Pink Puffer Kids Final

Perpetual succour hospital department of family & community medicine Family case presentation: “ I got pink puffer kids” LIZA D. MARIPOSQUE, M.D. 1 ST Year FAMED Resident March 2009

INTRODUCTION

GENERAL OBJECTIVE
To present a family with asthmatic children
To review the management of Bronchial asthma in pediatric age group.

Specific Objectives:
To present a case of a 2 year old asthmatic child.
To present the family dynamics and function.
To discuss interventions and recommendations.

INDEX CASE PROFILE
W. C., 2 Years and 6 months old, female, child from Sitio Upper La guerta, Lahug, Cebu City.
Chief Complaint: recurrence of difficulty of breathing.

PRENATAL, NATAL & POST-NATAL HISTORY
Prenatal at 3 months AOG regularly at Brgy. Lahug Health Center. Episodes of asthma attacks noted throughout the course of pregnancy.
Meds: Multivitamins and Salbutamol
Delivered, Fullterm at home by a Traditional Birth Attendant (TBA) and no complications noted.
BW = 6kg
BR = 3 rd /4

Exclusively Breastfed up to 18 months.
Weaning at 6 months.
No other known medical history.
No food and drug allergy.
Complete primary immunization @ Brgy. Lahug Health Center.
HFD: Asthma
Developmental milestone:
Normal at par with age

HISTORY OF PRESENT ILLNESS
18 months PTC:
Onset of nocturnal dyspnea especially at dawn.
Triggers: cough & colds
No fever
Consult and prescribed with Salbutamol syrup and Cotrimoxazole suspension with relief.
1 month PTC:
Onset of cough and coryza with recurrent nocturnal dyspnea for 2-3 episodes/week.

- Occasional wheezing and dyspnea was noted by the mother, especially when the weather condition changes.
-More often, decoction of “Gabon” herbal plants for cough and liniments (Efficascent Oil) or Vicks was applied on the chest during asthma attacks.

PHYSICAL EXAMINATION
Examined awake, responsive, cooperative, ambulatory, not in respiratory distress
Vital Signs:
BP = 90/60 mmHg Wt = 10 kg
HR = 80 bpm Ht = 79cm
RR = 46- 50 cpm
T = 36.5C
WFA = 82.44 % ( 1 st Degree Malnutrition )
WFH = 90% ( Mild Wasting )
HFA = 84.04% ( Severe Stunting )

Skin: no lesions, warm, good turgor
HEENT: Normocephalic, anicteric sclerae, pinkish palpebral conjunctivae, no alar flaring,
(+) clear nasal discharges (-) TPC
Neck : no lymphadenopathies
C/L: equal chest expansion, no chest retractions, no rales, (+) wheeze
CVS: adynamic precordium, distinct heart sounds, normal rate, regular rhythm, no murmur

Abd: globular, normoactive bowel sounds, flabby, soft, non-tender, no masses palpated, no hepatomegaly
Ext: no edema, strong pulses
CNS: within normal limits

IMPRESSION
BRONCHIAL ASTHMA, MILD PERSISTENT, PARTIALLY CONTROLLED.
UPPER RESPIRATORY TRACT INFECTION
1 st Degree Malnutrition, mild wasting, severe stunting

DISCUSSION

Childhood asthma
chronic inflammatory condition of the lung airways resulting in episodic reversible airflow obstruction when exposed to various risk factors.
The pathologic changes, linked to persistent airways inflammation and hyperresponsiveness of the lungs.

Epidemiology
Increasing prevalence of childhood asthma.
International study of Childhood Asthma & Allergies prevalence in 56 countries found 20x variation (range:1.6-36.8%)
~80% asthmatics report disease onset before 6 years old.
All young children experiencing recurrent wheezing, only a minority will go on to have a persistent asthma in later childhood.

Types of Asthma by Underlying Cause or Disease Process
Allergic asthma - triggered by environmental triggers called allergens.
Non-allergic asthma- triggered by factors other than allergens, such as irritants like smoke.
Occupational asthma - triggered by irritants in the workplace ( strong fumes or chemicals).
Exercise-induced asthma - triggered by exercise or vigorous exertion.
Cough-variant asthma - main symptom is continuous coughing. There may be shortness of breath, but generally there is no wheezing.
Medication-induced asthma - NSAIDS

Asthma Classifications by Severity Behrman, Kliegman, Jenson, et.al. Nelson Textbook of Pediatrics, 17 th Edn. p767 FEV 1 or PEF ≥80 of predicted; PEF Variability 20-30% 3-4 months ≥ 3 per week Mild Persistent FEV 1 or PEF >60 & ≤80% of predicted; PEF Variability >30% >1 time per week Daily symptoms, daily use of short acting ß-agonist Moderate Persistent FEV 1 or PEF ≤60 of predicted; PEF Variability >30% frequent Continual symptoms, limited physical activity, frequent exacerbations Severe Persistent FEV 1 or PEF ≥80 of predicted; PEF Variability <20% < 3 months <3 per week Mild Intermittent LUNG FUNCTION NIGHTS W/ SYMPTOMS DAYS W/ SYMPTOMS ASTHMA SEVERITY

Pathogenesis Asthma Triggers Airway Obstruction Airway Inflammation, Hyperresponsiveness, & Remodelling Status Asthmaticus Early phase:15-30mins Late Phase:4-12hr after allergen exposure DEATH

Clinical Manifestations ..
Diagnostic tools ..

