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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?

Although it is not uncommon for an asthmatic parent to express guilt for passing the disease on to their child. It is narrow and soft (Dixon ef al 2009). it is recommended that the reader also reviews the embryological development of the sensory system and the skeletal system (Box 1).while acknowledging that genes play a part . The respiratory system begins at the nasal cavity and consists of a conducting portion and a respiratory portion. This means a relatively small obstruction can compromise the airway radius causing a significant increase In respiratory effort. is controversial. are switched on and off by the genes of both parents. Whether infants are obligatory nose breathers. 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. When considering the development of the respiratory system it is important to set if in context with the development of other systems. 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). which forms layers of tissue. 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).can emphasise the complexity of the condition. As childhood is a period of rapid growth in the lungs and the immune system. approximately 4 to 5cm from cricoid to carina. Although the baby's respiratory system will not carry out its primary physiological function until after it is born. The larynx is higher in the neck at the level of C3-4 than in an adult (C4-5). For example. The tissues that give rise to the respiratory system are the endoderm and the mesoderm (Figure 1). The conducting portion includes the nasal cavity. The airways are smaller and less developed than in adolescents. alveolar ducts.from the Greek alphabet (Stoelting and Miller 2007). larynx. bronchi and bronchioles. This is important when considering children with asthma because a small amount of mucus or oedema can seriously reduce the NURSING CHILDREN AND YOUNG PEOPLE Ectoderm Mesoderm Endoderm September 2011 | Volume 23 | Number 7 . The shape of the epiglottis is different from in the adult and resembles more of an uppercase omega (Q) . The trachea is short in the infant. diaphragm and lungs do form early in the embryonic period. The size and shape of the larynx is different. or not. the respiratory tract. improve its management and possibly eradicate the condition.Continuing professional development Embryology The embryo's blueprint comes from the genetic contribution of the parents. trachea. and this can influence the course of an asthmatic attack. it would be impossible for the parents to influence the genetics of their child. The respiratory tract matures. page 29). Rudimentary formation commences about the fourth week of gestation. developmental factors should be considered in the pathogenesis of childhood asthma (Chung 2011) Anatomy The shape and size of the head. Asthma is increasingly being understood as a complex interaction between a child's genes and the child's environmental factors (Chung 2011). The children's nurse could point out that genetics is a lottery: during the early embryonic phase the disc of specialising cells. the children's nurse . This may help to ensure that parents do not blame themselves or each other. 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. 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). but the nostril size is small and can get narrowed or blocked with mucus and crusted secretions. pharynx. The respiratory portion consists of the respiratory bronchioles. In the future there may be techniques in genetic engineering which will identify children who are more at risk of the disease. 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. Because of the interconnectivity of the air entry points with the face and their role in Transverse section of trilaminar emb maintaining homeostasis. alveolar sacs and the alveoli. the proximity of the developing trachea to the oesophagus of the upper gastrointestinal system and the dual role of the oropharynx.

