UpdatePresented by:

Katy Zahner BSN, RN, CCRN

Georgetown University Nurse Educator Student

Objectives

At the completion of this module, the learner will be able to: Describe the pathophysiology , common triggers

and clinical manifestations of the child with asthma Identify current medication and treatment options

for the child with an acute asthma exacerbation Summarize considerations for intubation for a child

with asthma

Facts

Most common chronic disease of childhood (1 out of 11 children)

2 million Emergency Room visits per year

Pathophysiology

Chronic inflammatory disorder of the airways characterize by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness

Results from complex interactions among inflammatory cells, mediators, and the cells and tissues present in the airway

Inflammatory response to stimuli airway edema and accumulation and secretion of mucus spasm of smooth muscle of bronchi and bronchioles therefore decreasing diameter airway remodeling causing permanent cellular changes

Triggers Allergens

Outdoor – Trees, shrubs, molds, pollens

Indoor – Dust or dust mites, mold and cockroach antigen

Exposure to chemicals

Exercise

Cold air – changes in weather

Environment change

Colds and infections

Animals

Medications

Emotions

Conditions – GERD

Food additives

Foods – nuts, dairy

Endocrine – menses, thyroid

Clinical Manifestations

Cough – Barking, paroxysmal, irritative, non-productive then becomes rattling and productive

Shortness of breath

Prolonged expiratory phase

Audible wheeze

Cyanosis may or may not be present

Tripod position

Restlessness

Sweating

Hyperresonance on percussion

Clear breath sounds vs. wheezing

Care in the Emergency Room

Prehospital care Physical exam

Peak Flow

Children with SPO2 < 92% often require more aggressive treatment and likely admission

“Silent chest” = severe obstruction and is ominous sign

Asthma score

ABG

Radiography

Clinical pathway

Pediatric Asthma Score

Medications

1st line therapyAlbuterol

NebulizedShort acting beta agonist/bronchodilator2.5mg-5mg q20 min x 3MDI = 4-8 puffs q20min x3

Medications

Albuterol Intermittent and continuous nebulizer dosing

2.5mg for children 5kg to 10 kg 5mg for children for children for children > 10 to

20kg; and 7.5mg for children > 20kg Severe exacerbations 0.5mg/kg/hr up to 20 mg/hr Drawback - tachycardia and jitteriness

Medications

Ipratropium Anticholinergic Acts synergistically with albuterol. NOT as a

single agent 250-500mcg + beta agonist x 1-3

Medications

Corticosteroids Cornerstone therapy alongside beta agonists Dexamethasone has been proven to be just

as effective Effective for both acute and chronic

inflammation Work synergistically with beta agonists Steroids increase the expression of beta agonist

receptors and prevent their downregulation when beta agonists are administered

Medications

Steroids Methylprednisolone

1mg/kg divided q12 MAX 1 time dose – 240mg

Prednisone 1-2 mg/kg/day MAX 1-time dose 60mg/day

Dexamethasone 0.6-1.0 mg/kg PO, IM, IV MAX dose 16mg

Medications

Other Medications Used: Racemic epinephrine – Bronchiolitis and

Croup Epinephrine – RESERVED FOR SEVERE

EXACERBATIONS Terbutaline – Parenteral, for severe

exacerbations Aminophylline – No longer recommended Magnesium Sulfate – Associated with

hypotension Montelukast – Not recommended in acute

asthma

Respiratory Failure

Poor response to therapy Rising PaCO2 45-50 mmHg Severe hypoxia (PaO2 <60) Waning mental status or fatigue Impending respiratory arrest Cardiopulmonary arrest

Respiratory Failure – Now What?

BiPAPHelioxIntubation

Preoxygenate IV access Fluid bolus ETT (age in years / 4 + 3.5) Rapid sequence intubation Ketamine

Intubation

Vent settingsSIMVVt = 5 to 6 ml/kgRespiratory rate = Half normal for age I:E ratio = 1:3PEEP = 0-3cmH2O

Review

A 6 year old child presents to the ER with asthma exacerbation. Which of the following medications would be considered as first line therapy? Select all that apply.

a) Albuterol

b) Montelukast

c) Turbutaline

d) Corticosteroids

e) Ipatropium with albuterol

Answer – a, d, e

Review

Which of the following is an indication of impending respiratory failure in a child with asthma? Select all that apply.

a) ABG pH 7.38, PaCO2 45, PaO2 83

b) Clear diminished breath sounds

c) Coarse expiratory wheeze

d) Peak flow of 400

e) Child sitting in tripod position

Answer – a, b

Review

A mother presents to the ER with her 7 year old son who is complaining of shortness of breath. The mother states her child has asthma and was diagnosed at age 4. Which of the following triggers likely contributed to the child's asthma exacerbation?

a) Seasonal changes – pollen

b) Cats

c) Cockroach feces

d) Food

e) All of the above

Answer - e

THANK YOU!