quickLESSON about...

Asthma: Child/Adolescent

Description/Etiology
Asthma, a chronic disease characterized by reversible airflow obstruction due to inflammation and narrowing of the airways, is the most common chronic disease in childhood. Asthma is a significant cause of childhood morbidity and is associated with school absenteeism, emergency department and acute care visits, and hospitalizations. The exact cause of asthma is unknown. A genetic component is possible because a strong association has been found between the ADAM 33 gene and bronchial hyperresponsiveness/asthma; a family history of asthma has also been shown to increase risk for developing asthma. New research suggests certain environmental, psychological, and medical factors can increase risk for developing asthma. As in adult asthma, childhood asthma is classified based on symptom frequency and severity: intermittent, mild persistent, moderate persistent, and severe persistent. Status asthmaticus is characterized by an acute asthma attack of such severity that it is considered a medical emergency because it can lead to respiratory failure and death (see Quick Lesson AboutStatus Asthmaticus). Similar to treatment of asthma in adults, children are prescribed an individualized medication regimen of shortand long-acting agents. Children and/or family members are educated about the importance of strict adherence to the medication regimen, frequent medical surveillance, daily in-home monitoring of symptoms, correct use of nebulizers/inhalers and symptom monitoring devices, and avoidance of asthma triggers. The treatment team may include specialty clinicians in internal medicine, pulmonology, allergy, and respiratory therapy.

Facts and Figures

In 2003, an estimated 5 million children younger than 15 years of age in the United States had asthma. Asthma affects an estimated 10% of children, compared with 5% of adults. Between 50% and 80% of children with asthma develop symptoms before the age of 5 years.
ICD-9
493

Risk Factors
Children living in urban and low-income areas are more likely to develop asthma; in the U.S., Blacks are more likely than Whites to require hospitalization for asthma and to die from asthma. Risk factors and triggers for asthma include parental history of asthma; obesity; comorbid conditions (e.g., rhinitis, sinusitis, and gastroesophageal reflux disease [GERD]); allergies (to pollen, mold, dust mites, cockroaches, and animal dander); allergic hypersensitivity (e.g., allergic rhinitis and/or atopic dermatitis such as eczema); severe respiratory infection (e.g., pneumonia and bronchiolitis); low birthweight; exercise; and exposure to environmental factors (e.g., mold; cigarette smoke; fumes from household cleaning agents, paint, cedar, formaldehydes, and scented products; air pollution; ozone; nitrogen oxide [given off by gas stoves]; cold temperatures; and high humidity).

ICD-10
J45

ICD-10-CAN
J45

Authors
Gilberto Cabrera, MD Tanja Schub, BS

Reviewers
Darlene A. Strayer, RN, MBA Cinahl Information Systems Glendale, California Eliza Schub, BSN, RN Cinahl Information Systems Glendale, California Nursing Practice Council Glendale Adventist Medical Center Glendale, California

Signs and Symptoms/Clinical Presentation

Intermittent dry coughing, wheezing, intermittent nonfocal chest pain in younger children, chest tightness and shortness of breath in older children, tachypnea (i.e., rapid breathing), tachycardia, fatigue, and difficulty keeping up with the activity level of peers.

Assessment

44 Patient History
Ask about family history of asthma, risk factors, and history of asthma attacks, hospitalizations,

44 Physical Findings of Particular Interest 44 Laboratory Tests That May Be Ordered

Tachypnea, dry cough, wheezing, cyanosis, mucous production, and tachycardia are usual CBC with differential may reveal an increased number of immature leukocytes (called a left shift),
indicating infection; sputum culture may indicate infection; increased eosinophil count and serum IgE levels are indicative of allergic reaction Arterial blood gas (ABG) analysis of oxygen concentration, CO2 content, and pH levels determine asthma severity. Mild asthma may be characterized by PaO2, PaCO2, and pH; moderate asthma

medication use, and coexisting medical conditions

Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems

July 30, 2010

Published by Cinahl Information Systems. Copyright2010, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

44 Other Diagnostic Tests/Studies

Exhaled nitric oxide (FENO) test indicates the extent of airway inflammation

by normal PaCO2 and pH and PaO2; and severe asthma by PaO2, pH, and PaCO2

Pulmonary function tests identify peak expiratory flow rate (PEFR), forced expiratory volume in 1 second (FEV1), and forced vital capacity
(FVC); PEFR is based on weight, height, gender, and age and is appropriate for testing children 6 years of age