In addition. Saccular period Weeks 28 to 36 gestation Alveolar period Weeks 36 to term (Adapted from Dixon e! ai 2009) working diameter of the airway. future respiratory infections and predisposition to asthma. Further development of the terminal sacs and formation of the walls of true alveoli. giving shape to the left and right bronchial tree. Columnar cells develop and differentiate in the alveoli into type 1 and II. This means that the alveoli can be aerated via these connections even when the terminal bronchiole. many infants born at this early stage will die or survive to develop complex needs. Type 1 cells provide the alveolar surface area for gas exchange and type II cells secrete surfactant. Infants born at this stage are likely to do well and less likely to have complex needs.gestation Development of the respiratory bronchioles. As the child grows and matures so do the number of collateral ventilatory channels. 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. They are less likely to require aggressive support to sustain them. damage can be done to the future airways at this stage and there is a high correlation between maternal smoking. Development continues with some divisions. Increased vascularisation of the lung occurs. 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). This can be related to clinical severity and predictive of greater airflow obstruction (Bai 2010). Hyperplasia and hypertrophy contribute to the increase in smooth muscle mass. The canals of Lambert connect closely adjacent bronchioles and alveoli. The foregut divides into a dorsal portion. which becomes the oesophagus. Towards term the immune system starts to mature. Life is not possible if the fetus is born at this stage as there is no possibility of gas exchange. The diaphragm is formed between eight and ten weeks of gestation.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. and a ventral portion. which becomes the trachea and the early lung buds. such as a ventilator lung. These communications between the lower airways are thought to develop after infancy and up to six years of age. although infants born then require considerable supportive technology to sustain them. which directly supplies them. Canalicular period: Weeks 17 to 24-(. Supportive technology can cause damage. Despite considerable medical and nursing efforts. As the number of alveoli increase the respiratory surface area available tor gas exchange increases correspondingly. necessary to lower the alveolar surface tension and sustain lung inflation. and the pores of Kohn facilitate interalveolar connections (Dixon ef al 2009). 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. The channels of Martin are interbronchiolar connections. Although they are susceptible to seasonal epidemics such as respiratory syncytial virus (RSV) (Escobar ef a/2010). Elastic fibres develop. However. especially asthma (McCormick ei a/ 2011). 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). smooth muscle and true alveoli are present at 34 weeks' gestation. Until these pathways September 2011 | Volume 23 | Number 7 NURSING CHILDREN AND YOUNG PEOPLE . At 24 weeks' gestation the fetus is regarded as viable. Pseudoglandular period: Day 52 to 16 weeks gestation Formation of the major conducting airways and terminal bronchioles. Each bronchiole ends with two or three terminal sacs or primitive alveoli. are narrowed or blocked. including pulmonary insufficiency and predisposition to respiratory illness.

and will need intervention and help sooner. A child's diaphragm is flatter in shape making each contraction less efficient than that of the more mature young person. toxins. When the attack begins. normal breathing air enters through the child's nose. Eventually the child will begin to tire and start breathing less. Oxygen is needed to support normal metabolism and. via the interface between alveoli and capillary. page 30). larynx and into the trachea. as part of that process. some studies have suggested that decreased lung function can occur early. carbon dioxide . swimming.Continuing professional development develop. the natural response to a sensation of being short of breath is to become frightened. Now do time out 2. Because more air is being shifted in and out of the lungs more CO^ is washed out and the CO^ level will initially drop. the poorer their functional reserves. or inhaled substances. breathing is automatic and the child is usually unaware of the process. 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). Although most children will grow out of their asthma. The CO^ will start to rise and the pH will drop (respiratory acidosis).in some children . The body chemistry works best in a narrowly defined pH of 7. it may have an impact on the child's growth and development. With respiratory insufficiency the 0^ will drop (hypoxemia). where it is warmed. the child will need to work hard to breathe and maintain his or her blood gas. Appreciating the developmental differences in a child's anatomy and physiology underlines the fact that children are not small adults. which will help eliminate carbon dioxide. singing and . which branch off and become microscopic and terminate in tiny. In infants the ribs lie horizontally and the shape of the thorax is circular. such as in response to infections. In infancy the chest wall is thin with little muscle to stabilise it and. To maintain ventilation. moistened and filtered in the nasal cavity before travelling through the pharynx. This can lead to hyperventilation. this is called bronchospasm (Dixon ef al 2009) (Figure 3. the swollen narrowed airways of the asthmatic child having an attack causes airway turbulence and an audible wheeze.breath-holding behaviour. 