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Summary
Asthma is a chronic and acute condition that causes inflammation of the airways in response to allergens such
as viral infections and pollen. This article reviews the developmental anatomy and physiology of the respiratory
tract, and considers asthma diagnosis, treatment and management. This article is intended for the student or
the junior registered nurse, however the experienced mentor may find it useful as a framework to help them
support the learning needs of mentees.
ASTHMA IS A leading chronic disease among children
in most industrialised countries (Bacharier ef al 2008).
It is a condition that is linked to high morbidity and a
risk of death. The condition runs in families, particularly
those with eczema and other allergies (Bacharier ei
al 2008). The symptoms are unpleasant and can
affect the quality of a child's life, their daily activities,
how they see themselves (Hey 2008), and their selfconfidence (Vuillermin ef al 2010).
Absences from school can affect a child's
achievement and restrict their future education and
career options. Unskilled and non-professional workers
tend to be paid less than graduates. This could, in
turn, limit the resources they have available for their
own families. Understanding this point is important as
there is a high correlation between disability, disease
and poverty (Burchardt 2006, Preston 2006, Disability
Alliance 2010).
Although there is evidence that the prevalence of
asthma is now tapering off slightly (Malik ef ai 2010),
the incidence of childhood asthma has increased in
the past 50 years. The reasons for this are unclear,
however a number of lifestyle factors are incriminated,
such as exposure to tobacco smoke, diet, domestic
hygiene, and environmental factors such as pollution
and early life infections. In childhood, asthma
tends to be more common in boys than in girls
(Malik ef ai 2010) so there may be a hormonal facet
or gender influence.
About one million children in the UK have a
known diagnosis of asthma (National Institute for
Health and Clinical Excellence (NICE) 2007) which
NURSING CHILDREN AND YOUNG PEOPLE
Keywords
Anatomy, asthma
management,
embryology, inhaler
therapy, nebulisers,
respiratory system and
disorders, spacer devices
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The
and
The
The
Ectoderm
Mesoderm
Endoderm
Anatomy
The shape and size of the head, the large occiput of
the infant's head and the relatively short neck can
result in neck flexion which may compromise the
airway of the infant when consciousness is impaired or
when the infant is exhausted and sick. Whether infants
are obligatory nose breathers, or not, is controversial,
but the nostril size is small and can get narrowed
or blocked with mucus and crusted secretions. The
relatively large size of the infant's tongue in proportion
to the rest of the oral cavity can result in potential
obstruction of the airway (Stoelting and Miller 2007),
The larynx is higher in the neck at the level
of C3-4 than in an adult (C4-5), and the infant's
epiglottis enters the anterior pharyngeal wall at a 45
angle and projects more posteriorly than in the older
child (Figure 2, page 29). The shape of the epiglottis
is different from in the adult and resembles more of
an uppercase omega (Q) - from the Greek alphabet
(Stoelting and Miller 2007),
The size and shape of the larynx is different, the
cricoid ring is a complete ring of cartilage and the
narrowest point of the upper airway compared to
the vocal cords in the adolescent and young person
(Stoelting and Miller 2007), The trachea is short in the
infant, approximately 4 to 5cm from cricoid to carina.
It is narrow and soft (Dixon ef al 2009), The airways
are smaller and less developed than in adolescents.
This means a relatively small obstruction can
compromise the airway radius causing a significant
increase In respiratory effort. This is important when
considering children with asthma because a small
amount of mucus or oedema can seriously reduce the
NURSING CHILDREN AND YOUNG PEOPLE
Development
Embryonic period:
26 to 52 days
The lung begins to appear as ventral pouches from the foregut. The foregut divides into a
dorsal portion, which becomes the oesophagus, and a ventral portion, which becomes the
trachea and the early lung buds.
Development continues with some divisions, giving shape to the left and right bronchial tree.
Pseudoglandular period:
Day 52 to 16 weeks gestation
Formation of the major conducting airways and terminal bronchioles. The diaphragm is
formed between eight and ten weeks of gestation.
Life is not possible if the fetus is born at this stage as there is no possibility of gas exchange.
