BRONCHIOLITIS AND ASTHMA

PEDIATRIC NURSING

1. BRONCHIOLITIS Presented by Ms Arifa T N Second year M.Sc Nursing MIMS CON

2. INTRODUCTION Respiratory system Upper respiratory parts Lower respiratory parts Children Small Not well developed Very prone to get respiratory infections Bronchiolitis is one of the major infection affecting to child

3. Bronchiolitis It is a serious illness, characterized by inflammation of bronchioles, causing severe dyspnea. Bronchiolitis is an acute viral infection with a maximum effect at the bronchiolar level Infants are the most likely candidates

4. Epidemiology More or less confined to the winter and early spring Primarily a disease of first 2 years of life Peak incidence at 6 month of age Both epidemic and sporadic forms occurs

5. Etiology The exact etiology is not clear Virus : Primary atypical pneumonia, Influenza virus type (A, B and C) Adenovirus Respiratory syncytial virus (RSV) Herpes virus and Parainfluenza virus. Bacteria H. influenzae Pnenumococcus Streptococcus hemolyticus “ Allergy”

6. Risk factors Immunosuppression Very low birth weight Lung disease Severe neuromuscular disease Complicated congenital heart defects

7. Pathophysiology

8. Pathophysiology

9. Pathophysiology

10. Clinical manifetstions Rhinitis Nasal flaring Low grade fever Cough Wheezing Crackles Tachypnea Poor feeding Vomiting Diarrhea Dehydration Irritability Lethargy Poor fluid intake Distended abdomen Cyanosis

11. Investigations History Clinical presentation and chest examinations X ray : Emphysema, Prominent bronchiovascular markings and Small areas of collapse. Overinflated lungs wide intercostal space ELISA ABG analysis Virology

12. Treatment Supportive care at home Respiratory and contact isolation Humidified oxygen therapy Hydration : oral or parenteral Moderate to severe cases : CPAP Medications Bronchodilators (Neb: salbutamol or epinephrine ( racemic or levo ) Corticosteroids Epinephrine Nebulization with hypertonic saline Antibiotics for bacterial origin Antiviral agent ( ribavarin ( Virazid ))

13. Prevention Intramuscular palivizumab ( Synagis ) provides passive immunity to help protect these high-risk infants. A dose of 15 mg/kg is given every 30 days for 5 months beginning in October or November at the onset of the RSV season.

14. Multidisciplinary management Bronchodialators , Expectorents , corticosteroids and oxygen administration Diet therapy Respiratory therapy Occupational therapy

15. Nursing management Assessment Complete health history Examination Rate and character of respirations, breath sounds ( rales , ronchi ) Retractions, Inspiratory and expiratory efforts, Use of accessory muscles etc. Cyanosis Diaphoresis Hydration and poor capillary refill Psychological assessment

16. Nursing diagnosis Ineffective breathing pattern Ineffective airway clearance Activity intolerance Interrupted family process Parental anxiety Risk for injury

17. Planning and implementation Maintaining respiratory function Close monitoring Saline nasal drops Elevation of head end Supplemental oxygen Medications Support physiological function Promote rest and comfort Suction nasal passages before feeding Small and frequent diet Oral and IV fluids for rehydration

18. Reduce anxiety Thorough explanation and daily updation Reassurance Discharge planning and home care teaching Teach proper administration of medications Educate about recurrence and how to recognize symptoms

19. Evaluation The Childs respiratory rate is within normal range and has no signs of respiratory distress Hydration level Feeding Parents express confidence in caring of the child

20. ASTHMA

21. Introduction Asthma is a common chronic disorder in children characterized by bronchial constriction, hyperresponsive airways, and airway inflammation.

22. Definition Bronchial asthma, now regarded as a chronic inflammatory disorder of the lower airway is characterized by bouts of dyspnea (predominantly “expiratory”), as a result of temporary narrowing of the bronchi by bronchospasm , mucosal edema and thick secretions.

23. Most cases have had its origin in the very first 2 years of life. The peak incidence is, however, seen in 5 to 10 years of age group. Boys suffer twice as much as the girls. The illness too is more severe in them. Incidence in school-going age is around2%.

