7. Childhood asthma.pptx.ppt

Childhood Asthma
Dr. Rajalakshmi Murugan
Associate Professor
School of Nursing and Midwifery
Addis Ababa University
BRONCHIAL ASTHMA MSc
1
10/8/2023

CHILDHOOD ASTHMA
Objectives:
•Define Asthma
•Discuss the clinical manifestation of Asthma
• Explain the cause of Asthma
•Recognize factor triggers Asthma
•Classify severity of Asthma
10/8/2023
BRONCHIAL ASTHMA MSc 2

10/8/2023
3
Definition
 Asthma is a chronic inflammatory condition of
the lung airways resulting in episodic airflow
obstruction.

Definition
 Asthma is a chronic disease involving the
respiratory system in which the airways
occasionally constrict, become inflammated, and
are lined with excessive amounts of mucusoften in
response to one or more triggers.
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Definition
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 A chronic inflammatory disease of airways
that is characterized by increased
responsiveness of the tracheobronchial tree to
a multiplicity of stimuli and reversibility with or
without treatment.
 Asthma is a chronic inflammatory disorder of
the airways in which many cells & cellular
elements play a role (mast cells, eosinophils,
T lymphocytes, macrophages, neutrophils, &
epithelial cells).

Definition
 Asthma leads to recurrent episodes of
wheezing, breathlessness, chest tightness and
coughing (particularly at night or early
morning).
 Clinical symptoms in children 5 years and
younger are variable and non-specific.
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A Brief Review of A & P
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Respiratory system
The respiratory system has many parts:
 Upper and lower airways, that conduct air
in and out of the body.
 Lungs, where gas exchange takes place.
 Muscles, such as the diaphragm, that
provide the physical forces needed for
breathing.
 Skeletal elements, such as the ribs and
sternum, that provide support and
structure.
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Developmental considerations in
the paediatric respiratory system
 Prematurity: underdeveloped lungs/immune
system
 Floppy, narrow, short airway
 Soft, underdeveloped muscles
 Fewer alveolar units in childhood (lung not fully
grown till ~6 years of age)
 higher metabolic rate
 more frequent URI’s
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Global burden of paediatric
chronic respiratory disease
 Hundreds of millions suffer worldwide, ~ >500 million in
developing countries
 Burden of chronic respiratory diseases:
◦ frequency (commonest reason for primary care visits)
◦ economic impact (hospital care, medications)
 Asthma: ~ 300 million total, ~ 250 000 annual deaths
worldwide
◦ Large differences in prevalence between countries
◦ Mortality is high where access to essential drugs is
low.
 ~50% population of Ethiopians have access to
essential asthma medications 10/8/2023
10

Objectives of chronic respiratory
disease initiatives
 In developing countries,
decrease the burden of illness,
prevent avoidable deaths, and
increase the quality of life of
patients,
 via prevention and
management. 10/8/2023
11

Epidemiology
• Worldwide, childhood asthma appears to be increasing in
prevalence, despite considerable improvements in
management
• Globally, death rates from asthma in children range from 0
to 0.7 per 100,000 people
• Studies in different countries reported an increase in
asthma prevalence of about 50% per decade
• Approximately 80% of all asthmatic patients report disease
onset prior to 6 years of age
• Studies suggest that, the prevalence was 49.7
million(13.9%) among <15 years in Africa
12
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Epidemiology
 Bronchial asthma (BA) is one from the most
frequent chronic diseases in children and its
incidence continues to increase in the last
years. Conformable to ISAAC data
(International Study of Asthma and Allergy in
Children), BA affects 5-20% of children on the
earth globe, this index varying in different
countries (in USA %, in Canada, UK %, in
Greece, China – 3-6%).
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Epidemiology
 Asthma affects 5-10% of the population or an
estimated 23.4 million persons, including 7
million children.
 The overall prevalence rate of exercise-
induced bronchospasm is 3-10% of the
general population ,but the rate increases to
12-15% of the general population.
 Asthma affects an estimated 300 million
individuals worldwide. Annually, the World
Health Organization (WHO) 250,000 asthma
deaths are reported worldwide. 10/8/2023
14