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. This changes and by approximately six years of age the thorax is ellipsoidal in shape. while the pH may rise (respiratory alkalosis). In contrast. The respiratory system serves a vital function in maintaining metabolic homeostasis. It involves inflammation of the airways and airway reactivity causing a contraction of the bronchioles. breathing and homeostasis of the child? Breathing Although there is learned conscious override when children learn to control their breathing to enable speaking. 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.a waste gas . Anatomical differences List at least five differences in the anatomy of the young child compared to that of the adolescent. The situation can deteriorate if the asthma attack is not managed well. September 2011 | Volume 23 | Number 7 Defining asthma Asthma is a chronic condition that has periods of quiescence and exacerbation. Using the information provided. how can asthma change the airways. thin-walled sacs called alveoli (Tortora and Derrickson 2009).45 (Dixon ef al 2009). Because asthma causes bronchospasm and obstruction the patient cannot exhale completely which can result in air trapping and hyperinflation.35-7. such as pollen or tobacco smoke. The NURSING CHILDREN AND YOUNG PEOPLE . as a result. 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 asthmatic child may present with an altered blood gas depending on the severity and duration of the attack.is produced. passive. is highly compliant. This gas exchange is performed in the lungs. The asthmatic child can get into respiratory difficulties quickly. From the trachea the airways divide into the left and right main bronchi and further divide into increasingly smaller diameter airways called bronchioles. It results from a complex chain of events involving a number of cells and pathophysiological mechanisms. Although it may not change further with ageing (Chung 2011). A nurse who is aware of the detail of a child's respiratory system will understand that the younger the child. In quiet. To compensate for this instability infants use their abdominal muscles to assist with breathing. 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. 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.

even small changes can limit the amount of air that can flow through the bronchioles. When the child's condition improves. Normally a troublesome cough. particularly in infants and those under five years of age. Continuous. and children may become uncommunicative because they do not have the breath to speak. Babies can wheeze but because not all wheezes are caused by asthma. because of the altered anatomy of the ainways which results in a variable and reversible airflow obstruction: Tachypnoea. page 31). Relievers The first medicines used for children with mild intermittent asthma are treatments known as 'relievers' these are short-acting beta^ (ß^) agonists. parents might experience frustration that their infant is in and out of hospital with no diagnosis. Verbal and cognitively aware children might complain of a tight chest. Sinus Larynx Trachea Right lung Diagnosis Diagnosis can be difficult. For practical reasons these methods are not used in children under the age of five. a school-age child and a young person aged 14 (a suggested answer is on page 34).inflammatory responses. They provide relief from distressing symptoms of asthma during an acute attack. a preschool child. which can further block the airways. Oedema develops in bronchial tissue. In an asthma attack the inflammation becomes persistent and a number of changes occur in the ainways. epithelial cells slough off the airway wall and mix with the mucus to form thick plugs. are triggered as a result of the action of cells such as B and T lymphocytes. Spirometry and the measurement of peak expiratory flow (PEF) are the lung-function tools most frequently used to measure airflow obstruction in older children. there may be emotional distress and panic. Scottish Intercollegiate Guidelines Network 2011) (Table 1. neutrophils. because of the diameter of a child's ainway. Also. Asthma can affect children of all ages although it is hard to diagnose under the age of three (Amado and Portnoy 2006). Use of accessory muscles (seen as nasal flare. mucus secretion increases. macrophages and the chemical mediators produced by cells. mast cells. The smooth muscle contracts and. abdominal breathing and in-drawing of the musculature of the thoracic cage). Now do time out 3. on clinical symptoms and observation of features prevalent in asthma during clinical examination. Vital signs Define asthma to an anxious parent in layterms. which result in an attack. shoulder fixing. an infant aged three months. including restlessness and breathlessness. a toddler. 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. In the UK they are usually colour-coded Figure 2 Asthma attack symptoms The following are signs of respiratory distress. Children should begin treatment at the stage most appropriate to the severity of their symptoms. Frequent attacks can result in permanently narrowed airways. Bronchi Treatment and management Because there is no cure the aim of managing asthma is to achieve control of the condition by using the NURSING CHILDREN AND YOUNG PEOPLE September 2011 | Volume 23 | Number 7 . he or she should be maintained on the lowest step that controls their symptoms. eosinophils. instead. high-pitched musical-like wheeze because of airway turbulence. A diagnosis is based. The approach to asthma management allows treatment to be stepped up or down as required (British Thoracic Society. an infant just under a year. head bobbing. Construct a tabie of the average and normal vital signs of heart rate an(d respiratory rate for the following.

