Pediatric Asthma

By Sean Robertson EMT-P, I/C

Pediatric Asthma

Nine million U.S. children under 18 have been diagnosed with asthma

More than four million children have had an asthma attack in the previous year.

Asthma rates in children under the age of five have increased more than 160% from 1980-1994

Approximately 44% of all asthma hospitalizations are for children. Children 5-17 years of age missed 14.7 million school days due to

asthma in 2002 Approximately 40% of children who have asthmatic parents will

develop asthma.

AAAI Asthma Statistics 2006 http://www.aaaai.org/media/statistics/asthma-statistics.asp Accessed Oct. 26, 2008

Using a coffee stirrer, breathe in normally, then breath out through the stirrer. Repeat over and over…that’s what asthma feels like.

Simulating Asthma

The Immune System and Asthma

To get to the bottom of it, asthma is an allergic reaction.

Many asthmatics experience other allergic signs along with their asthma attack.

Such signs include itchiness of the chest, neck, and chin.

Itchy, red eyesStuffy, runny noseItchy oral and/or pharyngeal mucosa

Sensitization to an allergenEarly-phase response upon re-

exposure to an allergenLate-phase response to an allergen

Asthmatic Cascade

First time exposures to allergensInhalation (of pollen, mold, dust mites, etc.)Ingestion (swallowing a type of food or medication)Touch (coming into contact with poison ivy, latex, or certain metals, such as nickel)Injection (receiving a medication or being stung by an insect)

Sensitization

Antigen presenting cells (APC) recognize the foreign protein (or antigen) and swallow it (either phagocytosis or endocytosis).

The APC then “presents” itself to a T Lymphocyte, activating the T Lymphocyte to release Cytokines.

The Cytokines in turn activate B Lymphocytes.B Lymphocytes become Plasma Cells,

producing IgE antibodies specific to the antigen that started this whole cascade.

Sensitization

IgE

The surfaces of mast cells contain special receptors for binding IgE. The IgE antibody fits to this receptor like a module docking with the mother ship. This arrangement is such that when two adjacent mast-cell-linked IgE antibodies are in place, the allergen is drawn to both and attaches itself to both, cross-linking the two IgEs. When a critical mass of IgEs become cross-linked, the mast cell releases histamine and other inflammatory substances, and the allergic cascade begins.

An immunoglobulin associated with Mast Cells. Overexpression of IgE has been associated with

allergic/asthmatic hypersensitivity

IgE

Male et al. Immunology7th edition Chapter 3Murray, et al. Medical Microbiology5th edition,

The IgE antibodies are free floating and find Mast Cells

The IgE binds to receptors on Mast Cells.The system is now sensitized.If the same antigen that started the

whole cascade is encountered again, it will bind with the IgE “armed” Mast Cells, causing Mast Cell degranulation

Sensitization

Asthmatic Cascade

IgE

An immunoglobulin associated with MAST CELLS. Binds with MAST CELLS upon exposure to aeroallergen, causing MAST CELL degranulation. Overexpression has been associated with allergic

hypersensitivity

Mast Cells

Bradykinin

A nonapeptide messenger that is enzymatically produced from kallidin in the blood where it is a potent but short-lived agent of arteriolar dilation and increased capillary permeability. Bradykinin is also released from mast cells during asthma attacks

Prostaglandins

Powerful vasodilators Inhibits platelet aggregation Mediates Inflammation

Cytokine: A small protein released by cells that has a specific effect on the interactions between cells, on communications between cells or on the behavior of cells. The cytokines includes the interleukins, lymphokines and cell signal molecules, such as tumor necrosis factor and the interferons, which trigger inflammation and respond to infections.

Definition from Medicinenet.com

Cytokines

Airway Pathology

Excessive contraction of smooth muscle Hypertrophy Hyperplasia Usually extends to bronchioles Thickened basement membrane of bronchial

epithelium Overabundance and hypersecretion of goblet

cells Submucosal edema

Airway Changes

Pathophysiology of Asthma

Note the increased number of mucous glands.

Note the hypertrophy of the muscle layer.

Early Phase Vs. Late Phase Response

EARLY - minutes to 1 hour, may dissipate;

bronchospasm, early edema

LATE - several hours, rebound, inflammatory,

excess mucous, refractory bronchospasm

DUAL - progression

Before Your Shift...

Some things that you can do to help out your potential asthma patient.

Understand that perfume/cologne can be a strong trigger for asthma attacks. Please don’t douse yourself with the Fu Fu Juice.

Animal dander can also be a strong trigger. Please wear clean clothes and, if you have animals, use a lint roller to remove hair/dander.

If you smoke, please wash your hands after smoking and try to avoid letting your clothes become saturated with the smell of cigarette smoke.

Before the Call

Make sure you have a working stethoscope that fits comfortably

Make sure that your pulse oximeter has good batteries and a working sensor

Do you have enough oxygen to run a serious respiratory call?

En route to the Call

Approach the call with the presumption that the patient is truly sick.

Mentally prepare yourself for a respiratory call. Again… NEVER approach a respiratory call with

the presumption that the patient is “just hyperventilating” or “just a drama king/queen”

Did I stress that it is important to presume that all respiratory calls are true emergencies?

