Care of

Child With
Bronchial
Asthma
 Introduction
Bronchial asthma is the most common
chronic lower respiratory disease in childhood throughout
the world. It most often starts early in life and has variable
courses which may progress or remit over time. The word
‘ASTHMA’ is derived from Greek word which meant ‘to
pant heavily’ or ‘gasp for breath’.
Incidence
According to World Health Organization
(WHO)report,2004,300 million people suffer from
asthma around the globe. India has an estimated 15-20
million asthmatics with a prevalence of between 10%-
15% in 5-11 year old children.
 Definition
Asthma is defined as a chronic inflammatory
disorder of the airways which manifests itself as recurrent
episodes of wheezing and cough .It is characterized by
bronchial hyper-responsiveness and variable airflow
obstruction, that is often reversible either spontaneously
or with treatment.
 Classification
• Pollen
Extrinsic • Animal dander
asthma • Dust mite particles

• Chemicals
• Cleaning agents
• Air freshener
Intrinsic • Hot weather, cold weather
asthma • Laughter
• Stress
• Cigarette smoke

• Atopic-IgE mediated,
triggered by allergen
Other • Non-atopic-Non IgE-
classification mediated, triggered by
infection
• Exercise or drug induced
Etiology
unknown

Genetic-family history of asthma, genetic factors, pre-natal

influences

Environmental -Indoor/outdoor air biologics (air pollutants,

pollen, house dust mite, passive smoking), endotoxin, pets,
allergens etc.

Exercise may cause wheezing in children

Other Modifiable Risk Factors- urbanization, obesity, extreme

emotional expression, occupation
 Trigger Factors of Asthma
 Air pollutants like ozone, Sulphur dioxide,
pollen and cold dry air
 House dust, powder
 Smoke
 Strong odors
 Pets with furs
 Certain foods
 Allergic rhinitis or viral infection
 Emotional disturbances or fear of
punishment
 Exhaustion
 Sudden change of climate
Pathophysiology
Exposure to specific antigen

Activated mast cells, t-lymphocytes, eosinophils release histamine,

leukotrienes, cytokines and prostaglandins

Bronchospasm and edema of bronchial

mucosa

Increased bronchial
secretion

Airway inflammation and obstruction

Hyperinflation of lungs and air trapping

Ventilation perfusion mismatch

Hypoxemia
cont…
 Clinical Manifestation
• Recurrent spasmodic cough initially non
productive.
• Dyspnea with prolonged expiration and
wheezing.
• Use of accessory muscles of expiration.
• Increased expiratory rate.
• Tight feeling in the chest.
• Pallor, cyanosis.
• Subcostal and intercostal retractions, drooping
shoulder.
• Restlessness , fatigue.
• In severe attack child shows air hunger, feeble
breath sounds.
• Barrel-shaped chest may be seen.
Acute Asthma Exacerbation

 Status asthmaticus or acute severe asthma or acute

severe exacerbation.
 It refers to an asthma attack that does not improve with
traditional treatment , such as inhaled bronchodilators.
 This attacks may last for several minutes or even hours.
It is a medical emergency and should be treated with
intensive care.
 Symptoms include- tachypnoea, laboured respiration
and use of accessory muscles of respiration,
diminished breath sounds, distressing cough,
decreased ability to speak in phrases or sentences,
anxiety, fatigue, headache, diaphoresis, impaired
mental functioning, muscle twitching.
Cont...co
Asthma Exacerbations are classified as mild, moderate,
severe and life threatening.

• It is characterized by dyspnea only

Mild with activity and pick expiratory
Exacerbation flow(PEF) > 70% of predicted or
personal best.

• It manifests with dyspnea that

Moderate interferes with or limit usual activity
and PEF 40-60% of predicted or
Attacks personal best.

• It is identified when there is

dyspnea at rest , which interferes
Severe Attacks conversation and PEF<40% of
predicted or personal best

• It may cause extreme dyspnea with

Life-threatening inability to talk ,perspiration and
Attacks PEF< 25% of predicted and
personal best
Complications
 The most commonest complication of bronchial asthma is
Emphysema. Other symptoms include-
 severe hypoxemia
 cardiac arrythmia
 Atelectasis
 Pneumothorax
 Bronchiectasis
 Cor-pulmonale
 Respiratory failure
 Congestive cardiac failure
Diagnosis
History taking
Physical examination
spirometry
Sputum test
CT-Scan
Chest X-ray
 Management
 Medical Management
Initial treatment depends on the severity of child’s
asthma .The goal of asthma treatment is to keep symptoms under
control ,meaning that child has:
 Minimal or no symptoms.
 Few or no asthma flare-ups.
 No limitations on physical activities or exercise.
 Minimal use of quick relief (rescue) inhalers.
 Few or no side effects of medication.
Cont……