24. Etiology Triggers/excitatory factors Allergy to certain foreign substances Inhalants like pollen, smoke, dust * and powder, Foods like egg, meat, wheat and chocolate, Food additives, and Drugs like aspirin and morphine Respiratory infection: commonly viral Emotional disturbances Exercise: “exercise-induced asthma” Change of climate/weather Puberty changes: Endocrinal changes

25. Predisposing Factors Heredity : A family history of asthma or some other allergic disorder is often forthcoming. Childhood infections like measles and pertussis . Constitution : An asthmatic child is basically labile, highly stung and over conscientious

26. Pathophysiology Factors ending up with lower airway obstruction in asthma include: Mucosal inflammation (especially edema) Excessive mucosal secretions (mucus, inflammatory cells, cellular debris) Bronchial hyperresponsiveness with bronchospasm

27. Types Three types of asthma are: Extrinsic : This is IgE -mediated and precipitated by an allergen Intrinsic : This is non- IgE -mediated and precipitated by a respiratory infection (usually, viral) Mixed : This is usually exercise-induced or aspirin induced

28. Exposure to an allergen which interacts with specific mast cell bound IgE , reaction occur in two phases: Early Phase/Reaction Within minutes, mast cell release histamine, leukotriens C, D and E, prostaglandins, platelet activating factor and bradykinin causing mucosal edema, secretion and bronchospasm Late Phase/Reaction: This is characterized by clinical manifestations of asthma. It follows 3-4 hours later with release of mast cell mediator

29. Clinical features Onset of an asthmatic paroxysm is usually sudden and often occurs at night Asthmatic aura Tightness in the chest, Restlessness, Polyuria or itching A typical attack consists of Marked dyspnea, bouts of cough and chiefly “expiratory wheezing”. Cyanosis, pallor, sweating, exhaustion and restlessness are often present. Pulse is invariably rapid. Children with severe bronchial asthma over a prolonged period may develop a barrel-shaped chest deformity.

30. Diagnosis Clinical profile Detect the responsible allergen . A peak expiratory flow (PEFR) meter is very useful in confirming diagnosis of asthma

31. Treatment Specific Measures Acute Mild Exacerbation Beta2 agonists (oral, inhalation (MDI with spacer) or nebulization ) Prednisolone , 1-2 mg/kg/day (O) or inhalation steroids Acute Moderate Exacerbation Oxygen inhalation until oxygen saturation > 95% Nebulization with beta-2 agonists, every 2minutes for one hour, then 4-6 hourly Prednisolone , 1-2 mg/kg (O) stat and then daily for 5-7 days

32. Treatment Acute Severe (Life-threatening) Exacerbation Immediate oxygen inhalation, Subcutaneous injection of adrenaline Nebulization with beta-2 agonists ( salbutamol , terbutaline ), every 20 minutes and IV hydrocortisone, every 6-8 hourly. Additional Measures Mild sedation: Phenobarbital &Tranquilizers Expectorants to remove excessive secretions Antibiotics Maintenance of fluid and electrolyte balance

33. Types of inhalation devices

34. Status Asthmaticus Status asthmaticus is defined as a state in which an asthmatic patient continues to suffer from dyspnea in spite of administration of sympathomimetic agents as well as aminophylline / theophylline . He is a candidate for receiving treatment in an intesive care unit.

35. Score 0 to 4 : No immediate danger Score 5 to 6 : Impending respiratory failure Score 7 or above : Respiratory failure Clinical respiratory scoring system

36. Nursing management Assessment Identify the child’s current respiratory status first by assessing the ABCs Observe the child’s color, and assess the respiratory and heart rates Auscultate the lungs for the quality of breath sounds Inspect the chest for retractions Attach a pulse oximeter; a SpO 2 reading of less than 92% indicates hypoxemia Assess skin turgor, intake and output, and urine specific gravity. A spirometry reading may be attempted

37. Assess Asthma Management

38. Psychosocial Assessment Assess the child’s anxiety or fear Parents anxiety Concerns about finances, missing work, or other family members at home

39. Nursing diagnosis Ineffective airway clearance Impaired gas exchange Fluid electrolyte imbalances Anxiety/ fear Ineffective family health management

40. Planning and implimentation Maintain airway patency Humidified supplemental oxygen Sitting position Medications Meet fluid needs Oral and IV fluids Intake -output chart Avoid ice beverages Promote rest and stress reduction Group tasks Calm environment Promote relaxation and rest

41. Support family participation Parents involvement in care Reassurance Provide frequent updates Encourage to take breaks as needed Discharge planning and home care teaching Educating parents

42. Community based care Promote asthma management skills Child focused education Health maintenance Environmental control School management

43. Evaluation Reorganization of early symptoms Avoid asthma triggers Childs response to treatment

44. Conclusion

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