Pediatric Asthma Asthma is a chrnic (lng-lasting) inflammatry disease f the lwer airways f the lungs in which varius triggers cause narrwing which leads t difficulty breathing. These changes cmmnly ccur in respnse t changes in the envirnment including weather, allergens (such as dg r cat dander, mld, r dust), fds, r respiratry infectins (clds). It is imprtant t remember that Asthma is a reversible prcess which can be treated and cntrlled with prper interventin An Asthma exacerbatin cnsists f swelling and inflammatin f the airways, increased mucus prductin, and reversible tightening f the tiny muscles that surrund the airways (brnchspasm). In severe cases f asthma, damage t the lungs can accumulate ver time, resulting in permanent narrwing f the airways This disease is cmmnly fund in children, althugh it can als ccur in adults. Amng children, asthma is a leading cause f hspitalizatin, chrnic disease, and schl absenteeism. Children with asthma may be able t breathe nrmally mst f the time. When they encunter a substance that can cause prblems (a "trigger"), an asthma attack (exacerbatin) can ccur. Belw is a list f cmmn asthma triggers. tbacc smke dust pllen exercise viral infectins, such as the cmmn cld animals (hair r dander) chemicals in the air r in fd mld changes in weather (frequently cld weather) strng emtins aspirin and ther medicatins In recent years, there has been a wrldwide increase in the number f children with asthma. This trend has been linked t envirnmental factrs, including air pllutin. Hwever, it is imprtant t understand that indr triggers can play just as much f a rle as utdr triggers in bringing n an asthma exacerbatin. 1
Asthma, allergies, and eczema is a grup f cnditins in patients with atpy, an immune system that is hyper-respnsive t freign entities. An acute allergic reactin t nuts can be cnfused with an asthma attack as the signs and symptms are similar (shrtness f breath, tightening f the chest). It is imprtant t remember this, as an acute allergic reactin can lead t immediate cardirespiratry arrest if untreated. It is imprtant t gather a cmprehensive histry (OPQRST/Sample histry) n these patients and nt t fcus in nly n what seems bvius. A thrugh histry can lead t differential diagnses shedding light n mre pssible causes. Children's airways are narrwer than thse f adults. This means that triggers that may cause nly a slight respnse in an adult can be much mre serius in children. In children, it can appear suddenly with severe symptms. Fr this reasn, it is imprtant that asthma be diagnsed and treated crrectly. Fr sme children, this may mean taking daily medicatin even during times when the child is nt having symptms f asthma. Symptms During an asthma attack, peple may have difficulty breathing and may begin t breathe very rapidly. They may als feel shrt f breath, even at rest. The child with asthma may need t use the muscles arund the chest (accessry muscles) t help with breathing. Wheezing and cughing are als imprtant signs that can ccur during an attack, r even when a child is feeling well. A persistent night-time cugh is ne cmmn sign f asthma, even in children withut ther symptms. Signs and tests Often a dctr can hear the effects f asthma in a patient's lungs. Smetimes, an instrument called a spirmeter is used t test a child's breathing in rder t help make the diagnsis f asthma. 2
Spirmeter When an asthmatic patient is having an attack, that persn must wrk harder t mve air in and ut f the lungs. Patients with asthma can use a hme mnitr called a 'peak flw meter' t assess their ability t breathe. A lss f peak flw can signal an asthma attack. Peak flw meter Treatment Families and their pediatrician r pulmnligist shuld wrk tgether as a team t develp and carry ut a plan that includes eliminating asthma triggers and mnitring symptms, and a plan fr what t d when a child's asthma starts t act up. 3
Medicatins There are tw basic kinds f medicatin fr the treatment f asthma: This mdule will include the trade names here as the EMT will run int these medicatinss while extracting Hx s frm the patient. Lng term medicatins-- used n a regular basis t prevent attacks, nt fr treatment during an attack. inhaled sterids (e.g., Azmacrt, Vanceril, AerBid, Flvent) prevent inflammatin leuktriene inhibitrs (e.g., Singulair, Acclate) lng-acting brnchdilatrs (e.g., famterl, Serevent) help pen airways crmlyn sdium (Intal) r nedcrmil sdium aminphylline r thephylline (nt used as frequently as in the past) cmbinatin f anti-inflammatry and brnchdilatr (Advair) Quick relief (rescue) medicatins -- used t relieve symptms during an attack. shrt-acting brnchdilatrs (e.g., Prventil, Ventlin, Xpenex, and thers) ral r intravenus crticsterids (e.g., prednisne, methylprednislne) stabilize severe episdes Children with mild asthma (infrequent attacks) may use relief medicatin as needed. Thse with persistent asthma mst likely take cntrl medicatins n a regular basis t prevent symptms frm ccuring. A severe asthma attack requires a medical evaluatin and may require hspitalizatin, xygen, and intravenus medicatins. Althugh these are the same medicatins used t treat adults, there are different inhalers and dsages especially fr children. In fact, children ften use a nebulizer t take their medicatins rather than an inhaler, because it can be difficult fr them t use an inhaler prperly. Families can play a very imprtant rle in the cntrl f asthma by helping get rid f the indr triggers that wrsen asthma. Fr example, it is extremely imprtant t eliminate tbacc smke frm the hme. This is the single mst imprtant thing that a family can d t help a child with asthma. Just having peple smke "nt in 4