 Long term control medications: preventive

long term control medications reduce
inflammation in child’s airways that lead to
symptoms. In most cases, these medications
should be taken daily.
 Inhaled corticosteroids: These medications
include fluticasone, budesonide,
beclomethasone.
 Methylxanthines : Theophylline is the most
common drug.
 Leukotriene modifiers: these oral
medications include montelukast, zafirlukast
and zileuton.
 Anticholinergics: Ipratropium bromide.
 Ketotifen
 Cont…
 Medication used for acute relief of
symptoms(Relievers): Quick relief
medications quickly open swollen airways.
They are needed for rapid short-term
symptom relief during asthma attack.
 Inhaled short acting beta-2 adrenergic
agonists(SABA) like salbutamol,
terbutaline, act within minutes and effect
lasts for several hours.
 Oral and intravenous corticosteroids :
these medications relieve airway
inflammation caused by severe asthma. Ex-
Prednisone, Methylprednisolone.
Management of Acute
Asthma Exacerbations
Immediate hospitalization is required considering the condition as medical emergency.
Mild Exacerbation

• Usually treated at home with inhaled short acting beta-2 agonist.

Short course of oral systemic corticosteroids may be required.
Moderate attacks

• May be relieved from frequent inhaled short-acting beta-2 agonist

and oral systemic corticosteroids
Severe attack

• It requires emergency hospitalization and gets partial relief from

frequent inhaled beta -2 agonist .IV inhalation and Adjunctive
therapies are useful
Life-threatening attack

• Managed with immediate hospitalization and intensive care but

gets no relief by frequent inhaled short acting beta-2 agonist. IV
corticosteroids and adjunctive therapies are useful.
Interim management in between
asthma attacks
 Identification of offending allergens and to avoid and
to hyposensitize the allergens.
 Treatment of focal infections ;Ex- tonsillitis,
adenoiditis , nasal polyps, sinusitis etc.
 Chest physiotherapy, postural drainage and breathing
exercise.
 Change environment to avoid environmental
allergens and physiological stress.
 Physiotherapy and counselling of the family and child
guidance clinic or by professional person.
 Parental education about long term home based care,
consent supervision ,emotional support, continuation
of medication ,regular follow up and care of acute
attack.
 Different Inhaler Devices

Inhaled short and long

term control medications are used by
inhaling a measured dose of
medication.
 MDI: It is a pressurized inhaler
that delivers medication by using
a propellant spray.
 It is used for children more than 6
years of age.
 Drugs appropriate for MDI are
beta-2 adrenergic agonists,
steroids, atropine derivatives.
 Cont…

 MDI with spacer: Here MDI is

used with a spacer. A spacer is a
plastic tube that holds the spray
from puffer(inhaler). Using a
spacer improves the chances of
getting more medicine to lungs.
 It can be used for infant and
younger children.
 The drug is administered through
a mouthpiece of the spacer.
 Bronchodilators and steroids can
be administered effectively with
this devices.
 Cont…

 MDI with spacer and mask: A

facemask is attached with MDI and
spacer.
 It is useful in infants who can not
breathe through mouth .
 Maintain inhalation efficiency.
 Bronchodilators and steroids can be
administered effectively with this
devices.
 Cont…

 Dry Powder Inhaler(DPI): It is a

breath actuated device that delivers the drug
from the particles contained in a capsule or
blister that is punctured prior to use; eg.
Rotahaler.
 Rotahaler is used for steroids and beta-2
adrenergic.
 This device don’t need patient’s cooperation.
 It may be useful for children below 5 years.
 Easy handling and management.
 Portable.
 Cont…

 Nebulizer: The nebulizer transforms

liquid medicines into particles.(eg;
aerosol, mist)breathable through a
mouth piece or mask.
 A nebulizer kit consists of an air compressor,
nebulizer cup, mouth piece or mask, and
measuring device for medication.
 Provides therapy for patients who cannot
use other inhalation
modalities(MDI,DPI),sick patients, very
young infants.
 Allow administration of large doses of
medication.
 Drugs available for nebulization are beta-2
adrenergics, steroids, atropine derivatives.
 Elimination of Trigger
Factors
• Keep the children’s room clean and dust free.
• Use light cloth sheets as curtains.
• At home, things should be cleaned periodically and in
absence of the child near vicinity.
• Pets should be kept at distance from the child.
• Avoid certain plants ,which have allergic pollens in the house
or surrounding.
• Avoid to refrain from excessive activities if the child feels
fatigue.
• Avoid exposure to strong smell perfume , wet paints
disinfectants and smoking.
• Avoid going to heavily polluted areas for long time.
Patient Education

