CASE STUDY: Bronchial Asthma

Asthma is a predisposition to chronic inflammation of the lungs in which the airways (bronchi) are reversibly narrowed. During asthma attacks (exacerbations of asthma), the smooth muscle cells in thebronchi constrict, and the airways become inflamed and swollen. Breathing becomes difficult,hat Makes a Child More Likely to Develop Asthma.

There are many risk factors for developing childhood asthma. These include:

Presence of allergies Family history of asthma and/or allergies Frequent respiratory infections Low birth weight Exposure to tobacco smoke before and/or after birth Being male Being black Being raised in a low-income environment

Signs and symptoms to look for include: Frequent coughing spells, which may occur during play, at night, or while laughing. It is important to know that cough may be the only symptom present. Less energy during play Rapid breathing Complaint of chest tightness or chest "hurting Whistling sound (wheezing) when breathing in or out How Can I Tell If My Child Has See-saw motions (retractions) in the chest from labored breathing Asthma?

Shortness of breath, loss of breath Tightened neck and chest muscles Feelings of weakness or tiredness Dark circles under the eyes Frequent headaches Loss of appetite

Keep in mind that not all children have the same asthma symptoms, and these symptoms can vary from asthma episode to the next episode in the same child. Also note that not all wheezing or coughing is caused by asthma. In kids under 5 years of age, the most common cause of asthma-like symptoms is upper respiratory viral infections such as the common cold.If your child has problem breathing, take him or her to the doctor immediately for an evaluation.

Why Is Asthma is often difficult to diagnose in infants. However, in older children the disease can often be diagnosed based on your child's medical history, symptoms, and physical exam.

Asthma Diagnosed In Children?

Medical history and symptom description.Your child's doctor will be interested in any history of breathing problems you or your child may have had, as well as a family history of asthma, allergies, a skin condition called eczema, or other lung disease. It is important that you describe your child's symptoms -- cough, wheezing, shortness of breath, chest pain or tightness -- in detail, including when and how often these symptoms have been occurring. Physical exam.During the physical examination, the doctor will listen to your child's heart and lungs.

Tests.Many children will also have a chest X-ray and pulmonary function tests. Also called lung function tests, these tests measure the amount of air in the lungs and how fast it can be exhaled. The results help the doctor determine how severe the asthma is. Generally, children younger than 5 are unable to perform pulmonary function tests. Thus doctors rely heavily on history, symptoms and examination in making the diagnosis.

Bronchial asthma triggers may include:

Tobacco smoke Infections such as colds, flu, or pneumonia Allergens such as food, pollen, mold, dust mites, and pet dander Exercise Air pollution and toxins Weather, especially extreme changes in temperature Drugs (such as aspirin, NSAID, and beta-blockers) Food additives (such as MSG) Emotional stress and anxiety Singing, laughing, or crying Smoking, perfumes, or sprays Acid reflux

CASE ABSTRACT

On 24th day of September 2009, baby X, a 1 year and 2 month old boy was admitted to the hospital under the service of Dr. M. Colasito with a chief complaint of DOB & wheezing, this was associated with fever. He was advice to secure consent for management and for RR monitoring every 2 hours.

On the same day, the child was hooked with D5 0.3Nacl 500cc x 12, the baby was subjected under nebulization for every hour for the first four hours then contrapted with O2 @ 2LPM via NC. Then after, he received few medication; Hydrocortisone 40mg IV q6, Benadryl 9mg IV stat dose, Cefuroxime 500mg IV q12 ANST as ordered by Dr. Colasito.

After a few hours, he was subjected under CBC and chest X-ray AP-L. Then after, he was encouraged to have DAT with SAP.
Sept. 25, 2009 8:45am IVF was replaced with D5 IMB 500cc x 12 and nebulization was adjusted q4 and he was encouraged to continue rest. On the following day he was on D5 IMB # 2 500cc x 12. He is currently under observation with no further doctors order as of this day.