There is marginal evidence that it has some good effect. i M September 2011 | Volume 23 | Number 7 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). It is a new generation of medicine. Preventers For children who do not have their asthma sufficiently well controlled with a pro re nata (PRN) reliever. mood swings. They are regarded as suitable for children under 12 years (NICE 2007). Although the effective dosage will vary from child to child. ß^agonists are bronchodilators with a rapid onset of action. LABAs work by relaxing smooth muscles and are taken one or twice a day. Mucus Increased mucus blue. The effectiveness of these medicines builds up with time. In the UK. The effects of long-term exposure to steroids are not fully known (Sridhar and Widened blood vessels Blood vessels McKean 2006). NICE guidance does not recommend it for children under 11 years of age (NICE 2010). preventers can be tried. pink or orange. The Royal College of Physicians devised three questions which have been successfully NURSING CHILDREN AND YOUNG PEOPLE . relaxing the smooth muscle of the bronchioles and relieving bronchospasm. and children with co-ordination problems such as cerebral palsy. 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. Other treatments and add ons Inhaled corticosteroids (ICS) Sometimes called glucocorticoids. They work by blocking the binding of leukotrienes to the receptors on bronchial smooth muscle. for most children they are effective at low doses. Example medications include beclometasone and budesonide (Asthma UK 2010). 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. such as prednisolone. heartburn or indigestion and on adrenal function. and should only be prescribed for patients over 12 years and the child should be monitored by senior doctors (NICE 2010). 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. which are important mediators of inflammation in the upper and the lower airways. has a range of side effects.I Continuing professional development 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. They are administered by a metered dose inhaler (MDIs). As they do not have anti-inflammatory action they are used in conjunction with an inhaled steroid. brown. but this needs to be balanced against not inconsiderable side effects (Seddon ef al 2006). when compliance is good these drugs reduce inflammation in the airways (Asthma UK 2010). such as salmeterol. children with learning disabilities. preventers can be colour-coded red. Leukotriene receptor antagonists Leukotrienes are a group of chemicals produced by mast cells. these are another anti-inflammatory therapy for the treatment of a child's asthma symptoms. They may be associated with slower growth and there are other side effects on the flora of the mouth. Oral steroid therapy. Preventers decrease the distressing symptoms of asthma. Contracted muscle Muscle Swelling and inflammation Long-acting ß^ agonists (LABAs) These are an add-on therapy for children aged more than five years and can be used to improve symptom control. beige. Pocket-size breathactuated inhalers can be used for co-operative young people. improve lung function and reduce airway reactivity to triggers. Theophylline The role of xanthines as an add on is controversial. is given with caution with young children as a rescue therapy and only under the direction and review of a senior clinician. They help to reduce inflammation in the ainways.