However, damage can be done to the future airways at this stage and there is a high
correlation between maternal smoking, future respiratory infections and predisposition
to asthma.
Canalicular period:
Weeks 17 to 24-(- gestation
Saccular period
Weeks 28 to 36 gestation
Alveolar period
Weeks 36 to term
Development of the respiratory bronchioles. Each bronchiole ends with two or three terminal
sacs or primitive alveoli. At 24 weeks' gestation the fetus is regarded as viable, although
infants born then require considerable supportive technology to sustain them. Supportive
technology can cause damage, such as a ventilator lung. Despite considerable medical and
nursing efforts, many infants born at this early stage will die or survive to develop complex
needs, including pulmonary insufficiency and predisposition to respiratory illness, especially
asthma (McCormick ei a/ 2011).
Increased vascularisation of the lung occurs. Elastic fibres develop; smooth muscle and true
alveoli are present at 34 weeks' gestation. Infants born at this stage are likely to do well and
less likely to have complex needs. They are less likely to require aggressive support to sustain
them. Although they are susceptible to seasonal epidemics such as respiratory syncytial virus
(RSV) (Escobar ef a/2010).
Further development of the terminal sacs and formation of the walls of true alveoli. Columnar
cells develop and differentiate in the alveoli into type 1 and II. Type 1 cells provide the alveolar
surface area for gas exchange and type II cells secrete surfactant, necessary to lower the
alveolar surface tension and sustain lung inflation. Towards term the immune system starts
to mature. Prematurity and exposure to supplemental oxygen during the neonatal period
predisposes to RSV infection and these have independent associations with the development
of recurrent wheezing in the third year of lite (Escobar ei al 2010),
Age of viability
What is regarded as the age of viability and
why is it not possible to sustain life before
this? Why is it important to take a full
antenatal history when an infant or young
child is admitted with wheezing?
Anatomical differences
List at least five differences in the anatomy
of the young child compared to that of the
adolescent. Using the information provided,
how can asthma change the airways,
breathing and homeostasis of the child?
Breathing
Although there is learned conscious override when
children learn to control their breathing to enable
speaking, swimming, singing and - in some children
- breath-holding behaviour, breathing is automatic
and the child is usually unaware of the process. In
quiet, passive, normal breathing air enters through
the child's nose, where it is warmed, moistened and
filtered in the nasal cavity before travelling through the
pharynx, larynx and into the trachea. From the trachea
the airways divide into the left and right main bronchi
and further divide into increasingly smaller diameter
airways called bronchioles, which branch off and
become microscopic and terminate in tiny, thin-walled
sacs called alveoli (Tortora and Derrickson 2009).
The structure and linings of the airways are
relatively smooth and this encourages the flow of
air over them so that breathing is relatively silent.
September 2011 | Volume 23 | Number 7
Defining asthma
Asthma is a chronic condition that has periods of
quiescence and exacerbation. It involves inflammation
of the airways and airway reactivity causing
a contraction of the bronchioles; this is called
bronchospasm (Dixon ef al 2009) (Figure 3, page 30).
It results from a complex chain of events involving a
number of cells and pathophysiological mechanisms.
Asthma could be regarded as an immune-inflammatory
response condition where the normally protective and
beneficial inflammatory reactions start to occur in
the airways when there is no need for them to react,
such as in response to infections, toxins, or inhaled
substances, such as pollen or tobacco smoke. The
NURSING CHILDREN AND YOUNG PEOPLE
Tachypnoea.
Use of accessory muscles (seen as nasal flare, head
bobbing, shoulder fixing, abdominal breathing and
in-drawing of the musculature of the thoracic cage).
Continuous, high-pitched musical-like wheeze
because of airway turbulence.
Normally a troublesome cough.
Also, there may be emotional distress and panic,
including restlessness and breathlessness. Verbal and
cognitively aware children might complain of a tight
chest, and children may become uncommunicative
because they do not have the breath to speak.
Now do time out 3.
