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What is asthma?
a chronic inflammatory disorder of the airways in which many cells play a role
ex: mast cells
T lymphocytes

a complex disorder involving biochemical, immunologic, infectious, endocrine, and psychologic factors
In children that are susceptible, inflammation causes recurrent episodes of?
chest tightness
(occurs esp. at night or in the early morning)
Asthma episodes can be associated with airflow limitation or obstruction that is?
reversible either spontaneously or with treatment
The inflammation also causes an increase in bronchial __________ to a variety of stimuli.
The four categories of asthma are?
mild intermittent
mild persistent
moderate persistent
severe persistent
The mild intermittent category has the least number of?

frequency or intensity until the last category of?
symptoms...symptoms increase in?

severe persistent asthma
Asthma is the most common chronic disease of?

school absences...and is responsible for a major portion of pediatric admissions to the? the primary cause of?

ER and hospital
What is the strongest predictor for developing asthma?
IgE-mediated response to common aeroallergens
What is atopy?
the genetic predisposition for the development of an IgE-mediated response to common aeroallergens
20% to 40% of children with asthma have no evidence of?
allergic disease
What contributes to increased airway reactivity in asthma?

bronchospasm and obstruction antiinflammatory agents are the key component in treating asthma....another important component of asthma is?
What mechanisms are responsible for the obstructive symptoms in asthma?
inflammation and edema of
the mucuous membranes
accumulation of tenacious
secretions from mucous
glands, and
spasm of the smooth muscle of
the bronchi and bronchioles
which decreases the
caliber of bronchioles
Asthma Severity Classification in Children 5 Years of Age and Older: Clinical Features Before Treatment or Adequate Control

Step 1: Mild Intermittent Asthma
Symptoms less than twice
Nighttime symptoms less than
2 times monthly
PEF or FEV1 is greater than
or equal to 80% of
predicted value
PEF variability less than 20%
Asthma Severity Classification in Children 5 Years of Age and Older: Clinical Features Before Treatment or Adequate Control

Step 2: Mild Persistent
Symptoms greater than 2 times
weekly, but less than one
time a day
Nighttime symptoms greater
than 2 times a month
PEF or FEV1 is greater than
80% of predicted value
PEF variability 20% to 30%
Asthma Severity Classification in Children 5 Years of Age and Older: Clinical Features Before Treatment or Adequate Control

Step 3: Moderate Persistent
Daily symptoms
Nighttime symptoms greater
than 1 night per week
PEF or FEV1 is greater than
60% to less than 80% of
predicted value
PEF variability greater than
Asthma Severity Classification in Children 5 Years of Age and Older: Clinical Features Before Treatment or Adequate Control

Step 4: Severe Persistent
Continual symptoms
Frequent nighttime symptoms
Peak expiratory flow (PEF)
or forced expiratory
volume in 1 second (FEV1)
is less than or equal to
60% of predicted value
PEF variability greater than
Triggers tending to precipitate or aggravate asthmatic exacerbations include?
Outdoor: trees, shrubs,
weeds, grasses, molds,
pollens, air pollution
Indoor: dust or dust mites
mold, cockroach

Irritants: tobacco smoke,
wood smoke, odors, sprays
Exposure to occupational
Cold air
Changes in weather or
Environmental change: moving
to new home, starting new
school, etc.
Colds and infections
Animals: cats, dogs, rodents
Medications: aspirin,
nonsteroidal antiinflam-
matory drugs (NSAIDS),
antibiotics, B-blockers
Strong emotions: fear, anger,
laughing, crying
Conditions: GERD,
tracheoesophageal fistula
Food additives: sulfite
Foods: nuts, milk/dairy
<Endocrine factors: menses,
pregnancy, thyroid disease>
Nursing Alert!