PHYSICAL ASSESSMENT

I. General Information Name: Patient X Age: 1 year old Sex: Male II. Vital Signs Temp: 36.0 Pulse: 12 Resp: 23

III. Anthropometric Measurement: Height: Weight: Head Circumference: Abdominal Circumference: 49 cm Chest Circumference:

81 cm 9 kg 48 cm

48 cm

IV. General Appearance: Patient shows no signs of distress, mobile and calm V. Skin

Patient skin color is fair, smooth texture, dry and warm to touch.

V. Head

Normocepahalic, posterior and anterior fonatanelles are closed. No depression upon palpation. Hair is fine wit even distribution. Scalp has no scars or lesions without nits. Symmetrical eyelids and eyebrows. Eyelashes evenly distributed. Smooth cornea and lens. Anicteric sclera. Pupils are responsive and reactive to light and have an equal size. Conjunctivas are pink.\

VII. Ears

Properly aligned, soft, and non tender pinna. Levels at the outer canthus of the eye. Ear canal has some cerumen. Appears smooth, nasolabial folds is symmetrical. Septum is found in midline. No nasal discharge.

VIII. Nose

IX. Mouth and Pharynx Lips are pinkish in color, moist, symmetrical and smooth. Gums and buccal mucosa are pinkish in color, smooth and moist. Soft and hard palate are intact. Uvula is found at the midline. Tongue moves freely. Tonsils are not inflamed. X. Neck moves freely trachea is in the midline No palpable nodules. Thyroid is non palpable

XI. Chest and lungs

Cylindrical Breathing is irregular with wheezing to ronchi sound.

XII. Heart

Precordium is flat Apical pulse is located at the fifth intercostals space left midclavicular line.

XIII. Abdomen

Appears slightly protuberant and normoactive sounds upon palpation.

XIV. Back and extremities

Nails and nail beds are pinkish in color. Peripheral pulses are symmetrical. Peripheral pulses are symmetrical. Extremities symmetrical in size. Spine is in the midline.

ANATOMY AND PHYSIOLOGY

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis. The lower respiratory tract consists of the bronchi, bronchioles and the lungs. The major function of the respiratory system is to deliver oxygen to arterial blood and remove carbon dioxide from venous blood, a process known as gas exchange.

In the mediastinum, at the level of the fifth thoracic vertebra, the trachea divides into the right and left primary bronchi. The bronchi branch into smaller and smaller passageways until they terminate in tiny air sacs called alveoli.

Bronchi and Bronchial Tree

The cartilage and mucous membrane of the primary bronchi are similar to that in the trachea. As the branching continues through the bronchial tree, the amount of hyaline cartilage in the walls decreases until it is absent in the smallest bronchioles. As the cartilage decreases, the amount of smooth muscle increases. The mucous membrane also undergoes a transition from ciliated pseudostratified columnar epithelium to simple cuboidal epithelium to simple squamous epithelium.

The alveolar ducts and alveoli consist primarily of simple squamous epithelium, which permits rapid diffusion of oxygen and carbon dioxide. Exchange of gases between the air in the lungs and the blood in the capillaries occurs across the walls of the alveolar ducts and alveoli.

The two lungs, which contain all the components of the bronchial tree beyond the primary bronchi, occupy most of the space in the thoracic cavity. The lungs are soft and spongy because they are mostly air spaces surrounded by the alveolar cells and elastic connective tissue. They are separated from each other by the mediastinum, which contains the heart. The only point of attachment for each lung is at the hilum, or root, on the medial side. This is where the bronchi, blood vessels, lymphatics, and nerves enter the lungs.

Lungs

The right lung is shorter, broader, and has a greater volume than the left lung. It is divided into three lobes and each lobe is supplied by one of the secondary bronchi. The left lung is longer and narrower than the right lung. It has an indentation, called the cardiac notch, on its medial surface for the apex of the heart. The left lung has two lobes.