Infants and
School age puberty
preschooler
Explain the
pathophysiology of Instruct patients about
Do not discomfort asthma to the patients continuing treatment
patient during using simple terms and without interruption.
treatment. Motivate metaphors to make According to their
them in treatment. them understand the understanding educate
Encourage and need for treatment . them about
compliment Instruct patients about pathophysiology and
inhalation to abdominal breathing treatment. Compliment
habituate them cheerfully as if they them to achieve self
gradually were playing some kind fulfilment and lead to
of game self management.
 Nursing Management
 Nursing Assessment- Assess for
 wheezing
 Coughing
 Dyspnea
 Expectoration of sputum
 Shortness of breath
 Tight feeling in chest
 Increase respiration
 Shoulder forward in attempt to use accessory muscles
for respiration
 Nursing Diagnosis- Ineffective airway clearance R/T
bronchoconstriction ,increased mucus production and
.
respiratory infection AEB wheezing, dyspnea and cough.
 goal – Maintenance of airway clearance
 Nursing Intervention –
 Auscultation of breath sounds, record the sound of breath ,eg-
wheezing, rhonchi.
 Keep the patient adequately hydrated.
 Teach and encourage the use of diaphragmatic breathing and
coughing exercises.
 Nurse in fowler or semi fowler’s position.
 Administer humidified oxygen.
 Administer nebulizer as ordered .
 Assist and prepare patient for postural drainage,
 Administer medications as ordered.
 Teach adequate use of inhaler devices.
 Nursing Diagnosis- Ineffective breathing pattern related to
decreased lung expansion AEB dyspnea and wheezing.
.
 goal – promoting effective breathing and gas exchange
 Nursing Intervention –
 Observe for cyanosis, breath sound, wheezing, respiratory rate,
apical pulse, blood pressure, peak expiratory flow.
 Obtain pulse oximetry.
 Monitor and record vital signs.
 Auscultate breath sounds and assess airway pattern.
 Encourage deep breathing and coughing exercises.
 Encourage increase in fluid intake.
 Encourage opportunities for rest and limit physical activities.
 Nursing Diagnosis- Activity intolerance R/T imbalance
between oxygen supply and demand AEB reduced daily
.
activity and exercise tolerance.
 goal – promoting optimum activity and relieving fatigue
 Nursing Intervention –
 Monitor vital signs and assess motor function .
 Note contributing factors of fatigue.
 Evaluate degree of deficit.
 Ascertain ability to stand and move about.
 Assess emotional and psychological factors.
 Avoid topics that irritate or upset patient.
 Provide environment conductive to relief of fatigue.
 Encourage patient to restrict activity and rest in bed as much as
possible.
 Plan care with rest periods between activities,
 Monitor vital signs before and after activity.
 Nursing Diagnosis- Parental fear and anxiety R/T child’s
.
hospitalization and breathlessness.
 goal – relief of parental anxiety
 Nursing Intervention –
 Establish trust relationship.
 Encourage them to express the concern.
 Explain the pathophysiology of asthma and possible causes ,eg-
smoking, perfume.
 Explain all procedures to the child.
 Explain effect of medication and need of compliances.
 Nursing Diagnosis- Deficient knowledge due to insufficient
. information on child’s condition.
 goal – parent education
 Nursing Intervention –
 Determine parent’s level of understanding.
 Encourage them to verbalize their queries.
 Teach the techniques of using inhaler devices.
 Inform them about trigger factors and need for minimizing those
factors.
 Involve the parents in child care.
 Teach the importance of follow up and routine health check up.
 Nursing Diagnosis- Risk for deficient fluid volume R/T
. difficulty in taking fluids ,insensible fluid loss from
tachypnea and diaphoresis.
 goal – maintenance of fluid volume
 Nursing Intervention –
 Assess for signs of dehydration.
 Monitor intake and output daily.
 Maintain IV infusion as prescribed.
 Encourage oral fluids when capable.
 Provide a humidified environment to maintain hydration.
 Correct dehydration slowly as overhydration can cause
increased accumulation of intestinal pulmonary fluid.
 Nursing Diagnosis- Risk for suffocation R/T between
. individual and allergens ,bronchospasm ,mucus secretions
and edema.
 goal – prevention of suffocation
 Nursing Intervention –
 Educate the parents to avoid the trigger factors of asthmatic
episodes.
 Eliminate allergens and other stimuli from the environment.
 Prevent child’s exposure to smoke,
 Administer bronchodilators to relive bronchospasm.
 Teach parents to use inhalers when prescribed and emergency.
 Provide high fowler’s position for optimum lung expansion.
 Monitor vital signs before and after administration of IV
aminophylline infusion if prescribed.
 Reduce fear for anxiety to decrease respiratory efforts.
 Nursing Diagnosis- Risk for injury(respiratory
. acidosis/electrolyte imbalance)R/T hypoventilation,
dehydration.
 goal – prevention of complications(respiratory acidosis or
electrolyte imbalance)
 Nursing Intervention –
 Monitor ABG values .
 Administer sodium bicarbonate as prescribed to prevent or
correct acidosis.
 Prevent vomiting and dehydration.
 Employ measures to improve ventilation like timely inhaler use,
high fowler’s position ,adequate rest etc.
 Monitor serum electrolytes frequently.
 Monitor IV infusion at prescribed rate.
n

 Expected outcome
1. child will exhibit signs of normal respiration ,optimum
activity ,adequate hydration and no risk of suffocation and
acidosis.
2. The parents will demonstrate less anxiety, increased
interest in child care and adequate knowledge on home
care of the child.
conclusion

Asthma is not fatal unless severe

complications are developed. Occasionally, a child
with severe acute asthma or status asthmaticus may
continue to adult life as long term chronic illness.
Relatively, the condition has good prognosis.