Airflow is determined by what 5 factors?
airway lumen size
degree of bronchial wall
mucus production
smooth muscle contraction
muscle hypertrophy
Pathophysiology of asthma?

airway resistance to airflow...because the bronchi normally dilate and elongate during inspiration and shorten on expiration, the respiratory difficulty is more pronounced during what phase of respiration?

smooth muscle arranged in spiral bundles around the airway causes narrowing and shortening of the airway, which significantly increases what?

expiratory phase...increased resistance in the airway causes forced expiration through the narrowed lumen...the volume of air trapped in the lungs increases as airways are functionally closed at a point between the alveoli and the lobar bronchi. The trapping of gas forces the individual to breathe at higher or lower lung volumes?

inspire...this causes fatigue, decreased respiratory effectiveness, and increased oxygen consumption...the inspiration occurring at higher lung volumes hyper-
inflates the alveoli and reduces the effectiveness of the the severity of obstruction increases, there is a reduced alveolar ventilation with what 4 results?
Clinical manifestations of asthma?
hacking, paroxysmal,
irritative, and nonpro-
becomes rattling and
productive of frothy, clear
gelatinous sputum

shortness of breath
prolonged expiratory phase
audible wheeze
may have a malar flush and
red ears
lips deep, dark red color
may progress to cyanosis of
nail beds or circumoral
sweating may be prominent as
the attack progresses
older children may sit
upright with shoulders in
a hunched-over position,
hands on the bed or chair,
and arms braced
may speak with short, panting
broken phrases

hyperresonance on percussion
coarse, loud breath sounds
wheezes throughout lung
prolonged expiration
generalized inspiratory and
expiratory wheezing;
increasingly high pitched

barrel chest
elevated shoulders
use of accessory muscles of
facial appearance: flattened
malar bones, circles
beneath the eyes, narrow
nose, prominent upper teeth
What are the classic manifestations of asthma?

upper respiratory infection...when does the first attack frequently occur?

respiratory infection...what might some children experience at the front of the neck or over the part of

however...children may experience symptoms that range from acute episodes of shortness of breath, wheezing, and cough followed by a quiet period to a relatively continuous pattern of chronic symptoms that fluctuate in severity...
an attack may develop gradually or appear abruptly and may be preceded by what kind of infection?

between ages 3 and 8 infancy an attack usually follows what kind of infection?

a prodromal itching
Interpreting Peak Expiratory Flow Rates

What does green (80% to 100% of personal best) indicate?
signals all clear...asthma is under reasonably good symptoms are present, and the routine treatment plan for maintaining control can be followed
Interpreting Peak Expiratory Flow Rates

What does yellow (50% to 79% of personal best indicate)?
signals caution..asthma is not well acute exacerbation may be present...maintenance therapy may need to be the practitioner if the child stays in this zone
Interpreting Peak Expiratory Flow Rates

What does red (below 50% of personal best) mean?
signals a medical alert...severe airway narrowing may be occurring...a short-acting bronchodilator should be administered...notify the practitioner if the peak expiratory flow rate (PEFR) does not return immediately and stay in yellow or green zones
Nursing Alert!

Shortness of breath with air movement in the chest restricted to the point of absent breath sounds accompanied by a sudden rise in respiratory rate is an ominous sign indicating?
ventilatory failure and imminent asphyxia
What is the diagnosis of asthma primarily based on?
clinical manifestations
physical exam
lab exams to a lesser extent
radiographic exams are used
primarily to rule out
other diseases and to
evaluate coexisting disease
What is sufficient evidence to establish a diagnosis of asthma?
chronic cough in the absence
of infection or diffuse
wheezing during the
expiratory phase of
What are pulmonary function tests (PFTs)?
a method of evaluating the presence and degree of lung disease, as well as response to therapy
At what age can spirometry be performed reliably?
5 or 6 years old
What does peak expiratory flow rate (PEFR) measure?

peak expiratory flow meter (PEFM)
measures maximum flow of air that can be forcefully exhaled in 1 second...measured in liters per minute using a what kind of meter?
How many zones of measurement are typically used to interpret PEFR?
With the PEFR, each child needs to establish a?
personal best value during a 2-3 week period when child's asthma is stable...child records PEFR at least twice per day..comparisons are made
What is skin testing useful in identifying?
specific allergens...information obtained by the puncture technique correlate better than intracutaneous tests with symptoms and measurements of specific IgE antibody
What is provocative testing?
direct exposure of the mucous membranes to a suspected antigen in increasing concentrations, helps to identify inhaled allergens
What test is used to help identify antigens against various foods and is often useful in determining appropriate therapy?
radioallergosorbent test (RAST)
For skin testing, allay childrens' fears by explaining what is done. How many "pricks" are involved?

one prick on the arm to demonstrate how it feels...what is the skin pierced with?

a drop of allergen...the child can also
a series of 8 on each site, for a total of 30 tests...very young, anxious patients may benefit from?

a stylet rather than a regular needle and syringe...what is then placed on the site?