and Scullion 2005) Add inhaled LABA. Benefit from LABA but control still inadequate . 200mcg is an appropriate starting dose for many patients. Add an inhaled steroid 200-800 micrograms (meg)* daily (400mcg is an appropriate starting dose for many patients). 'Example doses: some children will have medication individually prescribed. Maintain a high dose inhaled steroid at 2. Inhaled short-acting ß^ agonist as required.continue LABA. No response to LABA . leukotriene receptor antagonist or slow release theophylline. Add inhaled steroid 200-400mcg daily or leukotriene receptor antagonist if an inhaled steroid cannot be used.continue LABA and increase steroid dose to 800mcg/day . In children aged two to five years consider trial of leukotriene receptor antagonist. for example. and oral ßj agonist bronchodilators.continue LABA.000mcg'day.if not already on this dose. for example. Refer patient to respiratory paediatrician.stop LABA and increase inhaled steroid to 400mcg daily. If control still inadequate. Refer patients to a respiratory specialist. In children under two years consider proceeding to step four. Start at dose of inhaled steroid that is appropriate to the severity of the disease. If control still inadequate. No response to LABA . (Adapted from British Thoracic Society and Scottish Intercollegiate Guidelines Network 2 0 1 1 . institute trial of other therapies. Step 3: add-on therapy Add inhaled long-acting ß^ agonist (LABA). Benefit from LABA but control still inadequate . for example. institute trial of other therapies. Assess control of asthma: Good response to LABA . Start at dose of inhaled steroid appropriate to the severity of the disease.stop LABA and increase inhaled steroid to 800mcg* daily.000mcg/day. Children aged five to 12 years Children aged under five years Inhaled short-acting ß^ agonist as required. Addition of a fourth drug. Step 5: continuous or frequent use of oral steroids Use a daily steroid tablet in the lowest dose providing optimal control. leukotriene receptor antagonist or slow release theophylline. Assess control of asthma: Good response to LABA . slow release theophylline.continue LABA and increase steroid dose to 400mcg/day (if patient is not already on this dose). Referral to specialist respiratory paediatrician. Start at dose of inhaled steroid appropriate to the severity of disease. Consider other treatments to minimise the use of steroid tablets. Consider trials of: Increase inhaled steroid up to 800mcg/day. leukotriene receptor antagonists. Step 4: persistent poor control Consider trials of. NURSING CHILDREN AND YOUNG PEOPLE September 2011 | Volume 23 | Number 7 . Maintain a high dose inhaled steroid at 800mcg/day. Add Inhaled steroid 200-400mcg daily Use other preventer drug if inhaled steroid cannot be used.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^ (ßp agonist as required. Use a daily steroid tablet in lowest dose providing optimal control. Increasing inhaled steroid up to 2.

for example. • Patient education Any therapy is only as good as compliance and concordance with the products. to wash the child's face and rinse the mouth. more medicine is inhaled and the possibility of side effects is reduced. then compare and contrast those with the lifestyle of a child with chronic asthma. They are usetui because they make the aerosols easier to apply and more ettective. demonstrating five long slow breaths in and out ot the spacer. Compare and contrast Consider the usual dauy actixities of a well child. check the fit. « September 2011 | Volume 23 | Number 7 NURSING CHILDREN AND YOUNG PEOPLE . There is evidence that multiple doses of relievers are as good as nebuiisers (Asthma UK 2009). have the parents heard the child coughing? Has the child demonstrated their usual asthma symptoms during the day. Technique Shake the inhaler well. Nebulisers These are small plastic devices that can contain a prescribed drug in solution. it they are awake they may need to be swaddled to prevent them squirming and knocking the inhaler and spacer away. tor example cough. when possible. get down to the child's level. A spacer is a large plastic container. a demonstration on teddy and a few test runs with a placebo will back up the printed information. young children or those with additional needs. overly restraining a child can cause emotional distress that will create problems tor the future. Remove the inhaler and shake again. Now do time out 5. domestically clean is sufficient. wheeze. The three questions are: Has the child had difficulty sleeping because ot their asthma symptoms. It is worth spending time in parent education as good habits learned early might aid compliance later. Their involvement will help to underscore the health message that instructions are only ettective it followed. This process is repeated for each dose of the medicine. If the device is new to the parents and the child. Press the inhaler once and breathe with the child. This is achieved by washing the spacer in warm water with a small amount of household detergent. If the intant or child is prescribed several puffs. However. It the child is old enough they can be involved with this preparation as a game. Conclusion This CPD has introduced the developmental origins of the respiratory systems and considered aspects of the normal growth and physiology of the airways. Although nebulisers should ideally be used in hospital under medical supervision they are sometimes used in GPs' surgeries. complained ot chest tightness or seemed short ot breath? Has asthma intertered with the child's usual daily activities. The use of therapeutic holding is controversial but a therapy can only be effective it administered. tor example playing or school? Now do time out 4. 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). Unless the child is immunecompromised. diagrams and discussion. leaving it on a clean surface to air dry. which may result in the child receiving less ot the drug. I A suggested answer is given on page 34. 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. 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. This is because a higher concentration of the drug may coalesce and result in droplets adhering to the side of the spacer. place the mask over the child's tace and check the seal around the nose and mouth. 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. It is good practice. Apply and check the fit of the face mask on the spacer it the child needs to use one. With the child's consent. hospital emergency departments and on wards. with a mouthpiece at one end and an opening tor the aerosol inhaler at the other. Intants can have their drugs administered while sleeping. It children are very young and uncooperative an assistant or the parents might perform supportive holding. Compliance This is improved if the administration ot medication can be built into a child's routine. it is ineffective to administer them all at one time.Continuing professional development evaluated (Thomas ef al 2009). Spacers only work with an aerosol inhaler. This equipment needs to be kept clean. provide a drink or brush the teeth after administering medication to avoid deposits ot the drug lingering on the face or in the mouth. Fit the inhaler into the opening at the end of the spacer. Spacers A spacer is trequently used tor intants.