the huse" is nt enugh, as family members and visitrs can ff gas residual smke in n their clthes and in their hair. FYI Keeping lw levels f humidity and fixing leaks can reduce grwth f rganisms such as mlds. Expsure t cckraches can be reduced by cleaning and by keeping fd in cntainers and ut f bedrms. Bedding can be cvered with "allergy prf" plyurethane-cated casings t reduce expsure t dust mites. Detergents and cleaning agents in the hme shuld be unscented. All f these effrts can make a significant difference t the child with asthma, even thugh it may nt be bvius right away. An allergist can assist with a plan fr reducing the asthma triggers in the hme. A peak flw meter, a simple device t measure lung vlume, can be used at hme t help a patient "see an attack cming" and take the apprpriate actin, smetimes even befre any symptms appear. If a patient is nt mnitring asthma n a regular basis, an attack can be a surprise. Peak flw measurements can help shw when medicatin is needed, r ther actin needs t be taken. Peak flw values f 50-80% f the child's persnal best indicate a mderate asthma attack, while values belw 50% indicate a severe attack. Measuring peak flw is perfrmed in the hspital r dctr s ffice. It is nt use in prehspital emergency care. Many children under age 5 can't use a peak flw meter well enugh t make the resulting data useful, s their asthma must be managed by an adult wh needs t watch carefully fr the asthma signs. An age 5 "cutff" is smewhat arbitrary, hwever, and can be adjusted either way based n the abilities f the individual child. It's a gd idea t start using peak flw meters befre age 5 t get the child used t them, but nt t actually rely n them t much fr mnitring the child's cnditin. Expectatins (Prgnsis) With prper treatment and a team apprach t managing asthma (including, mst imprtantly, the family), mst affected children can live a nrmal life. Asthma, hwever, can be a life-threatening disease. It is imprtant fr families t wrk tgether with health care prfessinals t develp a plan fr the child with asthma 5
in rder t ensure prper treatment and t minimize the impact f this chrnic cnditin. Cmplicatins The cmplicatins f asthma can be severe. Sme include: chrnic cugh lack f sleep frm nighttime symptms decreased tlerance fr exercise and ther activity missed schl missed wrk fr parents truble breathing need fr emergency rm visits need fr hspitalizatin assisted ventilatin chrnic lung disease (permanent changes in the functin f the lungs) death Yes, DEATH. Peple d die frm asthma attacks. Preventin There is n fl-prf methd t prevent asthma attacks. Cuncil frequent patients that the best way t minimize the number f attacks is t fllw the asthma plan they develp with their dctr and t eliminate triggers (especially cigarette smke) as discussed abve. When families take cntrl f their hme envirnment, asthma symptms and exacerbatins can be significantly decreased. When a child begins t get symptms, a severe attack can be prevented by a quick respnse. An asthma actin plan can tell a family exactly what t d when symptms start t increase. Fllwing an asthma actin plan can prevent severe exacerbatins that therwise might result in hspitalizatin. Asthma can t be cured, but it can be cntrlled. 6
FIRST RESPONDER CARE By the time the family calls fr 911, it is prbably because they are having a difficult time cntrlling an asthma event. It may be due t pr management f the medicatin, nt having enugh f the medicatin, ineffective/expired medicatin r any ne f the many reasns beynd their cntrl. It really desn t matter because in reality, there is a pediatric patient that is depending n the EMT s initial care t make him/her feel better. Early interventins can save their lives. Presentatin Let s say yu respnd n a call with a 3 year ld, shrt f breath yu suspect is having an asthma attack. Yu enter the huse and prceed int the bedrm f the child and as yu enter the rm yu actually hear auditry wheezing. Yu can even hear them wheezing frm acrss the rm withut even putting the scpe t the patient! That s a very bad sign. Next, withut saying a wrd, yu ntice that the patient is using his assessry muscles t help him breathe. That s nt gd. Yu als ntice that the patient is tripding (t help align the structures f his airway). Nw yu hear the patient grunting (this helps splint his lwer airway pen). This patient needs help. Abve: Tripd psitin aligns the airways and makes it easier fr the patient t breath. Shrt f breath patients seek this psitin. The EMT - B plays a crucial rle in caring fr these sick children by: Perfrming rapid assessment Administering high flw xygen Calming the patient while preparing fr transprt. 7
It cmes dwn t ABC S. This may include suctining, rescue breathing, CPR Oxygen management. High flw O2 via nn re-breather mask. Utilize blw-by delivery if needed. Vitals including SPO2 Prper psitining. Assistance with the patient s wn rescue meds fr EMT-B Attentin t bdy temperature. Hyperthermic v. Hypthermic Attempt t btain a gd Hx frm the parent r guardian while ding a physical exam f yur patient. D nt upset the child f a respiratry illness. T much tactile stimulatin and stress can wrsen the cnditin. Deliver high flw Oxygen t yu patient in whatever way applicable s as nt t further upset yur patient. (NRB, Blw-by, BVM if inadequate breathing). We may have t rescue breathe fr this patient. Pull it ut f the bag and have it ready in the event it needs t be deplyed rapidly. Prepare the child and parents fr transprt. 8