Each lung is enclosed by a double-layered serous membrane, called the pleura. The visceral pleura are firmly attached to the surface of the lung. At the hilum, the visceral pleura are continuous with the parietal pleura that line the wall of the thorax. The small space between the visceral and parietal pleurae is the pleural cavity. It contains a thin film of serous fluid that is produced by the pleura. The fluid acts as a lubricant to reduce friction as the two layers slide against each other, and it helps to hold the two layers together as the lungs inflate and deflate.

The normal gas exchange depends on three processes:

Ventilation is movement of gases from the atmosphere into and out of the lungs. This is accomplished through the mechanical acts of inspiration and expiration. Diffusion is a movement of inhaled gases in the alveoli and across the alveolar capillary membrane Perfusion is movement of oxygenated blood from the lungs to the tissues

The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar in children and adults. However, children respond differently than adults to respiratory disturbances; major areas of difference include:

Poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers up to 4 months of age Increased susceptibility to ear infection due to shorter, broader, and more horizontally positioned eustachian tubes. Increased severity or respiratory symptoms due to smaller airway diameters A total body response to respiratory infection, with such symptoms as fever, vomiting and diarrhea

The neural system, composed of three parts located in the pons, medulla and spinal cord, coordinates respiratory rhythm and regulates the depth of respirations. The chemical processes perform several vital functions such as: Regulating alveolar ventilation by maintaining normal blood gas tension Guarding against hypercapnia (excessive CO2 in the blood) as well as hypoxia (reduced tissue oxygenation caused by decreased arterial oxygen [PaO2]. An increase in arterial CO2 (PaCO2) stimulates ventilation; conversely, a decrease in PaCO2 inhibitsventilation.

Control of gas exchange involves neural and chemical process

Asthma is an airway disease that can be classified physiologically as a variable and partially reversible obstruction to air flow, and pathologically with overdeveloped mucus glands, airway thickening due to scarring and inflammation, and bronchoconstriction, the narrowing of the airways in the lungs due to the tightening of surrounding smooth muscle. Bronchial inflammation also causes narrowing due to edema and swelling caused by an immune response to allergens.

Inflamed airways and bronchoconstriction in asthma. Airways narrowed as a result of the inflammatory response cause wheezing. During an asthma episode, inflamed airways react to environmental triggers such as smoke, dust, or pollen. The airways narrow and produce excess mucus, making it difficult to breathe. In essence, asthma is the result of an immune response in the bronchial airways.

Bronchoconstriction

The airways of asthma patients are "hypersensitive" to certain triggers, also known as stimuli (see below). (It is usually classified as type I hypersensitivity.) In response to exposure to these triggers, the bronchi (large airways) contract into spasm (an "asthma attack"). Inflammation soon follows, leading to a further narrowing of the airways and excessive mucus production, which leads to coughing and other breathing difficulties. Bronchospasm may resolve spontaneously in 12 hours, or in about 50% of subjects, may become part of a 'late' response, where this initial insult is followed 312 hours later with further bronchoconstriction and inflammation.

The normal caliber of the bronchus is maintained by a balanced functioning of these systems, which both operate reflexively. The parasympathetic reflex loop consists of afferent nerve endings which originate under the inner lining of the bronchus. Whenever these afferent nerve endings are stimulated (for example, by dust, cold air or fumes) impulses travel to the brain-stem vagal center, then down the vagal efferent pathway to again reach the bronchial small airways. Acetylcholine is released from the efferent nerve endings. This acetylcholine results in the excessive formation of inositol 1,4,5trisphosphate (IP3) in bronchial smooth muscle cells which leads to muscle shortening and this initiates bronchoconstriction.

Bronchial inflammation

The mechanisms behind allergic asthmai.e., asthma resulting from an immune response to inhaled allergensare the best understood of the causal factors. In both people with asthma and people who are free of the disease, inhaled allergens that find their way to the inner airways are ingested by a type of cell known as antigenpresenting cells, or APCs. APCs then "present" pieces of the allergen to other immune system cells. In most people, these other immune cells (TH0 cells) "check" and usually ignore the allergen molecules. In asthma patients, however, these cells transform into a different type of cell (TH2), for reasons that are not well understood.