Diagnosis
Diagnosis can be difficult, particularly in infants and
those under five years of age. Spirometry and the
measurement of peak expiratory flow (PEF) are the
lung-function tools most frequently used to measure
airflow obstruction in older children. For practical
reasons these methods are not used in children
under the age of five. A diagnosis is based, instead,
on clinical symptoms and observation of features
prevalent in asthma during clinical examination.
Vital signs
Define asthma to an anxious parent in layterms. Construct a tabie of the average and
normal vital signs of heart rate an(d respiratory
rate for the following, an infant aged three
months, an infant just under a year, a toddler, a
preschool child, a school-age child and a young
person aged 14 (a suggested answer is on page
34). At what point would you consider each
of these patients to have a tachycardia or be
tachypnoeic?
lowest amount of medication to control symptoms
while maintaining efficient respiratory function. Children
should begin treatment at the stage most appropriate
to the severity of their symptoms. When the child's
condition improves, he or she should be maintained
on the lowest step that controls their symptoms. The
approach to asthma management allows treatment to
be stepped up or down as required (British Thoracic
Society, Scottish Intercollegiate Guidelines Network
2011) (Table 1, page 31).
Relievers The first medicines used for children with mild
intermittent asthma are treatments known as 'relievers'
these are short-acting beta^ (^) agonists. They provide
relief from distressing symptoms of asthma during an
acute attack. In the UK they are usually colour-coded
Figure 2
Sinus
Larynx
Trachea
Right lung
Bronchi
Figure 3
Blood vessels
Swelling and
inflammation
Muscle
Increased
mucus
Mucus
Assessment tools
There are a number of tools available to check the
level of control a child has over their condition (see
The Childhood Asthma Test in the resource box
for an example). The Royal College of Physicians
devised three questions which have been successfully
NURSING CHILDREN AND YOUNG PEOPLE
Step 2: regular
preventer
therapy
Step 3: add-on
therapy
Referral to specialist
respiratory paediatrician.
or frequent
use of
oral steroids
Patient education
Any therapy is only as good as compliance and
concordance with the products. Inhaler therapy has
been central to the management ot children with asthma
and has been recommended tor difterent age ranges by
NICE since 2000 and 2002, Children's nurses play a
Conclusion
This CPD has introduced the developmental origins
of the respiratory systems and considered aspects
of the normal growth and physiology of the airways.
Practice profile
Now that you have read the article you might
like to write a practice profile. Guidelines to
help you are on page 36.
Resources
Clinical strategies
What communication strategies would you
use when a breathless > oung person is
admitted to the ward and suffers an acute
asthma attack during the admission process?
What would your priorities be during a
follow-up home visit where an infant had
been discharged from the emergency
department, or a medical assessment unit
following a period of breathlessness?
Suggested answers
to time out activities
on page 34
References
Amado M. Portnoy J (2006) Diagnosing asthma
in >ouiiK children. Current Opinion in Allergy and
Clinical Immunology, (i, 2, 101-105.
Time out 3
Age
Three months
90-160
30-40
More than 60
80-130
25-40
More than 60
Toddler
80-110
20-30
More than 50
Preschool
70-100
18-28
More than 40
School child
60-100
16-26
More than 40
Young person
60-90
15-20
More than 40
Time out 4
Normal child
Child has poor night's sleep. Disturbed when moved off high pillows, takes relievers.
Paces activity, breathless in the shower. Is slow to eat because higher respiratory
levels make chewing, swallowing and breathing difficult to co-ordinate.
Eats packed lunch. In the past, has had allergic reactions to muesli bake, lentil curry,
and kiwi fruit yogurt. This has made staff and parents anxious.
Is tired and makes little attempt with homework, falls asleep before bedtime
medicines. Has to sleep without toy teddy as a dust mite precaution.
with friends.
Sleeps with stuffed toy teddy.
Practice profile
What do I do now?
3. PortfoUo submission
1,000 words?
~ Have you kept a copy of the practice
profile for your own portfolio?
Have you completed the cut-out form and
attached it to your entry?
Job title:
Place of work:
Address
Practice Profile
RCN Publishing Company
Freepost PAM 10155
Harrow, Middlesex HAl 3BR
Article number:
First name:
Postcode
Surname:
Daytime tel:
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