1. Update Presented by: Katy Zahner BSN, RN, CCRN Georgetown University Nurse Educator Student

2. Objectives At the completion of this module, the learner will be able to:  Describe the pathophysiology, common triggers and clinical manifestations of the child with asthma  Identify current medication and treatment options for the child with an acute asthma exacerbation  Summarize considerations for intubation for a child with asthma

3. Facts  Most common chronic disease of childhood (1 out of 11 children)  2 million Emergency Room visits per year

4. Pathophysiology  Chronic inflammatory disorder of the airways characterize by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness  Results from complex interactions among inflammatory cells, mediators, and the cells and tissues present in the airway  Inflammatory response to stimuli  airway edema and accumulation and secretion of mucus  spasm of smooth muscle of bronchi and bronchioles therefore decreasing diameter  airway remodeling causing permanent cellular changes

5. Triggers  Allergens  Outdoor – Trees, shrubs, molds, pollens  Indoor – Dust or dust mites, mold and cockroach antigen  Exposure to chemicals  Exercise  Cold air – changes in weather  Environment change  Colds and infections  Animals  Medications  Emotions  Conditions – GERD  Food additives  Foods – nuts, dairy  Endocrine – menses, thyroid

6. Clinical Manifestations  Cough – Barking, paroxysmal, irritative, non-productive then becomes rattling and productive  Shortness of breath  Prolonged expiratory phase  Audible wheeze  Cyanosis may or may not be present  Tripod position  Restlessness  Sweating  Hyperresonance on percussion  Clear breath sounds vs. wheezing

7. Care in the Emergency Room  Prehospital care  Physical exam  Peak Flow  Children with SPO2 < 92% often require more aggressive treatment and likely admission  “Silent chest” = severe obstruction and is ominous sign  Asthma score  ABG  Radiography  Clinical pathway

8. Pediatric Asthma Score

9. Medications  1 st line therapy  Albuterol  Nebulized  Short acting beta agonist/bronchodilator  2.5mg-5mg q20 min x 3  MDI = 4-8 puffs q20min x3

10. Medications  Albuterol  Intermittent and continuous nebulizer dosing  2.5mg for children 5kg to 10 kg  5mg for children for children for children > 10 to 20kg; and 7.5mg for children > 20kg  Severe exacerbations 0.5mg/kg/hr up to 20 mg/hr  Drawback - tachycardia and jitteriness

11. Medications  Ipratropium  Anticholinergic  Acts synergistically with albuterol. NOT as a single agent  250-500mcg + beta agonist x 1-3

12. Medications Corticosteroids  Cornerstone therapy alongside beta agonists  Dexamethasone has been proven to be just as effective  Effective for both acute and chronic inflammation  Work synergistically with beta agonists  Steroids increase the expression of beta agonist receptors and prevent their downregulation when beta agonists are administered

13. Medications Steroids  Methylprednisolone  1mg/kg divided q12  MAX 1 time dose – 240mg  Prednisone  1-2 mg/kg/day  MAX 1-time dose 60mg/day  Dexamethasone  0.6-1.0 mg/kg PO, IM, IV  MAX dose 16mg

14. Medications Other Medications Used:  Racemic epinephrine – Bronchiolitis and Croup  Epinephrine – RESERVED FOR SEVERE EXACERBATIONS  Terbutaline – Parenteral, for severe exacerbations  Aminophylline – No longer recommended  Magnesium Sulfate – Associated with hypotension  Montelukast – Not recommended in acute asthma

15. Respiratory Failure  Poor response to therapy  Rising PaCO2 45-50 mmHg  Severe hypoxia (PaO2 <60)  Waning mental status or fatigue  Impending respiratory arrest  Cardiopulmonary arrest

16. Respiratory Failure – Now What?  BiPAP  Heliox  Intubation  Preoxygenate  IV access  Fluid bolus  ETT (age in years / 4 + 3.5)  Rapid sequence intubation  Ketamine

17. Intubation Vent settings  SIMV  Vt = 5 to 6 ml/kg  Respiratory rate = Half normal for age  I:E ratio = 1:3  PEEP = 0-3cmH2O

18. Review  A 6 year old child presents to the ER with asthma exacerbation. Which of the following medications would be considered as first line therapy? Select all that apply. a) Albuterol b) Montelukast c) Turbutaline d) Corticosteroids e) Ipatropium with albuterol Answer – a, d, e

19. Review  Which of the following is an indication of impending respiratory failure in a child with asthma? Select all that apply. a) ABG pH 7.38, PaCO2 45, PaO2 83 b) Clear diminished breath sounds c) Coarse expiratory wheeze d) Peak flow of 400 e) Child sitting in tripod position Answer – a, b

20. Review  A mother presents to the ER with her 7 year old son who is complaining of shortness of breath. The mother states her child has asthma and was diagnosed at age 4. Which of the following triggers likely contributed to the child's asthma exacerbation? a) Seasonal changes – pollen b) Cats c) Cockroach feces d) Food e) All of the above Answer - e

21. THANK YOU!