Is tired and makes little attempt with homework, falls asleep before bedtime medicines. Has to sleep without toy teddy as a dust mite precaution.

Child awakes feeling refreshed. Enjoys breakfast before school. Walks, cycles or ains to school with fnends. Runs in school playground. Participates in games and sports. Cleans out school hamster cage. Secure in the friendships of peers. Has a positive body image. Eats school dinners, drinks a range of cordials and can share some peanut brittle with some friends. Rushes through homework before playing football with friends. Sleeps with stuffed toy teddy.

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Continuing professional development

Practice profile
What do I do now?
'n Using the information in section 1 to guide you, write a practice profile of between 750 and 1,000 words - ensuring that you have related it to the article that you have studied. See the examples in section 2. _ Write 'Practice Profile' at the top of your entry followed by your name, the title of the article, which is: understanding childhood asthma and the development of the respiratory tract, and the article number, which is NCYP8. (Ampete all of the requirements of the cut-out form provided and attach it securely to your practice profile. Failure to do so will mean that your practice profile cannot be considered for a certificate. You are entitled to unlimited free entries. Using an A4 envelope, send for your free assessment to: Practice Profile, RCN Publishing Company, Freepost PAM 10155, Harrow, Middlesex H A l 3BR by July 2012. Please do not staple your practice profile and cut-out slip - paper-clips are recommended. You can also email practice profiles to practiceprofile@ rcnpublishing.co.uk. You must also provide the same information that is requested on the cut-out form. Type 'Practice Profile' in the email subject field to ensure you are sent a response confirming receipt. You will be informed in writing of your result. A certificate is awarded for successful completion of the practice profile. Feedback is not provided: a certificate indicates that you have been successful. Keep a copy of your practice profile and add this to your professional profile copies are not returned to you. that she will sit next to her patients when talking to them. She makes a conscious decision to pay attention to her own body language, posture and eye contact, and notices that communication with patients improves. This forms the basis of her practice profile. Example 2 After reading a CPD article on 'Wound care', Amajit, a senior staff nurse on a surgical ward, approached the nurse manager about her concerns about wound infections on the ward. Following an audit which Amajit undertook, a protocol for dressing wounds was established which led to a reduction in wound infections in her ward and across the directorate. Amajit used this experience for her practice profile and is now taking part in a region-wide research project.

1. Framework for reflection

Study the checklist (section 3). What have I learnt from this article? - To what extent were the intended learning outcomes met? What do I know, or can I do, now, that I did not/could not before reading the article?

What can 1 apply immediately to my practice or client/patient care? Is there anything that I did not understand, need to explore or read about further, to clarify my understanding? What else do I need to do/know to extend my professional development in this area? What other needs have I identified in relation to my professional development? How might I achieve the above needs? (It might be helpful to convert these to short/ medium/long-term goals and draw up an action plan.)

3. PortfoUo submission
Checklist for submitting your practice profile Have you related your practice profile to the article? Have you headed your entry with: the title 'Practice Profile'; your name; the title of the article; and the article number? Have you written between 750 and

: i

2. Excunples of practice profile entries

Example 1 After reading a CPD article on 'Communication skills', Jenny, a practice nurse, reflects on her own communication skills and re-arranges her clinic room so

1,000 words? ~ Have you kept a copy of the practice profile for your own portfolio? Have you completed the cut-out form and attached it to your entry?

Continuing professional development: practice profile

Please complete this form using a ballpoint pen and CAPITAL letters only, then cut out and send it in an envelope no smaller than 9x6 inches to: Practice Profile RCN Publishing Company Freepost PAM 10155 Harrow, Middlesex HAl 3BR Full title and date of article: Job title: Place of work: Address Article number: First name: Surname: Postcode Daytime tel:

September 2011 | Volume 23 | Number 7

NURSING CHILDREN AND YOUNG PEOPLE

Copyright of Nursing Children & Young People is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.