The resultant TH2 cells activate an important arm of the immune system, known as the humoral immune system. The humoral immune system produces antibodies against the inhaled allergen. Later, when a patient inhales the same allergen, these antibodies "recognize" it and activate a humoral response. Inflammation results: chemicals are produced that cause the wall of the airway to thicken, cells which produce scarring to proliferate and contribute to further 'airway remodeling', causes mucus producing cells to grow larger and produce more and thicker mucus, and the cell-mediated arm of the immune system is activated. Inflamed airways are more hyper-reactive, and will be more prone to bronchospasm.

The "hygiene hypothesis" postulates that an imbalance in the regulation of these TH cell types in early life leads to a long-term domination of the cells involved in allergic responses over those involved in fighting infection. The suggestion is that for a child being exposed to microbes early in life, taking fewer antibiotics, living in a large family, and growing up in the country stimulate the TH1 response and reduce the odds of developing asthma.

Allergens from nature, typically inhaled, which include waste from common household pests, the house dust mite and cockroach, as well as grass pollen, mold spores, and pet epithelial cells;

Stimuli

Indoor air pollution from volatile organic compounds, including perfumes and perfumed products. Examples include soap, dishwashing liquid, laundry detergent, fabric softener, paper tissues, paper towels, toilet paper, shampoo, hairspray, hair gel, cosmetics, facial cream, sun cream, deodorant, cologne, shaving cream, aftershave lotion, air freshener and candles, and products such as oil-based paint.

Medications, including aspirin,-adrenergic antagonists (beta blockers), and penicillin. Food allergies such as milk, peanuts, and eggs. However, asthma is rarely the only symptom, and not all people with food or other allergies have asthma. Use of fossil fuel related allergenic air pollution, such as ozone, smog, summer smog, nitrogen dioxide, and sulfur dioxide, which is thought to be one of the major reasons for the high prevalence of asthma in urban areas.

Various industrial compounds and other chemicals, notably sulfites; chlorinated swimming pools generate chloramines monochloramine (NH2Cl), dichloramine (NHCl2) and trichloramine (NCl3)in the air around them, which are known to induce asthma. Exercise or intense use of respiratory system. The effects of which differ somewhat from those of the other triggers, since they are brief. They are thought to be primarily in response to the exposure of the airway epithelium to cold, dry air.

Early childhood infections, especially viral upper respiratory tract infections. Children who suffer from frequent respiratory infections prior to the age of six are at higher risk of developing asthma,particularly if they have a parent with the condition. However, persons of any age can have asthma triggered by colds and other respiratory infections even though their normal stimuli might be from another category (e.g. pollen) and absent at the time of infection. In many cases, significant asthma may not even occur until the respiratory infection is in its waning stage, and the person is seemingly improving. In children, the most common triggers are viral illnesses such as those that cause the common cold.

Hormonal changes in adolescent girls and adult women associated with their menstrual cycle can lead to a worsening of asthma. Some women also experience a worsening of their asthma during pregnancy whereas others find no significant changes, and in other women their asthma improves during their pregnancy. Psychological stress. There is growing evidence that psychological stress is a trigger. It can modulate the immune system, causing an increased inflammatory response to allergens and pollutants. Cold weather can make it harder for patients to breathe. Whether high altitude helps or worsens asthma is debatable and may vary from person to person.

The fundamental problem in asthma appears to be immunological: young children in the early stages of asthma show signs of excessive inflammation in their airways. Epidemiological findings give clues as to the pathogenesis: the incidence of asthma seems to be increasing worldwide, and asthma is now very much more common in affluent countries. In 1968 Andor Szentivanyi first described The Beta Adrenergic Theory of Asthma; in which blockage of the Beta-2 receptors of pulmonary smooth muscle cells causes asthma. Szentivanyi's Beta Adrenergic Theory is a citation classic using the Science Citation Index and has been cited more times than any other article in the history of the Journal of Allergy and Clinical Immunology.