What creatures are one of the most frequently identified in children allergic to inhalants?
house dust mites
The most important method to eliminate dust mites is to keep the humidity in the house?
lower than 50% which is the level below which dust mites do not survive

(other allergins are cockroaches, mouse
What can be used to help eliminate triggers of an asthmatic attack?
What two classes are asthma medications categorized into?
long-term control meds
(preventer meds)
quick-relief meds (rescue
Define long-term meds (preventer meds)?
achieve and control inflammation
Define quick-relief meds (rescue meds)?
treats symptoms and exacerbations
How are many of the asthma meds given?
by inhalation with a nebulizer or a low-metered dose inhaler (MDI)
What should the metered-dose inhaler (MDI) always be attached to when an inhaled corticosteroid is administered?

to prevent yeast infections in the mouth...spacers are also important for children having a difficult time with inhaler technique
spacer...what is the purpose?
Most inhalers use ____ ______
instead of chlorofluorocarbons in order to protect the ozone layer.
dry powder

(these are breath activated; inhale quickly and deeply)
If infants and very young children are having difficulty with inhalers, they can receive med through an?

normally with mouth open to provide direct route to trachea mixed with saline and nebulized with compressed should the patient breathe?
How are corticosteroids (antiinflammatory drugs) used?
treats reversible airflow
controls symptoms
reduces bronchial hyper-
reactivity in chronic
How may corticosteroids be administered?
Are oral meds metabolized fast or slow?
What is the onset of action of oral meds?
up to 3 hours after administration
What is the peak effectiveness of oral meds?
occurs within 6-12 hours
How may oral systemic meds by given?
for short periods of time
ex: 3- or 10-day bursts to control PERSISTENT or SEVERE PERSISTENT asthma
What are the long-term adverse effects of oral meds?
Cushing syndrome
impaired immune mechanisms
adrenal suppression
What are inhaled steroids used for?

long-term prevention of
suppression, control, and
reversal of inflammation

these meds have few side effects (cough, dysphonia, oral thrush)...which category do these drugs help long-term?
A decreased risk of death from asthma can be achieved by?
regular use of low-dose inhaled corticosteroids
Use of inhaled corticosteroids at low doses DOES NOT have long-term significant effects on?
bone mineral density
ocular toxicity
suppression of adrenal/
pituitary axis
How often should hcps monitor growth of children and adolescents who are taking corticosteroids?
3 to 6 months
What is cromolyn sodium?
a nonsteroidal antiinflammatory drug (NSAID) for asthma

has minimal side effects (occasional coughing with powder...may be given via nebulizer or MDI)
What is the MOA for cromolyn sodium?
stabilizes mast cell
inhibits activation and
release of mediators from
eosinophil and epithelial
inhibits acute airway
narrowing after exposure
to exercise
cold dry air
sulfur dioxide
What is nedocromil sodium?
asthma maintenance drug
has both antiallergic and
antiinflammatory properties
and few side effects
What are some b-adrenergic agonists that are used for treatment of acute exacerbations and for prevention of exercise-induced bronchospasm?
The b-adrenergic agonists can be given via?
oral preparations
parenteral preparations
which form of b-adrenergic med has a more rapid onset...inhaled or oral?
What are the troublesome systemic side effects inhalation of b-adrenergic drugs reduces?
What is the most that inhaled b-adrenergic drugs should be taken for acute symptoms?
not to be taken more than 3 to 4 times daily
What is salmterol (Serevent)?