Epidemiology
 Asthma affected an estimated 262 million
people in 2019 and caused 461000 deaths .
 Considering sub-Saharan Africa alone, the
prevalence of asthma was 4.6% (7,270,000
cases) for children under 5 years, 5.5%
(15,167,000 cases) for 5–14 years, 2.7%
(13,388,000 cases) for 15–49 years, 3.9%
(3,232,000 cases) for 50–69 years and 5.8%
(1,097,000 cases) for 70+ years.May 16, 2019
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Epidemiology
 A total of 2951 children aged 13 and 14 years
were enrolled into the study, of which 1393
(47.2%) were males and 1558 (52.8%) were
females. 557 children (18.2%) reported that
they have had wheezing at least once in the
last 12 months while only 84 children (2.8%)
reported to have "Bronchial
Asthma".(International Study of Asthma and
Allergies in Children (ISAAC) Mekele)
Ethiopia.
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Epidemiology
 Study done in Addis Ababa with 6 month and
years old school children.The prevalence of
ever wheeze, wheeze in the past 12 months,
ever diagnosed asthma, exercise induced
wheeze in the past 12 months, and dry cough
at night in the past 12 months were 13.1% .
Diet (eating pasta 3 time per week in the past
12 months) and fuel for cooking (kerosene)
were significantly associated with wheezing in
the past 12 months.
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Research studied in addis ababa in 2021 the result shows that A total of 105
asthmatic children were enrolled in the study. Most were female (n=57, 54%); the
mean age was 9.0 + 1.7 years. In the previous school year, 34 (32.4%) children had
severe wheezing limiting speech and 15 (14.3%) had more than 12 episodes of
wheezing. Most students (n=70; 66.6%) missed > 5 school days due to asthma
related symptoms, and 33 (31.4%) children were admitted to a health care facility
for an asthma exacerbation. Increases in asthma severity or symptom-induced
sleep disturbance were both associated with decreased school performance.
Epidemiology

Pathophysiology
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 Other associated histopathologic
abnormalities of the airways characteristic of
asthma include
 epithelial damage,
 sub epithelial collagen deposition with basement
membrane thickening, and
 mucus gland and smooth muscle hypertrophy.

Mechanism – Asthma Inflammation
Source: Peter J. Barnes, MD
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Pathogenesis
 Airflow obstruction in asthma is the result of numerous
pathologic processes
 In the small airways, bronchoconstriction of smooth
muscle encircling the airways lumens restricts or
blocks airflow
 A cellular inflammatory infiltrate and exudates
distinguished mainly by eosinophils can fill and
obstruct the airways and induce epithelial damage
 Helper T lymphocytes and other immune cells that
produce proallergic, proinflammatory cytokines (IL-4,
IL-5, IL-13), and chemokines mediate this
inflammatory process
21
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Factors Influencing the Development
and Expression of Asthma
Host factors –
 Genetic
1. Genes predisposing to atopy
2. Genes predisposing to airway hyper responsiveness
 Obesity
 Sex
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Risk factors for BA
development in children
 Familial antecedents of BA and other allergic diseases.
 Contact with home dust containing dust mite:
Dermatophagoides pteronyssinus.Contact with fur-bearing
animals (cat, dog, etc.).
 Contact with mould (species of fungi Alternaria, Aspergillus,
Candida, Penicillium).
 Contact with the pollen of different plants.Smoke of
cigarettes, after woods burning.Presence of cockroaches.
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Risk factors for BA
development in children
 Alimentary (fish, egg, cow’s milk etc.) and drug
allergensMeteorological factors (cold air, fog).
 Physical activity,Environmental
pollution,Presence of gastroesophageal reflux.
 Drugs and vaccines (antibiotics – penicillin,
cephasoline, tetracycline etc., sulfonamides,
NSAID, colorants, etc.)
 Viral infections,Stress factors
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Etiology
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 The cause of childhood asthma has not been
pinpointed interplay between genetic and
environmental factors
 Environmental factors influence immune
development toward the asthmatic phenotype
in susceptible individuals
 Genetics concordance of asthma between
monozygotic twins is 0.74, and a 0.35
concordance between dizygotic twins