Pathogenesis

In 1995 Szentivanyi and colleagues demonstrated that IgE blocks beta-2 receptors. Since overproduction of IgE is central to all atopic diseases, this was a watershed moment in the world of allergy.

It is recognized with increasing frequency that patients who have both obstructive sleep apnea and asthma often improve tremendously when the sleep apnea is diagnosed and treated. CPAP is not effective in patients with nocturnal asthma only.

Asthma and sleep apnea

If gastro-esophageal reflux disease (GERD) is present, the patient may have repetitive episodes of acid aspiration. GERD may be common in difficult-to-control asthma, but according to one study, treating it does not seem to affect the asthma. When there is a clinical suspicion for GERD as theand cause gastro-esophageal of the asthma, an Esophageal Asthma pH Monitoring is required to confirm the reflux disease diagnosis and establish the relationship between GERD and asthma.

RADIOLOGY DEPARTMENT Case No. : Age : Examination:

09-3148 1 Yr. old and 2 Months Chest PA/L (Radial)

ROENTGENOLOGICAL REPORT: Point hazy opacity and present in the inner part of both Lungs. No definite Hilar Adropathy is. The heart is normal in size and in configuration. The Diaphragm, CP sulci & the Thoracic cage are intact. No other Remarks. IMPRESSION: Beginning bilateral Bronchopneumonia

Bronchopneumonia Bronchopneumonia or bronchial pneumonia (also known as lobular pneumonia) is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobes. It is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia.

Component & Quantity Hemoglobin: M: 12-17 g/dl F: 11-15 g/dl

Result

12.6 g/dl

Hematocrit: M: 40-54% F: 37-47%

WBC Count: 5,000-10,000/ cu mm RBC Count: M: 4.5-6.0/ cu mm F: 4.0-5.5/ cu mm Reticulocyte Count Platelet Count: 150,000-400,000 / L

34.5%

17,200 / cu mm
4.28 / cu mm Result Adequate

Hematocrit: Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding, cirrhosis of the liver, and malignancies. The most common cause of increased hematocrit is dehydration, and with adequate fluid intake, the hematocrit returns to normal. However, it may reflect a condition called polycythemia vera that is, when a person has more than the normal number of red blood cells. This can be due to a problem with the bone marrow or, more commonly, as compensation for inadequate lung function (the bone marrow manufactures more red blood cells in order to carry enough oxygen throughout your body).

WBC:

An elevated number of white blood cells is called leukocytosis. This can result from bacterial infections, inflammation, leukemia, trauma, intense exercise, or stress. A decreased WBC count is called leukopenia. It can result from many different situations, such as chemotherapy, radiation therapy, or diseases of the immune system. Counts that continue to rise or fall to abnormal levels indicate that the condition is getting worse. Counts that return to normal indicate improvement.

Platelet Count: If platelet levels fall below 20,000 per microliter, spontaneous bleeding may occur and is considered a life-threatening risk. Patients who have a bone marrow disease, such as leukemia or another cancer in the bone marrow, often experience excessive bleeding due to a significantly decreased number of platelets (thrombocytopenia). As the number of cancer cells increases in the bone marrow, normal bone marrow cells are crowded out, resulting in fewer platelet-producing cells.

Name of the drug

Classificati on Antihistami ne

Dosage/ Frequency 9 mg q 8 hours stat

Route

Mechanism of Action

Indication

Nursing Responsibilities Determine why the medication was ordered and assess symptoms that apply to the individual patient

IV

Generic: Diphenhy dramine

Brand name: Benadryl

Diphenhydramine Treatment of works by blocking symptoms of allergies the effect of histamineat H1 rec eptor sites. By blocking the H1 receptor on peripheral nociceptors, diphenhydramine decreases their sensitization and consequently reduces itching that is associated with an allergic reaction.

