Explainers

Nursing Children with Asthma


Asthma is a chronic disease that can not only be life limiting, but life threatening. The World Health Organisation defines asthma as “a disease characterised by recurrent attacks of breathlessness and wheezing, which can vary in severity and frequency from person to person”.  In Australia, asthma affects between 14 and 16% of children, making it one of the more common chronic illnesses experienced by children.

Signs and Symptoms of Asthma

In recognising asthma in children you might notice signs of respiratory distress. They may have costal /intercostal recession or a tracheal tug. Nasal flaring or head bobbing in younger children may also be apparent.

On auscultation of the chest, reduced air entry and/or wheeze may be heard. Often in cases of asthma exacerbation, an audible wheeze can be heard without the need for a stethoscope. A child may be unable to speak in sentences or even may be short of breath just walking a short distance. BEWARE of the silent chest. If there is no audible wheeze and no obvious breath sounds (listen to common lung sounds), this does not mean the child isn’t having an asthma attack –it could mean they are having a severe asthma attack.

History is important when assessing asthma. Is there any family history of atopy? Does the child usually need an inhaler and if so, when did they last need it? Any previous ICU admissions? Any viral prodrome?

On presentation to ED, many children may already have seen a GP or commenced treatment at home. Assessing the child in regards to previous recent treatment is also useful to assess treatment efficacy. A child who has had back-to-back Salbutamol at the GP’s surgery may need more than just six puffs of his inhaler.

Although sometimes the diagnosis of asthma in younger children is sometimes difficult, the National Asthma Council has developed the below table to aid clinicians in decision-making. The RCH Melbourne’s Asthma Guidelines also advise to consider bronchiolitis as an alternative in children under 12 months – in these children, Salbutamol will provide little therapeutic relief.

 

Asthma more likely Asthma less likely
More than one of:

  • wheeze
  • difficulty breathing
  • feeling of tightness in the chest
  • cough
Any of:

  • symptoms only occur when child has a cold, but not between colds
  • isolated cough in the absence of wheeze or difficulty breathing
  • history of moist cough
  • dizziness, light-headedness or peripheral tingling
  • repeatedly normal physical examination of chest when symptomatic
  • normal spirometry when symptomatic (children old enough to perform spirometry)
  • no response to a trial of asthma treatment
  • clinical features that suggest an alternative diagnosis
AND
Any of:

  • symptoms recur frequently
  • symptoms worse at night and in the early morning
  • symptoms triggered by exercise, exposure to pets, cold air, damp air, emotions, laughing
  • symptoms occur when child doesn’t have a cold
  • history of allergies (e.g. allergic rhinitis, atopic dermatitis)
  • family history of allergies
  • family history of asthma
  • widespread wheeze heard on auscultation
  • symptoms respond to treatment trial of reliever, with or without a preventer
  • lung function measured by spirometry increases in response to rapid-acting bronchodilator
  • lung function measured by spirometry increases in response to a treatment trial with inhaled corticosteroid (where indicated

 

Treatment of Children with Asthma

Global Statistics for Asthma.

Global Statistics for Asthma.

Once the diagnosis of asthma has been established, the usual initial treatment is an inhaled bronchodilator (beta-agonist). Salbutamol is most commonly used. Oxygen should only be used for hypoxia (saturations of  less than 90 %), not for work of breathing or wheeze. With this in mind, a Cochrane review concluded that “holding chambers (spacers) were just as efficacious in delivering beta-agonist relievers as nebulisers”. Use a spacer for all children; smaller ones are easier to use, store and hold. Large volume spacers should only be used with older children. Practically, a smaller spacer can be used for all ages and with good effect.

Salbutamol is either age or weight dependent. As a general rule, children younger than six (or less than 20 kgs) should receive six puffs of Salbutamol via a MDI or 2.5 mgs via a nebuliser. Children over six require 12 puffs or 5 mg. Initially, in an acute presentation, Salbutamol is given as a ‘burst’ –that is every 20 minutes for three doses, then reviewed and given as needed.

Some clinicians also choose to give inhaled ipratropium bromide (atrovent) as an initial treatment. There is some evidence to suggest this may be helpful (Rodrigo and Castro-Rodriguez, 2005 and Munro and Maconochie, 2006). It can be given as a burst with the Salbutamol as an initial treatment.

Prednisolone is also given orally in acute asthma exacerbations. The current RCH guidelines advise 2 mg per kg as an initial dose and then 1 mg per kg per dose per day for two more days. Caution is advised when considering giving steroids to pre-schoolers. The new advice is to give only if the child will be admitted to a children’s ward or ICU with a wheeze that responds to bronchodilators in this age range.

For children who are sicker and are slower to respond to inhaled therapy, IV medications should be considered. IV magnesium sulphate is considered a good option for the management of acutely unwell children. It is a smooth muscle relaxant, although its exact mechanism is unclear. Hospital policies vary but if more than two doses of magnesium are given this is often an indication that admission to a hospital with HDU or ICU facilities is required. The child will at the very least need to be admitted under the care of a paediatrician. IV Salbutamol is also an option and once again is likely to lead to admission. From experience, IV magnesium is used much more commonly than IV Salbutamol due to potential side effects.

Long-Term Treatment of Children with Asthma

Preventative options for children with frequent episodic asthma should be considered. Montelukast (singlair) or a low dose inhaled corticosteroid such as flixitide can be used as first line preventers. Children requiring a preventer should be taken to a GP regularly to help manage their asthma and monitor symptoms and exacerbations.

All patients with asthma, whether visiting a GP’s surgery or an emergency department, should receive a written asthma management plan. There is good evidence that written plans aid education and improve compliance. A safety net for both families and clinicians is good discharge advice, especially advice about when to return to hospital or seek a GP review. If a child needs Salbutamol more frequently than every three hours then review must be sought.

This advice is general in nature and local hospital clinical guidelines should be followed. A good resource for those seeking further information is The Royal Children’s Hospital Melbourne Clinical Practice Guidelines. This site also provides excellent parental handouts.

This article is the second in a series of articles about paediatric respiratory conditions and, ideally, should be read in conjunction with the previous article looking at Paediatric Respiratory Assessment.

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References

  • Davis,T (2015) ‘Asthma-Medical Management’ dontforgetthebubbles.com website accessed 19/12/2015
  • Cates,C,J.Welsh,E.J. Rowe,B.H (2013) Cochrane Review  ‘Holding chambers (spacers) versus nebulisers for delivery of beta-agonsist relievers in the treatment of an asthma attack’ Cochrane library, Cochrane.org.au accessed 14/12/2016
  • Munro,A. Maconochie, I (2006) ‘Best Evidence Topic Reports-Beta-agonists with or without anti-cholinergics in the treatment of acute childhood asthma?’ Emerg Med J 23(6):470
  • National Asthma Council Australia ‘Australian Asthma Handbook’ asthmahandbook.org.au  accessed 16/12/2016

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