added to anti-inflammatory
therapy and used for long-term prevention of symptoms, esp. nighttime symptoms, and exercise-induced bronchospasm
a long-acting bronchodilator that is used twice per day...what is it used for?
What is methylxanthines, principally theoplylline?
prevents asthma attacks
relieves symptoms
central respiratory stimulant
increases respiratory muscle
third line agent and not
necessary for treating
asthma exacerbations
may be taken sustained-release oral form, IV, IM, orally..
rectally is seldom used
What levels can theophylline toxicity occur at?
serum levels 20 micrograms/mL or greater
What are side effects of theophylline?
What are early signs of toxicity?
seizures and dysrhythmias
What levels can a patient who is on theophylline experience seizures and dysrhythmias?
greater than 30 micrograms/mL
What are 3 therapeutic managements of asthma?
allergen control
drug therapy
leukotriene modifiers
chest physiotherapy
What are leukotriene modifiers?
mediators of inflammation that cause increases in airway hyperresponsiveness...block inflammatory and bronchospasm effects
What are some examples of leukotriene modifiers?
montelukast sodium
Leukotriene modifers are an oral LONG-TERM therapy (not acute)given in combination with what other 2 meds?


this combination provides long-term control and prevention of symptoms in what category of asthma?
What new leukotriene med is used for the treatment of 12 yo and older?
omalizumab (Xolair)
What is the MOA of omalizumab?

many patients with asthma are atopic (genetically predispositioned) and possess specific IgE antibodies to allergens responsible for airway inflammation
a monoclonal antibody that blocks the binding of IgE to mast cells which eventually inhibits the inflammation that is associated with asthma....this MOA works well as an adjunct to treatment of asthma because?
How is omalizumab (Xolair) administered?
once or twice a month via subcutaneous injection
Omalizumab (Xolair) is an effective therapy for which kind of patients?
patients with symptomatic MODERATE to SEVERE allergic asthma that is poorly controlled with INHALED CORTICOSTEROIDS
What is exercise-induced bronchospasm (EIB)?

5 to 10 minutes after stopping activity...and stops when?
acute, reversible, usually self-terminating airway obstruction that develops during or after vigorous activity...reaching peak when?

another 20 to 30 minutes
What symptoms do patients with EIB display?
shortness of breath
chest pain or tightness
endurance problems during
What is required to make the necessary diagnosis of EIB?
an exercise challenge test in a laboratory
EIB is rare in what type of sports?
ones requiring short bursts of energey
ex: baseball
EIB is more common in what type of sports?
those that involve endurance
ex: soccer
distance running
Why is swimming well-tolerated by EIB children?

it prolongs expiration and increases the end-expiratory pressure within the respiratory tract (essentially pursed-lip breathing)
they are breathing air fully saturated with moisture and because of the type of breathing required in swimming....and why is exhaling under water beneficial?
Asthmatic children and those around them are fearful of the child's participation in strenuous activities and can be taught that?
exercise is beneficial and can be participate in with minimal difficulty, provided the asthma is under control...each case should be evaluated individually
What meds will usually permit full participation in strenuous exercise?
b-adrenergic agents
cromolyn sodium
What does chest physiotherapy (CPT) include?
breathing exercises
physical training
What do these therapies help produce?
physical and mental relax-
improve posture
strengthen respiratory
develop more efficient
patterns of breathing
Breathing exercises (chest physiotherapy) are beneficial because?
they prevent overinflation and improve efficiency of cough
When is chest physiotherapy (CPT) not recommended?
during acute, uncomplicated exacerbations of asthma
The controversial hyposensitization is not recommended for what kind of allergens?
ones that can be eliminated
ex: foods
animal dander
What is the initial dose composed of?

the size of the skin is it injected?

weekly intervals until a maximum tolerance is reached...and then what is the maintenance dose?

5- or 6-week
the offending allergen(s)...and it's based on what? often is it increased?

given at 4-week intervals...this may be extended to what intervals?

three years and then stopped....if no symptoms appear, what is assumed?

treatmentn is reinstituted
Nursing Alert!

