update presented by: katy zahner bsn, rn, ccrn georgetown university nurse educator student
TRANSCRIPT
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UpdatePresented by:
Katy Zahner BSN, RN, CCRN
Georgetown University Nurse Educator Student
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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
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Facts
Most common chronic disease of childhood (1 out of 11 children)
2 million Emergency Room visits per year
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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
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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
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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
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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
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Pediatric Asthma Score
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Medications
1st line therapyAlbuterol
NebulizedShort acting beta agonist/bronchodilator2.5mg-5mg q20 min x 3MDI = 4-8 puffs q20min x3
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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
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Medications
Ipratropium Anticholinergic Acts synergistically with albuterol. NOT as a
single agent 250-500mcg + beta agonist x 1-3
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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
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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
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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
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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
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Respiratory Failure – Now What?
BiPAPHelioxIntubation
Preoxygenate IV access Fluid bolus ETT (age in years / 4 + 3.5) Rapid sequence intubation Ketamine
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Intubation
Vent settingsSIMVVt = 5 to 6 ml/kgRespiratory rate = Half normal for age I:E ratio = 1:3PEEP = 0-3cmH2O
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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
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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
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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
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THANK YOU!