Week 5: School-aged & Asthma

What is asthma?

A reversible chronic obstructive inflammatory condition in which airways are hyper-reactive to environmental (allergens, irritants, infections) or intrinsic factors.

How common is asthma in children?

 It is the most common chronic disease affecting children.

What percentage of Canadian children are affected by asthma?

 7–20%.

 What worrying trend has been seen in Alberta?

Increased hospitalizations related to poor asthma medication use.

What percentage of patients use their device effectively?

Only 10–25%.

What percentage of patients are wrongly diagnosed with asthma?

 30%.

 Among preschoolers diagnosed with asthma, what percentage outgrow it?

50%.

What proportion of children with eczema also have asthma?

70%.

Why are children at increased risk for asthma complications?

Due to anatomy & physiology and determinants of health.

Why is a child at increased risk for asthma complications due to nasopharynx differences?

Smaller nasopharynx is easily occluded during infection. Smaller nares are easily occluded.

Why is a child at increased risk for asthma complications due to oral cavity differences?

Small oral cavity and large tongue means for increased risk of obstruction

Why is a child at increased risk for asthma complications due to their epiglottis?

Long floppy epiglottis is vulnerable to swelling with resulting obstruction 

Why is a child at increased risk for asthma complications due larynx and glottis?

Larynx and glottis are higher in neck increasing risk of aspiration

Why might a child be at increased risk for asthma complications due their differences in respiratory cartilage?

thyroid, cricoid and tracheal cartilages are immature so they may easily collapse when neck is flexed!

Why might a child be at increased risk for asthma complications due their differences in respiratory muscles?

immature muscles result in fewer muscles being functional in airway being less able to compensate to edema, trauma and injury

Why might a child be at increased risk for asthma complications due their differences in respiratory tissues?

Large amounts of soft tissue and loosely anchored mucous membranes lining airway increases risk of edema and obstruction! 

What is the leading cause of absenteeism from school in North America?

Atopic asthma.

What diagnoses create complexity in asthma differential diagnosis?

Bronchiolitis, Croup, and other upper/lower respiratory illnesses.

What is asthma prevalence directly linked to?

Social, economic, geopolitical, and environmental factors.

 Asthma is characterized as a reversible airway obstruction caused by what three factors?

1. Bronchial constriction (smooth muscle)
   
   

2. Chronic inflammation
   
   

3. Increased mucus production
   

 Inflammation in the small airways contributes to what percentage of total airway resistance?

50%.

What history is important in asthma diagnosis?

Medical and family history, especially allergies and eczema.

What are signs & symptoms of asthma in children >1 year?

Cough, wheeze, shortness of breath.

What history findings suggest asthma?

Recurrent admissions/treatment for reactive airway disease and documented response to bronchodilators or ICS.

What should nursing asthma assessment focus on from admission to discharge?

 Education.

What factors should be reviewed if asthma is not well controlled?

Technique, correct/empty/defective device, triggers, viral differentials, medication review, action plan.

Controlled asthma should be viewed as what?

 An expectation.

What must an asthma action plan include?

• Triggers and signs of uncontrolled asthma
  
  

• Instructions during loss of control
  
  

• When/how to seek additional help
  
  

• Instructions to maintain control (controller meds + environment mgmt)
  
  

Why may picture-based asthma action plans be helpful?

Suitable for caregivers with poor health literacy.

What are strategies for verbal communication in asthma education?

Patient-centred language, speaking slowly, repeating/confirming understanding.

What are criteria for controlled asthma?

• No day symptoms (outside exercise)
  
  

• No night symptoms
  
  

• No limits to physical activity
  
  

• No missed school/work
  
  

• No exacerbations
  
  

• Reliever medication only PRN
  
  

What are signs of a mild asthma attack?

Coughing, restlessness, irritability, tiredness, ↑ RR, tight chest, wheeze.

What are signs of a severe asthma attack?

Hypoxia, SOB, retractions, ↑ PRAM score, 3–5 word sentences, no improvement after reliever.

What is the truth about “hypoallergenic pets”?

They do not exist; dander, saliva, and urine are triggers.

 What types of irritants worsen asthma?

Lung irritants that cause inflammation or smooth muscle constriction.

Give examples of asthma triggers.

Pets, environment, bacteria, parasites, stress.

What is first-line controller medication for asthma?

Inhaled corticosteroids (ICS).

Should ICS be used intermittently or regularly?

 Maintenance, not intermittent.

What is the first-choice rescue medication?

Ventolin (Salbutamol).

Examples of ICS controllers for asthma?

QVAR >6y, Alvesco >6y, Pulmicort >6y, Flovent <6y.

Onset of ICS?

 <2 weeks.

 Key teaching point for ICS with MDI?

Always use a spacer to minimize thrush.

Example of LTRA?