Radioallergosorbent test (RAST) may identify allergens Pulse oximetry reveals decreased oxygen saturation levels Chest X-rays may reveal thoracic hyperinflation and peribronchial thickening

Treatment Goals

44 Maintain Optimum Respiratory Status and Reduce Risk of Complications

Monitor vital signs (particularly respiration), pulse oximetry, pulmonary function tests, and ABG results; administer prescribed treatment for
severity level Intermittent asthma For patients 5 years of age: a short-acting inhaled beta2-agonist (SABA) by face mask with spacer/holding chamber or nebulizer; or an oral beta2-agonist on an as-needed basis For patients > 5 years of age: daily medication may not be necessary, and SABA may be prescribed on an as-needed basis only. Educate about trigger avoidance Mild persistent asthma For patients 5 years of age: daily low-dose inhaled corticosteroids (e.g., a metered dose inhaler [MDI]) with holding chamber with or without dry powered inhaler (DPI) or face mask; alternative treatment is a leukotriene receptor antagonist or MDI with holding chamber or nebulizer of cromolyn For patients > 5 years of age: daily low-dose inhaled corticosteroids; alternative treatment is a leukotriene modifier, cromolyn, theophylline, or nedocromil Moderate persistent asthma: daily medium-dose inhaled corticosteroids or long-acting inhaled beta2-agonists combined with inhaled corticosteroids; alternative treatment is low-dose inhaled corticosteroids with theophylline or a leukotriene modifier Severe persistent asthma: daily long-acting inhaled beta2-agonists, high-dose inhaled corticosteroids, and, if needed, systemic corticosteroids Patients 5 years old with a viral respiratory infection receive a bronchodilator Frequently assess treatment efficacy and for respiratory distress, hypoxia, and adverse medication effects

44 Provide Emotional/Psychological Support and Educate

Assess patient anxiety level; encourage rest and promote calmness to decrease anxiety, which can further compromise breathing If developmentally-appropriate, teach diaphragmatic and pursed-lip breathing and coughing techniques to promote more effective respiratory effort

Food for Thought

44 Infants breastfed for more than 4 months may have a reduced risk for developing asthma 44 Despite the fact that smoking is particularly dangerous in individuals with asthma, asthmatic adolescents are as likely as their non-asthmatic peers to smoke cigarettes

Red Flags
44 Growth patterns should be closely monitored in children taking high doses of inhaled corticosteroids, due to the possibility that the medication will slow growth

What Do I Need to Tell the Patient/Patients Family?

44 Educate the patient/family/caregiver on the importance of adherence to the medication regimen; the correct use of nebulizers/inhalers and peak flow home monitoring devices; daily symptom monitoring to prevent emergencies; maintaining adequate hydration to help loosen secretions; keeping scheduled appointments for follow-up clinician visits; avoiding triggers (e.g., smoking and secondhand smoke, cold air, aspirin, and intense exercise); and controlling household pollutants (e.g., cockroaches, pet dander, mold, dust mites) by using humidifiers/HEPA filters, covering upholstered furniture and vents, and keeping air ducts, carpets, and bedding clean 44 Educate on signs of an oncoming attack: cough, fever, irritability, decreased appetite, anxiety, dry mouth, and/or circles under or around the eyes; provide and emphasize the importance of having an emergency plan for asthma exacerbations; recommend obtaining additional information from the Asthma and Allergy Foundation of America at http://www.aafa.org/

References
Ferri, F. F. (2010). Asthma. In F. F. Ferri (Ed.), 2010 Ferris clinical advisor: Instant diagnosis and treatment (pp. 100-108). Philadelphia: Mosby Elsevier. Guo, S.-E., Ratner, P. A., Johnson, J. L., Okoli, C. T., & Hossain, S. (2010). Correlates of smoking among adolescents with asthma. Journal of Clinical Nursing, 19(5-6), 701-711. Jackson, D. J. (2010). The role of rhinovirus infections in the development of early childhood asthma. Current Opinion in Allergy and Clinical Immunology, 10(2), 133-138. Kolski, G. B. (2010). Asthma in children. In E. T. Bope, R. E. Rakel, & R. Kellerman (Eds.), Conns current therapy 2010 (pp. 778-784). Philadelphia: Saunders Elsevier. Vuillermin, P. J., Robertson, C. F., Carlin, J. B., Brennan, S. L., Biscan, M. I., & South, M. (2010). Parent initiated prednisolone for acute asthma in children of school age: Randomised controlled crossover trial. BMJ, 340, c843.