Clinical manifestation
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 Intermittent dry coughing and/or expiratory
wheezing are the most common chronic
symptoms of asthma.
 shortness of breath and chest tightness in
older children
 younger children are more likely to report
intermittent, non focal chest “pain.
 Respiratory symptoms, worse at night, especially
during prolonged exacerbations triggered by
respiratory infections or inhalant allergens

Cont……………………….
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 decreased physical activity general fatigue
(possibly due to sleep disturbance)
 such as a history of other allergic conditions
(allergic rhinitis, allergic conjunctivitis, atopic
dermatitis, )
 Unequal or decreased breath sounds
 Use of accessory muscles (intercostals
retractions & nasal flaring ).
 Cyanosis

Asthma triggers
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 Common viral infections of the respiratory tract
 Aeroallergens in sensitized asthmatics
 Animal dander
 Indoor allergens
 Dust mites
 Cockroaches
 Molds
 Seasonal aeroallergens
 Pollens (trees, grasses, weeds)
 Seasonal molds
 Environmental tobacco smoke
 Air pollutants
 Ozone
 Sulfur dioxide
 Particulate matter
 Wood- or coal-burning smoke
 Endotoxin,
 Dust
• Strong or noxious odors or
fumes
– Perfumes, hairsprays
– Cleaning agents
• Occupational exposures
– Farm and barn exposures
– Formaldehydes, paint
fumes
• Cold air, dry air
• Exercise
• Crying, laughter,
hyperventilation
• Co-morbid conditions
– Rhinitis
– Sinusitis
– Gastroesophageal reflux

Diagnosis
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 The presence of risk factors, such as a history
of other allergic conditions (allergic rhinitis,
allergic conjunctivitis, atopic dermatitis, food
allergies), parental asthma, and/or symptoms
apart from colds
 quick resolution (within 10 min) or convincing
improvement in symptoms and signs of
asthma with administration of a short-acting
inhaled beta-agonist is supportive of the
diagnosis of asthma

Assessment
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 History - recurrent episodes of wheezing, often
with cough.
Physical examination:
 signs of respiratory distress
 absence of fever
 lower chest wall indrawing
 prolonged expiration with audible wheeze
 reduced air entry when obstruction is severe
 hyperinflation of the chest
 usually good response to treatment with a
bronchodilator

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 If the diagnosis is uncertain, give a dose of a
rapid-acting bronchodilator(adrenaline
/epinephrine and salbutamol).
 A child with asthma will usually improve
rapidly, showing signs such as a decrease in
the respiratory rate and in chest wall indrawing
and less respiratory distress.

Asthma Predictive Index for
Children
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 MAJOR CRITERIA
 Parent asthma
 Eczema
 Inhalant allergen
sensitization
• MINOR CRITERIA
– Allergic rhinitis
– Wheezing apart from colds
– Eosinophils ≥ 4%
– Food allergen sensitization
• Through a statistically optimized model for pre–school-
age children with frequent wheezing in the past year,
one major criterion OR two minor criteria provide a
high specificity (97%) and positive predictive value
(77%) for persistent asthma into later childhood

Assessment and Investigation
 History –ask about any breathing
problems child may have had, as well as any
family history of asthma, allergies, eczema, or
other lung disease. including when and how
often they happen.
 Physical exam. listen to child's heart and
lungs and look in their nose or eyes for signs
of allergies.
 Child might get a chest X-ray. If they’re 6 or
older, they may have a simple lung
test called spirometry.It measures the amount
10/8/2023
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Cont…
 They may include allergy skin
testing, blood tests (IgE or RAST (radio-
allergosorbent tests) .The RAST test is a blood
test that is used to see if an individual's blood
contains antibodies for a specific substance,
such as peanuts or pollen. These antibodies
are called immunoglobulin E, or IgE
antibodies.
 X-rays to tell if sinus
 infections or gastroesophageal reflux disease
(GERD) is making asthma worse.
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Severity classification of
asthma
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 Patient fits into the highest category that they meet one of the
criteria
 Severe Acute Asthma
 Exhaustion, Agitated
 Feeble respiration/Breathless at rest
 Persisting or worsening hypoxia
 Hunched forward
 Speaks in words rather than complete sentences
 Drowsiness, confusion
 Coma or respiratory arrest
 Hypercarbia, Fall in blood pH
 Peak flow rate less than 60% of normal

