Bronchial & Asthma in children and how to treat
List complications of bronchial asthma and bronchiolitis
Definition and Epidemiology of Bronchial Asthma
• Bronchial Asthma: A chronic obstructive disorder of the airways characterized by
bronchospasm and inflammation, which occur in response to a variety of stimuli
• Characterized by recurrent episodes of wheezing often associated with cough
• Symptoms may be reversible spontaneously or with treatment
Epidemiology
• Asthma is a common chronic disease, causing considerable morbidity
• Many asthma deaths could probably have been avoided
• Asthma is generally an under diagnosed and undertreated condition
• Asthma prevalence correlates well with reported allergic rhinoconjunctivitis and atopiceczema prevalence
• Approximately 80% of asthmatics report disease onset before 6 years of age
Risk Factors, Clinical Features and Diagnosis of Asthma
• Risk factors
o Family history or coexisting atopy
o Male sex
o Parental smoking
o Hospitalized for bronchiolitis in infancy
• Triggering factors
o Allergens/irritants
o Cold weather
o Dust
o Exercise
o Stress
o Infection of the upper air way
Clinical Features
• The child becomes anxious, restless and cyanotic, prefers a half sitting position and
perspires heavily
• Tachycardia, tachypnoea, cough
• Hyperventilation of the chest
• Lower chest wall indrawing
• Prolonged expiration with audible wheeze
• As the condition becomes worst, there will be:
o Use of accessory muscles of respiration
o Reduced air intake to the lungs
o Reduced wheezing
o Inability to speak
o Tripod sitting position
o Diaphoresis
o Pulsus paradoxus
Diagnosis and Differential Diagnosis
• Diagnosis is made following compatible clinical presentation and the below
investigations
o Lung function test (spirometry or peak flow meter)
o Radiological (acute attack presents with hyper-inflated lungs)
o Arterial blood gases (pulse oxymitor)
o Blood and sputum eosinophils
Differential diagnosis
🔰Viral bronchiolitis or other pulmonary infection
o Aspiration
o Air flow obstruction
Laryngotracheomalacia
Vascular ring,
Airway stenosis
Mediastinal mass
Foreign body
Vocal cord dysfunction
🔰Bronchopulmonary dysplasia, obliterative bronchiolitis
🔰Chronic congestive heart failure with ‘cardiac asthma’
Treatment of Bronchial Asthma
• The overall goal of therapy is to reverse the symptoms
• The secondary goal is to prevent or diminish the frequency of recurrence and to maintain
normal pulmonary functions
The treatment of asthma in children is divided into 4 main components:
💊Patient education
💊Assessment and monitoring of asthma severity with objective measures of the lung function test
💊Avoidance or control of asthma triggers eg. Perfumes spray
💊Establishing a comprehensive plan of pharmacological therapy and how to manage exacerbations
Management In-between Attacks
💊All upper airway infections are to be well treated to prevent a possible attack
💊Irritation by cold environment and smoke should be avoided
💊Children should sleep in a dust free environment
💊In persistent asthma, it may be necessary to give a child long term steroid therapy, preferably beclomethasone dipropionate, 100 micrograms 2 to 4 times in 24 hours
Management During Attacks
💊A child with the first episode of wheezing and no respiratory distress can usually be managed at home with only supportive care, a bronchodilator is not needed
💊A child with respiratory distress or has wheezing, give salbutamol by nebulizer or metered -dose inhaler, if salbutamol is not available then give subcutaneous epinephrine
💊Reassess the child after 30 minutes to determine subsequent treatment
💊If the distress is still present, admit and treat the child with rapidly acting
bronchodilators and oxygen
💊Give oxygen to all children who are cyanosed or if there is difficulty breathing which interferes with talking 1liter to 2liter in children's 2liters to 5liters in adults
🔰Short-acting, selective beta2-adrenoceptor agonists,
such as
salbutamol,
terbutaline and
bitolterol
🔰 Currently available long-acting beta2-adrenoceptor agonists
include
salmeterol,
formoterol,
bambuterol, and
sustained-release oral albuterol
🔰Tremors, the major side effect, have been greatly reduced by inhaled delivery, which allows the drug to target the lungs specifically
• Older, less selective adrenergic agonists, such as inhaled epinephrine and ephedrine tablets, have also been used
o Cardiac side effects occur with these agents at either similar or lesser rates to albuterol
• Anticholinergic medications, such as ipratropium bromide may be used instead
o They have no cardiac side effects and thus can be used in patients with heart disease
o They take up to an hour to achieve their full effect and are not as powerful as β2-
adrenoreceptor agonists
• Inhaled glucocorticoids are usually considered preventive medications, while oral
glucocorticoids are often used to supplement treatment of a severe attack
Refer to Handout 5.2: How to Give Rapid Acting Bronchodilators
Supportive Care
• Position
o Let the child be in the most comfortable sitting position
• Fluid
o Children with respiratory distress need maintenance IV fluids
• Feed by NGT
• Parent counselling and education
• General nursing care
Definition and Epidemiology of Bronchiolitis
• Bronchiolitis: A viral infection of the lower respiratory tract (bronchioles) that produces
obstruction of the small airways due to oedema with air trapping, resulting in respiratory
difficulty in infants
• Respiratory syncytial virus (RSV) is the major cause in > 90% of infants
• Other causes include:
o Parainfluenza virus
o Adenoviruses
Measles virus
o Bacteria invasion may occur
Epidemiology
• Bronchiolitis is a common illness of young children
• Approximately 50% of children have this illness during the first 2 years of life
• The infection is so severe in young infants that it occurs in epidemics
Clinical Presentation, Diagnosis and Differential Diagnosis of Bronchiolitis
Clinical Presentation
• Starts with upper respiratory infections (rhinorrhea, sneezing, cough and low grade fever)
• Wheezing that is not relieved by up to three doses of bronchodilator
• Hyperventilation of the chest, with increased resonance to percussion
• Lower chest wall indrawing
• Fine crackles or rhonchi on auscultation of the chest
• Difficulty feeding
• Nasal flaring
• Grunting in young infants
• Convulsions, lethargy or unconsciousness
• Acute symptoms last 5-6 days; recovery is complete in 10-14 days
Diagnosis
• Diagnosis is made based on the findings obtained from the history and examination, and results of the following
Investigations:
o Blood gases
o Full blood picture(FBP)
o Chest X-ray (air trapping, peribronchial thickening, atelectasis, increased linear
markings)
o Nasopharyngeal swab
Differential Diagnosis
• Acute asthma, associated with viral lower respiratory infection
• Congestive heart failure
• Pneumothorax
• Pneumonia
• Inhaled foreign body
• Pertussis
Treatment and Complications of Bronchiolitis
• Ensure ABCs
• Oxygen therapy to maintain oxygen saturation at ≥ 95%
o Give oxygen 2 L/min by nasal prongs, facemask or head box (or O2 tent)
o Use humidified oxygen with nebulizer where possible
o Continuous monitoring is recommended if supplemental oxygen is required
• Fluid therapy
o Give IV fluids in the following conditions:
Moderate-to-severe or severe respiratory distress
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