10. Primary Care Respirator)' Journal.as thma.luly 8 2011.uk Inhalers for Asthma. Second edition. 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. 164. Living with a Disability: a Message from Disabled Parents. 95. British Thoracic Society. 83-88. 57-6S. It can also be used as a resource for mentors to enhance their awareness of the academic level of those they mentor.) Dixon M et al (Eds) (2009) Nursing the High Dependency Child and Infant. 14. 95. 1. (1.) Chung H (2011) Asthma in childh(xxl: a complex.25-29. www.1. Paediatric Nursing. Korean . 533-541. 5. TAIIS. 32-36. Edinburgh. 6.cc/ilp5b Suggested answers to time out activities on page 34 References Amado M. Child Poverty Action Ciroup. Oxford. 915-922. Fifth edition. or a medical assessment unit following a period of breathlessness? Resources Asthma UK Materials to Help You and Your Patients. 227-231 McKean M. Archives of Disease in Childhood. National Institute for Health and Clinical Excellence (2010) Omaliiumab for the Treatment of Severe Permtent Allergic Asthma in Children aged 6to 11 Years. Current Opinion in Allergy and Clinical Immunology. Arclii\'es of Pédiatrie and Adolescent Medicine. Sridhar A.cc/4xynu British Guideline on the Management of Asthma National Ciinicai Guideline 101. London. Archives of Disease in Childhood.org. 18. 63. http://tiny. Routledge. McComnck MC et a. Annual Review of Public Health. Allergy. Archives of Disease in Childhood.xiet> is more common in children with asthma. iik/how_we_help/schools_early_ years/index. Philadelphia PA. 94. Daly W (2010) Nurse-led asthma services for children and young people: a survey of GPs' views. Elsevier Health Sciences.985-991. ww-vv.Anatomy and Physiology. 32. 24-28.Systemic Reviews Issue I.org/r67.ACTALL consensus report. TAIO. BTS. TA l.) Asthma UK (2009) Asthma Factße. 17. NY. London. (¡44. SIGN. :i4-38. medically attended infection with respirator> s>iic>tial virus during the first year of life. RCN. 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).10. Stoelting R.cc/z25zq Patient. Bracken M et al (2009) The importance of nurse-led hoine \1sits in the assessment of children with problematic asthma. Seddon F et al (200(>) Oral xanthines as maintenance treatment for asthma in children. Paediatric Nursing. 22. Oxford.asthma. Edgecomhe K et al (2010) Health experiences of adolescents with uncontrolled seyere asthma. London. Vuillermin P e( af (2010) An. Preston G (Ed) (2006) A Route Out of Poverty? Disabled People. Allergy. Furness J (2009) Paediatric respirator^' nursing posts in secondary care reduce asthma morbidity'. Wiley-Blackwell. 34. 1-5. Nursing Standard. 10.) Bacharier L el a/(2008) Diagnosis and treatment of asthma in childhood: a PR.(2011) Prematurit>^ an overview and public health implications.uk/info/Povert>articles/Povertyl23/ disability. NICE. Iley K (2008) The impact of asthma on children's lives: a social perspective. Archives of Disease in Childhood. Tortora G. 2.html (Lastaccessed: July8 2011. Work and Welfare Reform. Disability Alliance (2010) Disability Alliance Response R67. 8. 9. G'i.April 21.org. Issue 3. Royal College of Nursing (2010) Restrictive Physical Intervention and Therapeutic Holding for Children and Young People: Guidance for Nursing Staff. 5-34 Bal T (2010) Evidence for airway remodeling in chronic asthma. 2. Primary Health Care. NURSING CHILDREN AND YOUNG PEOPLE September 2011 | Volume 23 | Number 7 . 94. 101-105. Malik G et al (2010) Changing trends in asthma in 9-12 year olds between 1964 and 2009. Jeffcry K (2010) Supportive holding or restraint: terminology and practice. 8. 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.html (Last accessed: . Broady J (1999) Improving schools' asthma policies and procediores. McKean M (2006) Nedocromil sodium for chronic asthma in children Cochrane Database of Systematic Reviews. 367-379. 20 .uk/ guidelines/fuUtext/lOl BurchardI T (2006) Changing Weights and Measures: Disability and Child Poverty.cc/08gau British Thoracic Society Nebuliser Treatment Best Practice Guideline. (i. 22.8. New York. London. http://tiny. NICE. 96. 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. Practice profile Now that you have read the article you might like to write a practice profile.It has reviewed asthma at a basic level for students and junior staff.htm (Last accessed: July 8 2011.ssessing asthma control in routine clinical practice: u.loumal of Paediatrics. but provision is variable. 1.org. Guidelines to help you are on page 36. Frost S.se of the Royal College of Physicians '3 Questions'. iik/alLabout_asthma/factfUes/ index. Nursing Standard. 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. London. Wiley Publishers.sigaac. Derrickson B (2009) Principles of .co. ScuUion J (2005) A proactive approach to asthma. . Archives of Disease in Childhood.82-86. 624-629. http://tiny.disabiiit>alliancc. heterogeneous disease. Chapter 4. 780-784. 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 . Portnoy J (2006) Diagnosing asthma in >ouiiK children. www. http://tiny. 8. cpag. Carrent Opinion in Allergy and Clinical Immunology. Anderton J. Twelfth edition.il. Scottish Intercollegiate Guidelines Network (2011) Briti'ih Guideline on the Management of Asthma.cc/lqtdh The Childhood Asthma Test http://tiny. London. Cochrane TMabase of . Asthma UK (2010) Schook and Earty Years. Thomas M et al (2009) A. Miller R (2007) Basics in Anaesthesia. TilUe-Lehlond 1 et a/(2008) Airway retnodelling is correlated with obstruction in children with severe asthma. www.Asthma. wu-w. MacGregor J (2008) Anatomy and Physiology of Children.12.htm (Last accessed: April 2011. NICE. 3.

