Description/EtiologyAsthma, a chronic disease characterized by reversible airflow obstruction due to inflammation and narrowing of the airways, is the most common chronic disease in childhood. Asthma is a significant cause of childhood morbidity and is associated with school absenteeism, emergency department and acute care visits, and hospitalizations.

The exact cause of asthma is unknown. A genetic component is possible because a strong association has been found between the ADAM 33 gene and bronchial hyperresponsiveness/asthma; a family history of asthma has also been shown to increase risk for developing asthma. New research suggests certain environmental, psychological, and medical factors can increase risk for developing asthma.

As in adult asthma, childhood asthma is classified based on symptom frequency and severity: intermittent, mild persistent, moderate persistent, and severe persistent. Status asthmaticus is characterized by an acute asthma attack of such severity that it is considered a medical emergency because it can lead to respiratory failure and death (see Quick Lesson About…Status Asthmaticus).

Similar to treatment of asthma in adults, children are prescribed an individualized medication regimen of short- and long-acting agents. Children and/or family members are educated about the importance of strict adherence to the medication regimen, frequent medical surveillance, daily in-home monitoring of symptoms, correct use of nebulizers/inhalers and symptom monitoring devices, and avoidance of asthma triggers. The treatment team may include specialty clinicians in internal medicine, pulmonology, allergy, and respiratory therapy.

Facts and FiguresIn 2003, an estimated 5 million children younger than 15 years of age in the United States had asthma. Asthma affects an estimated 10% of children, compared with 5% of adults. Between 50% and 80% of children with asthma develop symptoms before the age of 5 years.

Risk FactorsChildren living in urban and low-income areas are more likely to develop asthma; in the U.S., Blacks are more likely than Whites to require hospitalization for asthma and to die from asthma. Risk factors and triggers for asthma include parental history of asthma; obesity; comorbid conditions (e.g., rhinitis, sinusitis, and gastroesophageal reflux disease [GERD]); allergies (to pollen, mold, dust mites, cockroaches, and animal dander); allergic hypersensitivity (e.g., allergic rhinitis and/or atopic dermatitis such as eczema); severe respiratory infection (e.g., pneumonia and bronchiolitis); low birthweight; exercise; and exposure to environmental factors (e.g., mold; cigarette smoke; fumes from household cleaning agents, paint, cedar, formaldehydes, and scented products; air pollution; ozone; nitrogen oxide [given off by gas stoves]; cold temperatures; and high humidity).

Signs and Symptoms/Clinical PresentationIntermittent dry coughing, wheezing, intermittent nonfocal chest pain in younger children, chest tightness and shortness of breath in older children, tachypnea (i.e., rapid breathing), tachycardia, fatigue, and difficulty keeping up with the activity level of peers.

AssessmentPatient History 4

Ask about family history of asthma, risk factors, and history of asthma attacks, hospitalizations, •medication use, and coexisting medical conditions

Physical Findings of Particular Interest 4Tachypnea, dry cough, wheezing, cyanosis, mucous production, and tachycardia are usual •

Laboratory Tests That May Be Ordered 4CBC with differential may reveal an increased number of immature leukocytes (called a left shift), •indicating infection; sputum culture may indicate infection; increased eosinophil count and serum IgE levels are indicative of allergic reactionArterial blood gas (ABG) analysis of oxygen concentration, CO • 2 content, and pH levels determine asthma severity. Mild asthma may be characterized by PaO2, PaCO2, and pH; moderate asthma July 30, 2010

ICD-9493

ICD-10J45

ICD-10-CANJ45

AuthorsGilberto Cabrera, MD

Tanja Schub, BS

ReviewersDarlene A. Strayer, RN, MBA

Cinahl Information Systems

Glendale, California

Eliza Schub, BSN, RNCinahl Information Systems

Glendale, California

Nursing Practice CouncilGlendale Adventist Medical Center

Glendale, California

EditorDiane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems

Asthma: Child/Adolescent

quickLESSONabout...