Hyposensitization injections should be administered only when?

anaphylactic reaction
with emergency equipment and meds readily available in the event of what reaction?
What percentage of children continue to have asthma through puberty and into adulthood?
Since frequency of asthma attacks are so diverse among each individual, the prognosis for control or disappearance of symptoms varies....the variation goes from rare infrequent attacks to those who are constantly?
wheezing and some are subject to status asthmaticus
What 3 criteria offer a greater liklihood of a poor prognosis?
when symptoms are severe and
symptoms have been present
for a long time
family history of allergy
Even children who outgrow their exacerbations continue to have what?

decreased lung function
airway hyperresponsiveness
and cough as adults....furthermore, airway hyperresponsiveness in adults appears to be associated with?
Death from asthma is rare, the death rate has
_______ over the years.

adolescent, with greatest increase in 10 to 14 data explains why
increased...which age group is most vulnerable?
What are some of the risk factors for asthma deaths (increasing incidence in 10 to 14 years old)?
early onset
frequent attacks
difficult-to-manage disease
history of respiratory
psychologic problems
(refusal to take meds)
dependency on or misuse of
drugs (high use)
presence of physical
stigmata (barrel chest
intercostal retractions),
abnormal pulmonary function
What is status asthmaticus?

a condition in which children continue to display respiratory distress despite vigorous therapeutic measures, especially use of which category of meds?
How does status asthmaticus develop?

pneumonia...which influences duration and treatment of attack...patient usually seen in ER, admitted to pediatric ICU
gradually or rapidly, and often occurs with complicating conditions, for example?
Nursing Alert!

Status asthmatic is a medical emergency that can result in what?
respiratory failure and death if untreated
How does the child act if in severe respiratory distress?
sweats profusely
remains sitting upright
refused to lie down
What might lead one to think a child with status asthmaticus is seriously hypoxic and ER bound?
a child who suddenly becomes agitated, or an agitated child who suddenly becomes quiet
What is therapy for status asthmaticus?
improvement of ventilation
correction of dehydration
and acidosis
treatment of any concurrent
How is the bronchospasm from status asthmaticus relieved?

corticosteroids (either orally or IV)...if the child doesn't respond to these 2 drugs, then give what med?

subcutaneous terbutaline...what other nursing interventions are adm
giving aerosolized short-acting b2-agonists (either intermittently or continuously) along with what other med?

subcutaneous epinephrine (1:1000 at a dose of 0.01 mL/kg with a maximum dose of 0.3 mL, or what other med can be given?

IV fluids
NPO except liquids
monitor child for pulmonary
Nursing Alert!

With status asthmaticus, dehydration should be correctly slowly because?
overhydration can increase accumulation of interstitial pulmonary fluid to exacerbate small airway obstruction
With status asthmaticus, nurse monitors and manages what? (4)

pulse oximetry
blood gases
serum electrolytes
correction of dehydration
electrolyte imbalance

she monitors this with what tools? (3)
With status asthmaticus, what is administered to humidify oxygen?
nasal prongs
Because oxygen is a stimulus for respiration, what might high levels cause?
significantly depressed respirations
What are the recommendations of asthma state concerning antibiotics?

fluids and medications...what is administered via MDI?
antibiotics should not be used to treat acute attacks except when a bacterial infection resulting from another condition such as pneumonia or sinusitis is the attack subsides, what is given orally (2)?

adrenergic agonists...and then discharge and followup care made
Physical assessment of asthma involves the same observations and techniques described in the general discussion of assessment what?
respiratory infection
(Chapter 7)
Characteristics of respiratory involvement are evaluated by? (3)
chest configuration
type of breathing
The goals for the child with asthma and the family are?
Child will not experience an
asthmatic episode
"" exhibit improved
ventilatory capacity
"" maintain optimal health
"" not develop complications
"" will engage in normal
activities for age
"" will receive appropriate
support and education
regarding the disease
and its management
One goal of asthma management is avoidance of?
an exacerbation
Parents are cautioned to avoid exposing a sensitive child to?
excessive cold
excessive wind
other weather extremes
other irritants
foods that provoke irritation
Nurses should advise parents to use other analgesics/antipyretics besides ______ because 2% to 6% of children with asthma are sensitive to it.