Assessment Challenges

have smaller airway anatomy tend to have greater emotional reactions to

uncomfortable and scary events are generally poor historians can have poor compliance with med’s want to be “normal” like the other kids

History

Usually directed to the parents Ask the parent to rate the attack on a scale from 1 to

10. Has the patient ever been intubated? Admitted? ICU? If the patient tracks his/her peak flows, ask them what

their best is and what their current is. 80-100% of their best is considered controlled asthma. 50-79% is a warning area indicating the need for

increased medicine usage 0-49% indicates a medical emergency and should be

taken very seriously

Treatment

Reassurance Get down on there level Oxygen IV (Asthmatics are almost always dehydrated) Albuterol (dose?) Epi (dose, route?) BVM Intubation

Case Study

You are called to a 06C2, 5 year old male with asthma. You arrive to find a frantic mother holding her child in her arms. Mother tells you that her son has had a cold for 5 days, but today, he became listless and didn’t seem to be breathing right.

Case Study

Case Study

On examination you find a gaunt appearing 5 year old. He seems to be staring off into space. His oral mucosa is dry and he has perioral cyanosis. You notice that his lungs are diminsihed, but you hear no wheezing. You see intercostal retractions, tracheal tugging, and nasal flaring. Central capillary refill is 5 seconds.

Case Study

Vital signs.Pulse 150 weak at the brachialBP 90/40RR 54, laboredSpo2 80% room air

Case Study

Treatment?O2? BVM?When is intubation considered?IV? IO?Fluids!EPI?Albuterol?

Case Study

Enroute, You administer O2 via cannula with 2.5 mg albuterol neb.

An IO was established in the patient’s right tibia and a fluid boluss was started

The patient became apneic and required BVM.

Soon after, the patient lost pulses and CPR was started.

Case Study

What were the possibilities with this case?

What other history could have been obtained?

Any different treatment (s) ?Why did the patient code?

Case Study 2

You are called to intercept with Torreon at 10 pm. The dispatch info is for an infant in respiratory distress. You arrive to find 2 EMT-B’s attending a 4 month old male. Mom is following in her car. Mom states that the baby has been sick with nasal discharge and cough x 3 days.

Case Study 2

The child is being given O2 8lpm via blow by.

He is breathing 70 times per minuteHis pulse rate is 220, strong at the

brachial site bilaterallyWhat physical signs might we also

see in this case?

Case Study 2

Mom states that the baby stopped taking food and fluids this morning.

This is what you find upon entering Torreon rescue

Case Study 2

You see obvious signs of air hunger (nasal flaring, see-saw breathing, intercostal retractions, tracheal tugging)

The child responds only to painful stimulus.

His lung sounds are mostly absent with a slight squeak on exspiration

Case Study 2

WHAT NOW????

Case Study 2

What do you want to do?What more do you want to know?How do you want to transport this

patient?

Any Questions???

Asthma Medications

What will they come up with next????

Accolate

Generic name: Zafirlukast Leukotriene receptor antagonist Taken twice daily One of the next generation med’s

aimed at controlling chronic inflammation.

Age ranges 5-Adult

Aerobid and Aerobid M Generic

name:Flunisolide Inhaled corticosteroid Usually taken 2-4 puffs

twice daily Use is preventative in

nature. Aerobid M has green

lettering and a green cap.

Aerobid M is the same as Aerobid, except it has a menthol flavor.

Advair

Generic Name: Fluticasone/Salmeterol

Combination of a corticosteroid and a long acting Beta agonist.

Taken twice daily. Used only for

prophylaxis.

Albuterol

Also known as… Ventolin Proventil Volmax Can be nebulized,

aerosolized, taken as a pill, or taken as a syrup

Generic MDI’s can be grey, white, red, blue, etc.

Alupent

Metoproterenol One of the older fast

acting beta agonists (I was placed on alupent when I was 5)

Available as MDI and Neb Sulution.

Azmacort Triamcinolone Inhaled corticosteroid Works well for asthma, but can be up to 8-

12 puffs twice daily.

Beclovent Beclomethasone Corticosteroid Inhaled via MDI twice

daily. Not widely used

anymore

Brethair

Terbutaline Beta agonist SQ/IM use is similar to

Epi. Can be nebulized No longer widely used

in asthma

Bronkosol

Isoetharine Beta agonist Nebulized Not widely used

anymore

No Image Available

Flovent

Generic Name: Fluticasone Proprianate Inhaled Corticosteroid Taken 2-4 puffs twice daily.

Foradil Formoterol Long acting beta

agonist Brand new med.

Intal

Generic Name: Chromalyn Sodium

Works as an anti-inflammatory by stabilizing Mast cell walls.

2 puffs 4 times daily make this medication difficult to comply with.

Maxair

Pirbuterol Short acting beta

agonist Alternative to

albuterol

Pulmicort Budesonide Corticostero

id One of the

newer steroids

Serevent

Salmeterol Long acting beta agonist A LOT of asthmatics are

on this drug, or Advair, which contains serevent.

Singulair

Montelukast Leukotriene

receptor inhibitor Another next

generation asthma medication.

Appropriate for ages 12 months-Adult

Theophylline

Numerous names Methylzanthine Acts as bronchodilater, but

also increases diaphragmatic contractility and decreases lung sensitivity to allergens and other asthma triggers

Tilade

Nedocromil Sodium Another Mast cell

Stabilizer. MOA similar to Intal

Xolair

Omalizumab

Binds serum free IgE, thereby blocking it from binding with Mast cells

Only available as SQ injection.

Dose is based on weight.

Xolair

Xopenex

Levalbuterol Short acting beta agonist Has been found to work

better than albuterol with lower doses and less side affects.

Only available as nebulized solution.

Kept in foil package and must be used within 7 days of opening package.