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by normal PaCO2 and pH and PaO2; and severe asthma by PaO2, pH, and PaCO2Exhaled nitric oxide (FENO) test indicates the extent of airway inflammation •

Other Diagnostic Tests/Studies 4Pulmonary function tests identify peak expiratory flow rate (PEFR), forced expiratory volume in 1 second (FEV1), and forced vital capacity •(FVC); PEFR is based on weight, height, gender, and age and is appropriate for testing children ≥ 6 years of age Radioallergosorbent test (RAST) may identify allergens •Pulse oximetry reveals decreased oxygen saturation levels •Chest X-rays may reveal thoracic hyperinflation and peribronchial thickening •

Treatment GoalsMaintain Optimum Respiratory Status and Reduce Risk of Complications 4

Monitor vital signs (particularly respiration), pulse oximetry, pulmonary function tests, and ABG results; administer prescribed treatment for •severity level

Intermittent asthma –For patients ≤ 5 years of age: a short-acting inhaled beta2-agonist (SABA) by face mask with spacer/holding chamber or nebulizer; or an 4

oral beta2-agonist on an as-needed basisFor patients > 5 years of age: daily medication may not be necessary, and SABA may be prescribed on an as-needed basis only. Educate 4

about trigger avoidance Mild persistent asthma –

For patients ≤ 5 years of age: daily low-dose inhaled corticosteroids (e.g., a metered dose inhaler [MDI]) with holding chamber with or 4

without dry powered inhaler (DPI) or face mask; alternative treatment is a leukotriene receptor antagonist or MDI with holding chamber or nebulizer of cromolyn For patients > 5 years of age: daily low-dose inhaled corticosteroids; alternative treatment is a leukotriene modifier, cromolyn, theophylline, 4

or nedocromilModerate persistent asthma: daily medium-dose inhaled corticosteroids or long-acting inhaled beta2-agonists combined with inhaled –corticosteroids; alternative treatment is low-dose inhaled corticosteroids with theophylline or a leukotriene modifier Severe persistent asthma: daily long-acting inhaled beta2-agonists, high-dose inhaled corticosteroids, and, if needed, systemic corticosteroids –

Patients ≤ 5 years old with a viral respiratory infection receive a bronchodilator 4

Frequently assess treatment efficacy and for respiratory distress, hypoxia, and adverse medication effects •Provide Emotional/Psychological Support and Educate 4

Assess patient anxiety level; encourage rest and promote calmness to decrease anxiety, which can further compromise breathing •If developmentally-appropriate, teach diaphragmatic and pursed-lip breathing and coughing techniques to promote more effective respiratory effort •

Food for ThoughtInfants breastfed for more than 4 months may have a reduced risk for developing asthma 4Despite the fact that smoking is particularly dangerous in individuals with asthma, asthmatic adolescents are as likely as their non-asthmatic peers 4to smoke cigarettes

Red FlagsGrowth patterns should be closely monitored in children taking high doses of inhaled corticosteroids, due to the possibility that the medication will 4slow growth

What Do I Need to Tell the Patient/Patient’s Family?Educate the patient/family/caregiver on the importance of adherence to the medication regimen; the correct use of nebulizers/inhalers and peak 4flow home monitoring devices; daily symptom monitoring to prevent emergencies; maintaining adequate hydration to help loosen secretions; keeping scheduled appointments for follow-up clinician visits; avoiding triggers (e.g., smoking and secondhand smoke, cold air, aspirin, and intense exercise); and controlling household pollutants (e.g., cockroaches, pet dander, mold, dust mites) by using humidifiers/HEPA filters, covering upholstered furniture and vents, and keeping air ducts, carpets, and bedding cleanEducate on signs of an oncoming attack: cough, fever, irritability, decreased appetite, anxiety, dry mouth, and/or circles under or around the eyes; 4provide and emphasize the importance of having an emergency plan for asthma exacerbations; recommend obtaining additional information from the Asthma and Allergy Foundation of America at http://www.aafa.org/

ReferencesFerri, F. F. (2010). Asthma. In F. F. Ferri (Ed.), • 2010 Ferri’s clinical advisor: Instant diagnosis and treatment (pp. 100-108). Philadelphia: Mosby Elsevier. Guo, S.-E., Ratner, P. A., Johnson, J. L., Okoli, C. T., & Hossain, S. (2010). Correlates of smoking among adolescents with asthma. • Journal of Clinical Nursing, 19(5-6), 701-711.Jackson, D. J. (2010). The role of rhinovirus infections in the development of early childhood asthma. • Current Opinion in Allergy and Clinical Immunology, 10(2), 133-138. Kolski, G. B. (2010). Asthma in children. In E. T. Bope, R. E. Rakel, & R. Kellerman (Eds.), • Conn’s current therapy 2010 (pp. 778-784). Philadelphia: Saunders Elsevier. Vuillermin, P. J., Robertson, C. F., Carlin, J. B., Brennan, S. L., Biscan, M. I., & South, M. (2010). Parent initiated prednisolone for acute asthma in children of school age: Randomised controlled crossover trial. • BMJ, 340, c843.