NSAIDS and tartrazine (yellow dye number 5, a common food coloring)
aspirin...including aspirin in Pepto Bismol...children with aspirin-induced asthma may also be sensitive to what meds?
Most children can recognize prodromal symptoms well before an attack which is about how many hours?

low-grade fever
itching (esp. in front of the
neck and chest),
6 hours and start therapy...objective signs that parents may observe include which symptoms?
Educating the child about use of equipment that delivers oxygen is a nursing priority as only 7% know what they're doing. For instance, the MDI device delivers meds how?
directly to the teach the child to breathe slowly and deeply
MDI spacers receive the med from the MDI, and THEN the child inhales the med...what else do spacers do?
prevent yeast infections in the mount when inhaled corticosteroids are administered via an MDI
The overuse of B2-agonists is dangerous. Avoid OTC drugs due to toxicity.
What type of immunization is important to receive annually in patients with persistent asthma?
Nebulizers must be kept absolutely clean to decrease chances of contamination with?
bacteria and fungi
What are important breathing tips for children?
promote diaphragmatic
side expansion
improved mobility of chest
Play techniques that can be used for younger children to extend their expiratory time and increase expiratory pressure include what?
blowing cotton balls
Ping-Pong ball on a table
blowing a pinwheel
blowing bubbles
preventing a tissue from
falling by blowing it
against the wall
Define pursed-lip breathing?
involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar's like blowing through a straw
<What is the classification of Vanceril?
corticosteroid (glucocorticoid)

can be used as an inhaler or nasal spray...if used as a nasal spray, have patient clear nose of any secretions before application to increase absorption
<What is the classification of Atrovent?
blocks SNS and causes bronchial smooth muscles to produce bronchodilatio...
decreases pulmonary secretions
<Are Vanceril and Atrovent appropriate for use during an asthma attack?
no...they're NOT fast-acting...they're used to prevent attacks from beginning
<Physician orders Albuterol 3 mg nebulization treatment STAT. What is the rationale for this order?
It's rapid-acting. It's a beta2 agonist and works to open the airways.
Clients may use it before engaging in physical activity that might cause an attack...preventative med
<If a patient's O2 sat was 88%, why was oxygen therapy not ordered?
need to open airway first...the oxygen won't help if airway not open
<What does nurse need to include when teaching about metered-dose inhaler?

2-3 seconds...breathe in slowly in about two or three seconds and then hold for about 10 seconds
how to hold head slightly
back to open airway
gently shake inhaler
keep lips closed while
when pressing down on
inhaler, exhale, then push
down to deliver dose and
then inhale for how long?
<How long should patient wait between puffs with metered-dose inhaler?
1 minute
<Should patient clean metered-dose inhaler?
yes...rinse with warm water only
<If taking steroid in a metered-dose inhaler, what mouth care should be taken?
rinse out mouth to avoid infection...Candida infection
<If the patient has a bronchodilator and a steroid-inhaled medication ordered, the bronchodilator, of course, should be administered first or second?
first...because it will open up the bronchioles and then take the steroid.
<How does nurse evaluate patient's ability to use a metered dose inhaler effectively?
demonstrate coordination and use of MDI
<What is the function of the peak expiratory flow meter (PEFM)?
demonstrates the highest rate that patient can blow air out of the lungs in one second...used to assess changes in pulmonary functions...remove things from mouth and close lips tightly around mouthpiece and keep tongue away from mouthpiece...blow out as hard and quickly as they can and they note the number by the marker...repeat this 3 times and wait 30 seconds in between each time...don't want the patient hyperventilating and passing out...record the highest of 3 readings and do this at the same time everyday...keep a chart....take it 15 minutes AFTER taking medications...establish rate during a 2-3 week period before when not having asthmatic problems...establish peak and watch progression of it gets lower, then they know that they need to change dosage on medication...a peak expiratory flow rate of 15-20% below the expected value for their age, gender, size is common for clients with asthma. Do this twice daily to assess symptoms and adjust drugs to manage inflammation.

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