Montelukast (Singulair).

Salmeterol Onset

1-2 hr

Salmeterol Duration

12 hours

Budesonide Onset & Duration

ICS < 2 weeks 

Salbutamol (Ventolin) Onset

5- 15 min

Salbutamol (Ventolin) Duration

< 4 hours 

Dexamethasone PO & Methylprednisolone IV Onset

4 hrs

Dexamethasone PO & Methylprednisolone IV Indicated treatment

Recommended systemic treatment of 4 days; after acute exacerbation

Salmeterol Onset

1-2 hr

Atrovent Onset

5-15 minutes

Atrovent Peak & Duration

1 hr ^ , 2-5 hr -

LTRA Indications?

Adjunct to ICS, effective in cold/exercise-induced asthma.

LTRA Side effects?

 Neuropsychiatric (sleep, hyperactivity, behavioural).

 Example of combination controller?

Symbicort >12y.

 Salmeterol onset & duration?

1–2 hr onset, 12 hr duration.

Example of SABA?

Salbutamol (Ventolin).

 SABA Onset & duration?

 5–15 min, <4 hr.

 SABA Side effects?

Hypokalemia, tachycardia, paradoxical bronchospasm, tremors.

Glucocorticoids Examples?

Dexamethasone PO, Methylprednisolone IV.

Glucocorticoids Onset

4 hrs.

Glucocorticoids Duration of systemic therapy

 4 days.

Glucocorticoids Side effects of prolonged therapy?

Hyperglycemia, HTN, growth suppression, osteoporosis, adrenal suppression, insomnia, mood changes.

Example of SAMA?

Atrovent

SAMA Mechanism

Blocks cholinergic receptors, inhibits smooth muscle contraction.

Anticholinergics Onset/peak/duration?

 Onset 5–15 min, peak 1 hr, duration 2–5 hr.

Can Atrovent be used at home?

No, not for home use.

Who are biologics for?

 Children with moderate to severe asthma.

biologics Major limitation?

Very expensive.

Spacer use <4 years?

Mask

Spacer use >4 years?

Mouthpiece.

Key teaching tips for spacer/MDI use?

 Tilt downward, ensure child calm, no whistling, don’t pre-spray, rinse mouth.

What are 3 factors associated with September asthma peak?

Stress, environment, bacteria/parasites.

 What are 4 strategies to reduce exacerbations?

Action plan, avoid triggers, rescue treatment PRN, check expiry dates.

What are 2 criteria for controlled asthma?

 No daytime cough, no nighttime cough.

A child is prescribed ICS once daily. What is the pharmacological classification?

 Corticosteroid.

What are 2 indicators for ICS?

prevent swelling & prevents loss of lung function

What is the correct administration for ICS via MDI?

Shake 10x, use spacer, rinse mouth.

What is the school-age, age range?

6 to 12 Years

What is school age marked by? 

the development of intellectual skills, independence, and reliance on peer groups

What is the physical growth and anatomy for school aged?

• Growth is slow and steady until the prepubertal growth spurt (girls 9–10 years; boys slightly later).

• The child's posture shows hips and shoulders level, with balanced thoracic and lumbar curves.

• Loss of deciduous teeth begins around age 6, and permanent teeth erupt.

• Heart muscle is typically fully developed around 5–10 years.

What are the motor development milestones for school aged?

• Fine and gross motor skills are refined through organized activities and sports.

• Gains coordination; learns to ride a two-wheeler, jump rope, and roller skate.

• Develops hobbies such as model building or playing a musical instrument

What is the cognitive development stage for school aged?

Piaget’s Concrete Operational Stage

What is the Concrete Operational Stage?

• The child uses logical thinking and can reason well if concrete objects are used in teaching.

• The concept of conservation (matter does not change when form is altered) is learned.

• They are able to concentrate for longer periods.

What is the psycho-social development stage for school aged?

Erikson’s Industry vs. Inferiority

What is Industry vs. Inferiority?

Child gains a sense of self-worth from accomplishments in school, sports, and hobbies

What is the psycho-sexual development stage for school aged?

Freud’s Latency stage

What is Freud’s Latency stage

The child’s sexual energy is at rest, focus is on social and cognitive growth

How do school aged engage in play?

Engages in cooperative play where cooperation and roles are important; reliance on rules.

Peers are increasingly important.

How do school aged engage communicate?

• Mature use of language; ability to converse and discuss topics for longer times.

• Understands body parts and organs, enabling better comprehension of illness and hospitalization.

• Teaching should use clear instructions, demonstrations, and be concrete.

What does school aged health and safety look like?

• Stresses include school performance, interpersonal relationships, and medical procedures.

• Common issues include ADHD, depression, and anxiety disorders.

• Injury prevention focuses on use of protective gear in sports, and avoiding firearm injury and motor vehicle crashes.