Name of the drug Generic name: Hydrocor tisone Brand name: Hydrocor tone, Cortef

Classificati on Antiinflammato ries Immunosu ppressants

Dosage/ Frequency 40mg q 6 hours

Route

Mechanism of Action Supresses normal immune response and inflammation

Indication

Nursing Responsibilities Assess affected skin prior to and daily daily during therapy. Note degree of inflammation and pruritus. Notify physician or other health care provider if symptoms of infection develop.

IV

Used in the management of a wide variety of allergic / immunologic reactions

Name of the drug Generic name: Cefuroxi me

Classificati on Antiinfective ( second generation cephalospo rins)

Dosage/ Frequency 500 mg q 12

Route

Mechanism of Action Cefuroxime is used to treat many kinds of bacterial infections, including severe or life-threatening forms.

Indication

Nursing Responsibilities Assess patient for infection at the beginning and throughout course of therapy Before initiating therapy, obtain a history to determine previous use of and reactions to penicillin s or cephalosporins. Observe patients for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify physician if these occur.

IV

Treatment of respiratory tract infections

Brand name: Ceftin, Kefurox, Zinacef

Name of the drug

Classifica tion

Dosage/ Frequency

Route

Mechanism of Action

Indication

Nursing Responsibilities

Generic Salbutamol Nebule name: Sulfate q 1 hour Duavent ( ipratropium salbutamol) Brand name: DuaNeb

Oral The combination nebuliza of ipratropium tion and albuterol is used to prevent wheezing, difficulty breathing, chest tightness, and coughing.

Management of reversible bronchospasms associated with obstructive airway diseases, bronchial asthma

Take care to ensure that the nebulizer mask fits the user's face properly and that nebulized solution does not escape into the eyes. Evaluate therapeutic response.

ASSESSMENT Subjective: Ubo sya ng ubo at di makahinga ng maayos as verbalized by the mother

DIAGNOSIS Ineffective breathing pattern related to painful/ineffe ctive cough

PLANNING After 8 hours of nursing interventions, the patients breathing pattern will be

INTERVENTIONS & RATIONALE -Monitor vital signs to serve as a baseline data. -Avoidance of irritants; smoking allergens, and industrial chemicals to prevent further irritation. -Increased based fluid intake to thin mucus and make it easier to expectorate. -Deep breathing exercise to improve air circulation and breathing.

EVALUATION -Goals partially met. -After 8 Hours of Nursing interventions, the px breathing pattern was improved.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTIONS & RATIONALE

EVALUATION

-Positioning to facilitate breathing (Fowlers or Orthopneic) -Providing adequate nutrition via small, frequent meals to meet nutritional requirements & to avoid suffocation. -Avoidance of extremes of heat and cold to avoid further cough. Interdependent: -Use of Meds: Bronchodilators, expectorants & liquefying agents.

ASSESSMENT Subjective Nahihirapan h uminga ang anak ko Objective -Restlessness -Irritability -TachycardiaP 181 -Cyanosis -Diaphoresis -Nasal Flaring -Tachypnea RR41 -Barrel chest -Wheezing on expiration

DIAGNOSIS Impaired gas exchange related to ventilation perfusion imbalance

PLANNING After 1 hour of nursing intervention the client will improve ventilation

INTERVENTIONS & RATIONALE Monitor RR,depth and effort including of accessory muscles ,nasal flaring and abnormal breathing patterns Auscultate every breath sounds every 12 hours Monitor the clients behavior for the onset of restlessness Observe for cyanosis of the skin especially note the color, tongue and oral mucus membrane

EVALUATION

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTIONS & RATIONALE Position the client in Semi fowlers with an upright position at 45 degree if possible Administer bronchodilator as ordered by the doctor

EVALUATION Goals met The client is improved ventilation from P-145 RR-22

Thank You for { Listening