Asthma and CF

Respiratory Continued: Asthma and Cystic Fibrosis

Learning Outcomes

  • Describe the physiologic effects asthma has on the respiratory system.

  • Identify short and long-term management for asthma.

  • Outline nursing interventions to perform when caring for a child with an acute asthma exacerbation.

  • Describe the physiologic effects cystic fibrosis has on the respiratory and gastrointestinal system.

  • Describe the daily care and maintenance a child with cystic fibrosis performs.

Asthma Facts

  • Prevalence:

    • 8.3% of Americans have asthma.

    • 26.5 million Americans (20.4 million adults, 6.1 million children) have asthma.

    • Almost 4,000 deaths annually due to asthma.

    • Results in 439,000 hospitalizations and 1.3 million emergency room visits per year.

  • Significance:

    • Most common chronic illness in children.

    • Primary cause of school absences (13.8 million/year).

    • Third leading cause of hospitalization in children under 15 years.

    • Estimated economic cost of asthma: $56 billion annually.

Asthma Overview

  • Definition:

    • Asthma is a chronic inflammatory disorder of the airways characterized by recurring episodic symptoms.

  • Core Symptoms:

    • Airway obstruction and bronchial hyperresponsiveness.

  • Pathophysiology:

    Figure 23-4

    -

    • A: Normal lung.

    • B: Bronchial asthma showing thick mucus, mucosal edema, and smooth muscle spasm leading to airway obstruction; results in labored breathing, particularly difficult expiration.

Asthma Classification

Asthma is classified into four categories based on symptom indicators and disease severity:

  • Intermittent Asthma:

    • Symptoms occur ≤ 2 times/week.

    • Nighttime symptoms ≤ 2 times/month.

    • No interference with normal activity.

    • Use of short-acting B-agonist (SABA) < 2 times/week.

  • Mild Persistent Asthma:

    • Symptoms occur > 2 times/week, but not daily.

    • Nighttime symptoms 1-2 times/month for ages 0-4, 3-4 times/month for ages 5-11.

    • Minor limitations in activity.

    • Use of SABA > 2 days/week, but not daily.

  • Moderate Persistent Asthma:

    • Daily symptoms.

    • Nighttime symptoms 3-4 times/month for ages 0-4, > 1 time/week but not daily for ages 5-11.

    • Some limitations in activity.

    • Uses SABA daily.

  • Severe Persistent Asthma:

    • Symptoms occur continually.

    • Nighttime symptoms > 1 time/week for ages 0-4, nightly for ages 5-11.

    • Limited activity.

    • Uses SABA several times/day.

Asthma Risk Factors

  • Genetics:

    • Family history of asthma and atopic conditions (e.g., allergies).

  • Environmental Factors:

    • Allergies influencing disease persistence and severity.

    • Viral respiratory infections (e.g., RSV).

    • Maternal smoking during pregnancy.

    • Smoking or exposure to secondhand smoke.

  • Demographic Factors:

    • Ethnicity (highest risk in African Americans).

    • Low birth weight.

    • Being overweight.

Asthma Symptoms

  • Classic Manifestations:

    • Dyspnea, wheezing, and coughing.

    • Recurrent episodes of wheezing and troublesome cough at night.

    • Coughing or wheezing after exercise or exposure to allergens.

    • Prolonged expiratory phase.

    • Colds that take over 10 days to resolve.

Asthma Triggers

  • Common Triggers:

    • Allergens (pollen, dust mites, animal dander).

    • Respiratory infections.

    • Secondhand smoke.

    • Extreme emotions or changes in weather.

    • Physical activity (especially in cold, dry air).

Diagnosing Asthma

  • Diagnosis Methods:

    • Based on clinical manifestations, medical history, physical exam, and laboratory tests.

    • Pulmonary Function Test (PFT):

    • Most accurate for diagnosing asthma severity; measures lung function; performed for children > 5-6 years old.

    • Peak Expiratory Flow Rates (PEFR) using a PEFM:

    • Measures the amount of air expelled in 1 second; evaluates asthma control.

    • Bronchoprovocation Testing:

    • Direct exposure to suspected antigens to identify triggers.

    • Skin Prick Testing (SPT):

    • Identifies allergens responsible for asthma symptoms.

    • Radiology or Laboratory Tests:

    • Assess other potential complications or conditions.

Goals of Asthma Management

  • The goals include:

    • Being free of symptoms.

    • Sleeping through the night without symptoms.

    • Participating fully in chosen activities.

    • Minimizing school or work absences due to asthma.

    • Reducing emergency care visits.

    • Minimizing medication side effects.

Managing Asthma

  • Nonpharmacological Therapy:

    • Focused on preventing exposure to airborne allergens and irritants (e.g., house dust, tobacco smoke, molds).

  • Pharmacological Therapy:

    • Follow the 2020 Asthma Management Guidelines by the National Institute of Health.