Good asthma management
1. Maintain normal activity
- Attend school regularly.
- Participate fully in the sport of their choice.
2. Sleep well without disturbance due to asthma.
3. Experience little to no adverse effects from asthma pharmacotherapy
5. Prevent chronic asthma symptoms.
6.Maintain normal lung function.
7. With early intervention, stay safe by keeping asthma exacerbations from becoming severe.

Four Components of Optimal Asthma Management:
Regular assessment & monitoring.
- check-ups q 2-4wks until good control is achieved.
- 2-4 per year to maintain good control.
- lung function monitoring.
2. Control of factors contributing to asthma severity.
- eliminate or reduce problematic environmental exposures.
- treat co-morbid conditions.
- Annual Influenza vaccination
3. Patient education

4. Asthma pharmacotherapy
- Quick-relief medications (“relievers”)
a. short-acting ß-agonists
b. inhaled anticholinergics
c. short-course systemic glucocorticoids

Long-term-control medications (“controllers”)
- Nonsteroidal anti-inflammatory agents.
- Inhaled glucocorticoids ..
- Sustained-release theophylline
- Long-acting inhaled ß-agonist
- Leukotriene modifiers
- Oral glucocorticoids.

Inhalers for Asthma
Reliever Inhalers:
- bronchodilator.
- as needed and for acute attack.
- if needed 3x a week or more to ease symptoms, a preventer inhaler is usually advised.
Long-Acting Bronchodilator Inhalers
- MOA is same with 'relievers', but work for up to 12 hours.
- salmeterol and formoterol.

Pressurised MDIs (Metered Dose Inhalers)
- contains a pressurized inactive gas that propels a
dose of drug in each 'puff'.
- easy to use, small & hand-carry.
- recommended for children ≥5 years old.
Breath-activated MDIs - ß-2 agonist.
- Alternatives to the standard MDI.
- require less co-ordination than the standard MDI.
- recommended for children ≥5 years old

Spacer devices
used with pressurized MDIs.
Decrease risk of fungal infection.
Recommended for ≤4 years old.
50% decrease delivery to the lungs due to electrostatic charge to the plastic which attracts the aerosol.

Dry Powder Inhalers (DPI)
- Recommended for ≥4 years old.
- Not be used for children in severe attacks w/ greatly reduced inspiratory flow.
Nebulizers
- No need any co-ordination to use, just breathe in and out.
- used mainly in hospital for severe
attacks of asthma when large doses of inhaled drugs are needed

Stepwise Approach for Managing Asthma in terms of Severity Behrman, Kliegman, Jenson, et.al. Nelson Textbook of Pediatrics, 17th Edn. p767 Step 1 + group education & monitoring Anti-inflammatory: low-medium dose inhaled glucocorticoids, & either LABA, Leukotriene Short acting ß-agonist - prn Step 3: Moderate persistent Step 1 + group education & monitoring Anti-inflammatory: low dose inhaled glucocorticoids, cromolyn, leukotriene modifier, nocromil. Alternative: sustained release theophylline Short acting ß-agonist - prn Step 2: Mild Persistent Step 1 + group education & monitoring + referral Anti-inflammatory: high-dose inhaled glucocorticoids + LABA, either leukotriene modifier, sustained release theophylline. Oral glucocorticoid Short acting ß-agonist - prn Step 4: Severe Persistent No daily medication needed LONG-TERM CONTROL MEDICATION Use of MDI & spacer, environmental control measures Short acting ß-agonist - prn Step 1: Mild Intermittent EDUCATION QUICK RELIEF MEDICATION ASTHMA SEVERITY

FEV 1 = forced expiratory volume in 1 second; PEF = peak expiratory flow. * Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate. † By definition, an exacerbation in any week makes that an uncontrolled asthma week. ‡ Lung function is not a reliable test for children 5 years and younger. One in any week† One or more/year* None Exacerbations <80% predicted or personal best (if known) Normal Lung function (PEF or FEV1)‡ More than twice/week None (twice or less/week) Need for reliever/rescue treatment Any None Nocturnal symptoms/awakening Any None Limitations of activities Three or more features of partly controlled asthma present in any week More than twice/week None (twice or less/week) Daytime symptoms Uncontrolled Partly controlled (Any measure present in any week) Controlled (All of the following) Characteristic Levels of asthma control according to the Global Initiative for Asthma (GINA ).