Continuing professional development Suggested answers to time out activities Time outs 1 and 2: answers can be found in the text and Box 1. circumstances. Participates in games and sports. Computer keyboards could be used. Has to sleep without toy teddy as a dust mite precaution. falls asleep before bedtime medicines. This has made staff and parents anxious. Secure in the friendships of peers. less acute. In the past. The child with asthma may not have the breath or the energy to participate in a lengthy two-way interaction. Additionally. Is slow to eat because higher respiratory levels make chewing. Sleeps with stuffed toy teddy. 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. Another idea is to engage and agree simple signs. Eats packed lunch. or recourse to a pad of paper for children who are cognitively advanced. Paces activity. Runs in school playground. relieve anxiety. breathless in the shower. questioning. Has a positive body image. Time outs 3 and 4: see tables below. Walks. and kiwi fruit yogurt. and make the child feel valued and importcint. Strategies that could be used include: closer observation and taking more cues from body language. Time out 3 nal range values and indicators of concer Example range of heart rates depend on the age of the child. Unable to take a turn to clean out school hamster cage. September 2011 | Volume 23 | Number 7 NURSING CHILDREN AND YOUNG PEOPLE . drinks a range of cordials and can share some peanut brittle with some friends. Poor body image and lack of confidence. summeirising. active listening. cycles or ains to school with fnends. or phrasing them in such a way that the questions only require a short answer. Disturbed when moved off high pillows. Cleans out school hamster cage. Stands out as little as possible. takes relievers. Rushes through homework before playing football with friends. Child awakes feeling refreshed. which alleviates the need to rush in to fill the pauses in the conversation. has had allergic reactions to muesli bake. children's nurses can enable successful and open communication by using strategies such as: making the overture. Is tired and makes little attempt with homework. Has allergy to fur and dander. lentil curry. swallowing and breathing difficult to co-ordinate. keeping the questions closed so the child only has to say 'yes' or 'no'. Time out 5: Under normal. Asthma may make a child temporally aphasie because they are so breathless but that child still has communication needs and wants to be heard. setting the context. paraphrasing and bringing the interaction to an acceptable closure. Good communication skills help to reassure the child. state of arousal and level of health and fitness (Breaths per minute) If tachypnoeic. state of arousal and level of health and fitness Example range of respiratory rates depend on the age of the child. Enjoys breakfast before school. Eats school dinners. giving the child more time to answer. 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. Has car ride to school with parent. Has no breath or energy to run in the playground or participate fully in games and sports. reflecting.

Using an A4 envelope. Middlesex H A l 3BR by July 2012. Jenny. then cut out and send it in an envelope no smaller than 9x6 inches to: Practice Profile RCN Publishing Company Freepost PAM 10155 Harrow. This forms the basis of her practice profile. • (Ampíete all of the requirements of the cut-out form provided and attach it securely to your practice profile.co. • • Feedback is not provided: a certificate indicates that you have been successful.Continuing professional development Practice profile What do I do now? 'n Using the information in section 1 to guide you. Failure to do so will mean that your practice profile cannot be considered for a certificate. which is: understanding childhood asthma and the development of the respiratory tract. What have I learnt from this article? . Framework for reflection Study the checklist (section 3). She makes a conscious decision to pay attention to her own body language. the title of the article.ensuring that you have related it to the article that you have studied. _ Write 'Practice Profile' at the top of your entry followed by your name. Excunples of practice profile entries • Example 1 After reading a CPD article on 'Communication skills'. See the examples in section 2. that she will sit next to her patients when talking to them. 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'. Harrow. a protocol for dressing wounds was established which led to a reduction in wound infections in her ward and across the directorate. need to explore or read about further. a senior staff nurse on a surgical ward. and the article number? Have you written between 750 and : i 2. RCN Publishing Company. Amajit used this experience for her practice profile and is now taking part in a region-wide research project. 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. and the article number. Type 'Practice Profile' in the email subject field to ensure you are sent a response confirming receipt.) 3. which is NCYP8. Please do not staple your practice profile and cut-out slip . write a practice profile of between 750 and 1. You are entitled to unlimited free entries. your name. posture and eye contact. Example 2 After reading a CPD article on 'Wound care'. now. or can I do. Freepost PAM 10155. You can also email practice profiles to practiceprofile@ rcnpublishing. 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.000 words . Amajit.uk. A certificate is awarded for successful completion of the practice profile.paper-clips are recommended.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.To what extent were the intended learning outcomes met? • What do I know. You must also provide the same information that is requested on the cut-out form. the title of the article. You will be informed in writing of your result. Keep a copy of your practice profile and add this to your professional profile copies are not returned to you. send for your free assessment to: Practice Profile. and notices that communication with patients improves. 1. a practice nurse. Following an audit which Amajit undertook. 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 . reflects on her own communication skills and re-arranges her clinic room so • 1. approached the nurse manager about her concerns about wound infections on the ward.

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