Asthma Severity Classification in Children

  • Step 5 or 6: Severe Persistent Asthma

    • Continual symptoms, frequent nighttime symptoms, severely limited activity.

    • PEF < 60% of predicted value; FEV1 < 75% of predicted value.

  • Step 3 or 4: Moderate Persistent Asthma

    • Daily symptoms, some limitations in activity.

    • PEF 60-80% of predicted value; FEV1 75-80% of predicted value.

  • Step 2: Mild Persistent Asthma

    • Symptoms > 2 times/week but < 1 time/day.

    • Nighttime symptoms limited to a few times a month.

    • PEF and FEV1 ≥ 80% of predicted value.

  • Step 1: Intermittent Asthma

    • Symptoms ≤ 2 times/week, no nighttime symptoms, normal PEF and FEV1 values.

Treatment Approach for Asthma in Children

  • Management for Ages 0-4:

    • PRN SABA, daily low-dose ICS.

    • Daily medium-dose ICS-LABA for persistent asthma.

  • Management for Ages 5-11:

    • Similar to ages 0-4, but may include leukotriene modifiers or Cromolyn for additional management.

  • Management for Ages 12+:

    • Includes more options such as long-acting beta-agonists and additional asthma biologics (e.g., anti-IgE).

Asthma Medication Categories

  • Quick-relief medications:

    • Used for acute symptoms (e.g., Albuterol).

  • Long-term control medications:

    • Inhaled corticosteroids (ICS), combinations with LABA, leukotriene modifiers, etc.

Asthma Control Tests

  • Asthma Control Test (ACT) and Childhood Asthma Control Test (C-ACT):

    • Measures the multidimensional nature of asthma control, guides treatment response.

    • Scoring:

      • >20 = Well controlled asthma

      • 16-19 = Not well controlled

      • <15 = Very poorly controlled.

Asthma Action Plan

  • Zones of Control:

    • Green Zone: No symptoms, normal activity.

    • Yellow Zone: Cough, wheeze, or increased symptoms; may need quick relief.

    • Red Zone: Severe symptoms or ineffectiveness of quick-relief medications; immediate medical assistance needed.

Patient Education for Asthma Management

  • Essentials:

    • Understanding how asthma affects airways, recognizing triggers, knowing medication types, and when to seek medical help.

Acute Asthma Care

  • Clinical Features:

    • Children may exhibit significant anxiety and respiratory distress during acute exacerbations.

    • Common treatments: beta-agonists, oxygen supplementation, and corticosteroids.

  • Nursing Interventions:

    • Continuous monitoring, calm presence, allow comfortable positioning, involve parents in care, and patient education.

Asthma Myths

  • Debunking common misconceptions:

    • Asthma can be fatal; medications are essential and safe; it is not purely psychological; symptoms may reappear at any age and should be actively managed.

Cystic Fibrosis Overview

  • Definition:

    • Cystic Fibrosis (CF) is a most common lethal genetic illness among Caucasian children, characterized by thick mucus and respiratory and digestive complications.

  • Inheritance:

    • Autosomal recessive trait; if both parents are carriers, risk of having an affected child is 1 in 4.

Cystic Fibrosis Clinical Manifestations

  • Key Features:

    • Increased viscosity of mucous gland secretions leading to obstruction.

    • Early manifestation includes meconium ileus in newborns.

Cystic Fibrosis Complications

  • Pulmonary Complications:

    • Stagnant mucus causes airway obstruction, bacterial growth (common pathogens include Pseudomonas aeruginosa).

  • Digestive Impact:

    • Impaired digestion and absorption leading to growth failure and need for pancreatic enzyme replacement.

Diagnosis of Cystic Fibrosis

  • Methods Include:

    • Newborn screenings, DNA testing, PFTs, sweat chloride tests - high sodium/chloride in sweat indicating CF.

Treatment Goals for Cystic Fibrosis

  • Objective:

    • Prevent pulmonary complications, ensure adequate nutrition, encourage activity, maintain quality of life.

  • Management of Pulmonary Problems:

    • Use of antibiotics, airway clearance therapies, and pulmonary hygiene practices.

  • Nutritional Support:

    • High-calorie, high-protein diets along with enzyme replacement therapy during meals.

Family and Emotional Support

  • Considerations:

    • Coping with the emotional impacts of chronic illness; family involvement in treatment regimens.

References

  • American College of Allergy, Asthma, and Immunology. (2023). Retrieved from https://acaai.org/asthma/asthma-101/facts-stats/

  • American Lung Association. (2023). Retrieved from http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/cystic-fibrosis/learn-about-cystic-fibrosis.html

  • Hockenberry, M.J., Wilson, D., & Rodgers, C.C. (2022). Wong’s Essentials of Pediatric Nursing (10th ed.). St. Louis, MO: Elsevier Mosby.