Probable Reasons for Poor Asthma Control
Incorrect choice of inhaler
Poor technique use of inhaler
Non-adherence to treatment
Individual variation in response to treatment
Smoking
Co-morbid rhinitis

Family dynamics

Family Profile
Mother : M. L., 24 years old, common law partner, unemployed, asthmatic
- educational attainment: Grade III
Father : W. C. Sr., 27 years old, common law partner, breadwinner (panday-mason), who earned only ~Ƥ 800/wk., occasional alcoholic drinker.
- educational attainment: 2 nd year High school

SIBLINGS :
Winmar. L. - 7 years old, male, 1 st child,
grade 1 in Lahug Elementary school.
2. Winnie C. Jr. - 5 years & 10 months old, male, 2 nd
child, asthmatic
3. Winjel C. - Index Patient, 2 years & 6 months old, female, 3 rd child, asthmatic
4. Winnie Rose C. - 10 months old, female, 4 th child

Marissa, Winnie Rose, Winnie Jr., Winjel House of Betty, the sister SITUATIONAL ANALYSIS

Lapuz-Caparida’s Hause Bedroom

Dining area

Deep well

Smilkstein’s Cycle of Family Function
FAMILY IN EQUILIBRIUM STREESFUL LIFE EVENTS: Asthma attacks & no permanent work CRISIS: Inadequate family income EXTRA-FAMILIAL RESOURCES: Free medical check-ups Free medicines Can borrow money from older sister Permanent work ADAPTATION

Impact of Illness
Stage I – Onset of Illness
Stage II – Reaction to Diagnosis (Impact phase)
Stage III – Major Therapeutic efforts
Stage IV – Early Adjustment to Outcome (Recovery)
Stage V – Adjustment to the Permanency of the
Outcome

Family Assessment Tools
Family Genogram
Family Circle
Family APGAR
Clinical Biography and Life Events
SCREEM

Family genogram lapuz-caparida family january 13, 2009 Entiquino, 49 @ x † Francisca 36, ͏͏ Ѿ @ Carmen 39 Betty 30 Rosela 27 Renante 25 Marissa 24, Roger 23 Jenny 22 Remarck 16 Queeny 10 Winnie Sr. 27, Winmar, 7 @ Winnie Jr. 5 @ Winjel, 2 Winrose, 10 mos. 1988 I ii III @ Rostica 59, Alejandro 60 Generoso 42 Dita 36 Rita 45 Ronnie 29 Amay 28 Benvienido 25 LEGENDS: @ - Asthmatic Index Patient † or X deceased recurrent urticarial rashes 5 months pregnant ͏͏ Ѿ Abella-Lapuz Jimenes-Caparida male female

FAMILY CIRCLE MARISSA WINMAR WINROSE WINNIE SR. WINJEL WINNIE JR. BETTY

FAMILY APGAR i INFORMANT: MARISSA CAPARIDA & betty 9 Total √ I am satisfied with the way my family and I share time together. R √ I am satisfied with the way my family expresses affection and responds to my emotions. A √ I am satisfied that my family accepts and supports my wishes to take on new activities and direction. G √ I am satisfied with the way my family talks over things with me and shares problems with me. P √ I am satisfied that I can turn to my family for help when something is troubling me. A Hardly ever Some of the time Almost always

screem Limitations in finances for medical check-up & medicine. Can borrow money from the eldest sister in case of emergency. Medical check-up with the family physician M edical Learns at home Primary education E ducational Inadequate monthly income. The father works as a construction worker E conomic Attends mass occasionally during fiesta, Christmas. Prays at home. R eligious Using herbal medicine & linements Herbal medicine C ultural Nobody can help the wife in attending the 4 children Interacts with neighbors and relatives. No known enemies. S ocial Pathology/Weakness Resource/ Strength

FAMILY DIAGNOSIS
Nuclear type of family with young children, highly Functional, Lower Class
Stage IV of the Family Illness Trajectory.
Father is the breadwinner; mother is the primary care giver; patriarchal
Health status of kids: poor
Religious practices: poor

interventions
Preventive measures & environmental sanitation.
Hypoallergenic diet
Medical advices
Family planning.

Medical check-up.
Follow – up check-up regularly.
Giving some free medicines.
Referred to pediatric pulmonologist for consult.

To continue the medical center. constructed by the PSH-Dept. of Family & Community Medicine.
To propose a nebulizer machine in the community center.
To propose a free medicines from the Brgy. Health Center & Bry. Lahug.
To suggest a vehicle from the Brgy. Lahug for emergency purposes.
To propose a free mass wedding in the community.
recommendations

THANK YOU!

Pink Puffer Kids Final

by liza mariposque on Jun 22, 2009

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