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Treatment
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Four Components of Optimal Asthma
Management
 REGULAR ASSESSMENT AND
MONITORING
 Asthma checkups
- Every 2–4 wk until good control is achieved
- 2–4 per yr to maintain good control
-Lung function monitoring

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 CONTROL OF FACTORS CONTRIBUTING
TO ASTHMA SEVERITIY
 Eliminate or reduce problematic environmental
exposures
 Treat co-morbid conditions: rhinitis, sinusitis,
gastroesophageal reflux
 ASTHMA PHARMACOTHERAPY
 Long-term-control versus quick-relief medications
 Classification of asthma severity for anti-inflammatory
pharmacotherapy
 Step-up, step-down approach
 Asthma exacerbation management

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 PATIENT EDUCATION
Provide a two-part care plan
 Daily management
 Action plan for asthma exacerbations

Asthma Management Goals
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 Achieve and maintain control of symptoms
 Maintain normal activity levels, including
exercise
 Maintain pulmonary function as close to
normal levels as possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma
medications
 Minimize need for reliever medications

Non Pharmacological
management
 Oxygen: administer oxygen via mask or nasal
cannula.
 Positioning: upright or leaning position in
older children.
 Nutrition: Increase feeding and fluid intake as
appropriate.
41
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Pharmacological management
 The choice of initial therapy is based on
assessment of asthma severity
 patients who are already using controller
therapy, modification of treatment is based on
assessment of asthma control and
responsiveness to therapy
42
10/8/2023

Cont.…
 Nebulizer
43
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Cont………………..
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 Prevent asthma mortality
 Patient/family satisfaction
 A child with the first episode of wheezing and
no respiratory distress can usually be
managed at home with supportive care and
with a bronchodilator.

Cont……………….
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 Rapid-acting bronchodilators
 Nebulized salbutamol
 Salbutamol by metered-dose inhaler with a
spacer device- Spacer devices (Some infants and
young children cooperate better when a face
mask is attached to the spacer instead of the
mouthpiece)

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 Subcutaneous epinephrine (adrenaline)
 If the above two methods of delivering
salbutamol are not available, give a
subcutaneous injection of epinephrine
(adrenaline)—0.01 ml/kg of 1:1000 solution
(up to a maximum of 0.3 ml), measured
accurately with a 1 ml syringe. If there is no
improvement after 15 minutes, repeat the dose
once.

Oral bronchodilators
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 Once the child has improved sufficiently to be
discharged home, if there is no inhaled salbutamol
available or affordable, then oral salbutamol (in
syrup or tablets) can be given.
 The dose is: 0.075-0.1 mg/kg 3-4 times a day.
Steroids
 If a child has a severe acute attack of wheezing
give hydrocotison IV 2mg/kg /dose every 6 hrs
until improvement is seen. For history of recurrent
wheezing, give oral prednisolone, 1 mg/kg, for 3
days. Steroids are not usually required for the first
episode of wheezing

Asthma education
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 Avoid triggers
 Take medications correctly
 Use preventors &relievers
 Monitor symptoms and PEFR
 Recognize worsening signs
 Seek medical help

Nursing management
 Education – position ,administration of fluid ,
maintain adequate diet
 Evaluation - cyanosis , breathing sound,
 Environment – avoid causing asthma or risk
for child must be eliminated
 Emotional support – for parents
 Regular follow up
 Maintain Hygiene
 10/8/2023
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10/8/2023
50
Thank you

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