Itchy trigger finger
The etiology of asthma is unknown; however, it does tend to run in families and there are definite triggers that can set off attacks at certain times. Teaching children to know their triggers can help prevent problems that can influence both the persistence and severity of the disease.
* cigarette smoke
* climate changes (such as extreme hot or cold temperatures)
* dust mites
* environmental changes (such as outdoor air pollution; chemical fumes; combustions devices, such as improperly vented fireplaces, kerosene heaters, gas ranges, or gas space heaters; and exposure to motor traffic emissions)
* animals (such as dogs, cats, and rodents)
* food allergies
* medications (such as beta-blockers, aspirin, nonsteroidal anti-inflammatory drugs, and antibiotics)
* strong emotions
* menses or pregnancy
* gastroesophageal reflux disease
* colds or infections.
Asthma is diagnosed differently depending on the child's age. Diagnosis for children ages 5 and up is the same as for adults. The healthcare provider will start with a medical history, asking questions about prior medications the child has taken, known triggers, a family history of asthma, or a history of eczema. The healthcare provider will then complete a head-to-toe physical exam, concentrating on the lungs. Pulmonary function tests will be done to show how well the child can exhale, including the use of a peak flow meter.
The peak flow meter measures the rate that the child can force air out of his or her lungs. The lower the number, the worse the asthma is. Peak flow meters are used not only to diagnose asthma, but also at home to monitor daily asthma status, to make changes in the medication regimen accordingly, and to help decrease the number of asthma exacerbations.
Diagnosis in children under age 5 is difficult due to the fact that wheezing and coughing can occur in conditions other than asthma such as viral infections. Children under age 5 generally aren't able to complete certain lung function tests due to their age. The healthcare provider may prescribe a bronchodilator if asthma is suspected. If the bronchodilator improves the child's symptoms, then he or she may have asthma.
There's no cure for asthma, but it can be properly managed. After being diagnosed by a pulmonologist, a treatment plan can be instituted to manage symptoms and prevent exacerbations.
Treatment for asthma is very specific for children, including maintenance medications, rescue medications, and immunotherapy. Healthcare providers may use the stepwise approach to step up treatment by adding a medication if they feel that the child's asthma isn't under control. They may step down treatment by lowering medication dosages if they feel it's well controlled.
Long-term control medications, also known as maintenance medications, are generally taken every day even if the child isn't experiencing symptoms. They may also be used seasonally to control symptoms at certain times of the year. Examples of long-term medications include inhaled corticosteroids, leukotriene modifiers, combination inhalers that contain an inhaled corticosteroid plus a long-acting beta agonist, and theophylline (not often used).
Quick relief, or rescue, medications are short-acting bronchodilators that generally give immediate relief of asthma symptoms. The most common is albuterol. Others include levalbuterol and pirbuterol. These medications may relieve symptoms, but they don't prevent an attack from occurring.
Immunotherapy may also be used in which the child receives allergy desensitization shots to control triggers that are caused by certain allergies. These injections may be given once a week to once a month.
Action plan at the ready
A care plan can be taught to school children and parents to help manage their symptoms. According to the CDC, an asthma action plan (also called a management plan) is a written plan that's developed with the family, child, and healthcare provider (see Sample asthma action plan). The goal of the action plan is to prevent asthma attacks, recognize triggers, and, ultimately, reduce ED visits.
A daily log of results is imperative. Many action plans use the zone system, which uses the colors green, yellow, and red (similar to the peak flow meter). Just like a peak flow meter, the zones help recognize worsening symptoms, if medications are working, and whether other factors are making the asthma symptoms worse.
If the child is in the green, or safety, zone, he or she feels good and is managing asthma symptoms to maintain an optimal level of health. The yellow, or caution, zone may indicate worsening symptoms and medications may be needed to bring the child back to the green zone. The red, or danger, zone indicates a flare-up or emergent situation.
The zone system is easy to follow, but requires the parents and child to monitor the child's pulmonary function every day, even twice a day, and at the time of an attack. It's also important to review with the child prescribed medications and how and when it's necessary to use them. By doing this, the symptoms of airway obstruction can be treated before they become acute.
The asthma action plan should also include:
* healthcare provider and ED phone numbers
* triggers that should be avoided
* all medications prescribed, when to use them, and the proper dosage of each one
* any actions necessary before certain activities or exercise.
This information should be shared with all people involved with the child, including teachers, school nurses, coaches, and healthcare providers. For example, if the child starts wheezing in gym class while playing a game, the coach or school nurse will know exactly what to do and treatment won't be delayed. The action plan should go everywhere with the child and be updated as the child grows and medication dosages change.
Another component of the action plan is educating the child's parents. Nurses can help by ensuring that parents understand the significance of reporting their child's asthma diagnosis to their school. The good news here is that federal and state legislation allows children to carry their own inhalers to school. However, parents need to sign a permission slip to allow their child to do so. Nurses can include this information when discharging patients to ensure parents make informed choices regarding their child's action plan.
When a child who's experiencing an asthma attack is brought to the ED, he or she is treated without delay. If the child is wheezing, even slightly, treatment is started immediately. The child is placed on continuous pulse oximetry to keep a close eye on the oxygen saturation level. He or she is given nebulizer treatments and, if necessary, I.V. methylprednisolone.
If the child continues to wheeze after several treatments, he or she is generally admitted. After being admitted, the child will receive nebulizer treatments as ordered, along with methylprednisolone every 6 hours.
When the child's asthma is under control, an action plan can be started or modified to keep an exacerbation from happening again.
Keeping kids happy and healthy!
Asthma can't be cured, but taking a proactive approach and having an asthma action plan can save lives. With a solid action plan and diligent documentation of daily results, we can help children stay healthy and manage their asthma. As nurses, we need to step up, educate, and continually reinforce all of the necessary steps needed to keep asthma under control so these children can live more active and healthier lives.
Use the mnemonic DREAD to teach the signs and symptoms of asthma.
* Reduction of breath sounds
* Expiratory wheezing
* Accessory muscle use
on the web
* American Academy of Allergy Asthma & Immunology: https://www.aaaai.org/conditions-and-treatments/library/at-a-glance/childhood-asthma.aspx
* American Lung Association: http://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-children-fact-sheet.html
* CDC: http://www.cdc.gov/asthma/children.htm
* KidsHealth: http://kidshealth.org/kid/asthma_basics/what/asthma.html
* Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/childhood-asthma/in-depth/asthma/art-20044022
* MedlinePlus: http://www.nlm.nih.gov/medlineplus/asthmainchildren.html
* National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/naci-in-action/napnap.htm
Learn more about it
Hockenberry MJ, Wilson D. Wong's Essentials of Pediatric Nursing. 9th ed. St Louis, MO: Mosby; 2009.
Matsui EC. Environmental control for asthma: recent evidence. Curr Opin Allergy Clin Immunol. 2013;13(4):417–425.
Stelmach I, Podlecka D, Eusebio MO, Grzelewski T, Pietruczuk M. The patents on glucocorticosteroids and selected new therapies for the management of asthma in children: update. Recent Pat Inflamm Allergy Drug Discov. 2014;8(1):41–47.© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. All world rights reserved.