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Continuing professional development

Understanding childhood asthma and


the development of the respiratory tract
NCYP8 Crawford D (2011) Understanding childhood asthma and the development of the respiratory
tract. Nursing Ctiildren and Young People. 23, 7, 25-34. Date of acceptance: May 18 2011.

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

could indicate that every classroom has two children


with asthma (NICE 2007). All schools should have
policies for dealing with children with asthma and
children's nurses should be effective in supporting the
development of these (Anderton and Broady 1999).
As care pathways change, managing asthma is
going to be as important to children's nurses who work
in the community as it is to those working in the acute
sector. There is evidence that home visits are valuable
to children with asthma (Bracken ef al 2009) and that
specialist asthma nurses reduce comorbidity (McKean
and Furness 2009). In addition, GPs believe that
children's nurse-led asthma services benefit surgeries
(Frost and Daly 2010).

Doreen Crawford is senior


lecturer. De Montfort University,
Leicester, and consultant editor
Nursing Children and Young
People

Keywords
Anatomy, asthma
management,
embryology, inhaler
therapy, nebulisers,
respiratory system and
disorders, spacer devices
This artide has been subject
to open peer review and
checked using antiplagiarism
software. For related articles
visit our online archive and
search using the keywords

Children's nurses have a role in enhancing


compliance with therapy and improving the
understanding of the condition, which has been
acknowledged to be poor, particularly in adolescence
(Edgecombe ef a/ 2010).

Aims and learning outcomes


The aim of this article is to increase children's nurses'
awareness of asthma and enhance their confidence
when dealing with children who present with the
condition. By reading this article and completing
the time out activities the reader will have a greater
understanding of:

The
and
The
The

underpinning of the developmental anatomy


physiology of the child's airways.
disease asthma.
management of asthma.

The impact asthma can have on the child.


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Continuing professional development


Embryology
The embryo's blueprint comes from the genetic
contribution of the parents. Asthma is increasingly being
understood as a complex interaction between a child's
genes and the child's environmental factors (Chung
2011). Although it is not uncommon for an asthmatic
parent to express guilt for passing the disease on to
their child, the children's nurse - while acknowledging
that genes play a part - can emphasise the complexity
of the condition. This may help to ensure that parents
do not blame themselves or each other. The children's
nurse could point out that genetics is a lottery: during
the early embryonic phase the disc of specialising cells,
which forms layers of tissue, are switched on and off by
the genes of both parents; it would be impossible for the
parents to influence the genetics of their child. In the
future there may be techniques in genetic engineering
which will identify children who are more at risk of the
disease, improve its management and possibly eradicate
the condition.
The tissues that give rise to the respiratory system
are the endoderm and the mesoderm (Figure 1),
Rudimentary formation commences about the fourth
week of gestation. Although the baby's respiratory
system will not carry out its primary physiological
function until after it is born, the respiratory tract,
diaphragm and lungs do form early in the
embryonic period.
When considering the development of the respiratory
system it is important to set if in context with the
development of other systems. For example, the
proximity of the developing trachea to the oesophagus
of the upper gastrointestinal system and the dual role
of the oropharynx. Because of the interconnectivity
of the air entry points with the face and their role in
Transverse section of trilaminar emb

Ectoderm
Mesoderm
Endoderm

September 2011 | Volume 23 | Number 7

maintaining homeostasis, it is recommended that the


reader also reviews the embryological development of
the sensory system and the skeletal system (Box 1), The
sensory system influences some of the triggers in asthma
and the muscular skeletal system can be developed with
exercise and physiotherapy making the thoracic cage
accessory muscles stronger, and this can influence the
course of an asthmatic attack.
The respiratory system begins at the nasal cavity
and consists of a conducting portion and a respiratory
portion. The conducting portion includes the nasal
cavity, pharynx, larynx, trachea, bronchi and bronchioles.
The respiratory portion consists of the respiratory
bronchioles, alveolar ducts, alveolar sacs and the alveoli.
The respiratory tract matures, develops and grows with
the child and the adult anatomical framework and
configuration is not in place until the age of seven to
eight years (MacGregor 2008), As childhood is a
period of rapid growth in the lungs and the immune
system, developmental factors should be considered in
the pathogenesis of childhood asthma (Chung 2011)

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

ibryological and fetal development of the respiratory system


Gestational age

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),

(Adapted from Dixon e! ai 2009)

working diameter of the airway. In addition, airway


remodelling with the increase in smooth muscle mass
has been shown to be an early finding in childhood
asthma (Tillie-Leblond ef a/ 2008), Hyperplasia and
hypertrophy contribute to the increase in smooth
muscle mass. This can be related to clinical severity
and predictive of greater airflow obstruction (Bai
2010). Now do time out 1,

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?

NURSING CHILDREN AND YOUNG PEOPLE

The number and size of the alveoli continue to


increase until approximately eight years of age. As the
number of alveoli increase the respiratory surface area
available tor gas exchange increases correspondingly.
As the child grows and matures so do the number of
collateral ventilatory channels. This means that the
alveoli can be aerated via these connections even when
the terminal bronchiole, which directly supplies them,
are narrowed or blocked. This is important as the lungs
can shunt air about and the gas exchange units do not
need to be directly connected to a main airway. The
channels of Martin are interbronchiolar connections. The
canals of Lambert connect closely adjacent bronchioles
and alveoli, and the pores of Kohn facilitate interalveolar
connections (Dixon ef al 2009). These communications
between the lower airways are thought to develop after
infancy and up to six years of age. Until these pathways
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Continuing professional development


develop, young children are at increased risk of
atelectasis and hyperinflation which can be associated
with asthma and infection (Dixon ef al 2009)

In contrast, the swollen narrowed airways of the


asthmatic child having an attack causes airway
turbulence and an audible wheeze.

The position of the ribs and the shape of the thorax


do much to ease the work of breathing in the mature
individual. In infants the ribs lie horizontally and the
shape of the thorax is circular. This changes and by
approximately six years of age the thorax is ellipsoidal in
shape. In infancy the chest wall is thin with little muscle
to stabilise it and, as a result, is highly compliant. To
compensate for this instability infants use their abdominal
muscles to assist with breathing. A child's diaphragm
is flatter in shape making each contraction less efficient
than that of the more mature young person.

The respiratory system serves a vital function in


maintaining metabolic homeostasis. Oxygen is needed
to support normal metabolism and, as part of that
process, carbon dioxide - a waste gas - is produced.

Appreciating the developmental differences in a


child's anatomy and physiology underlines the fact that
children are not small adults. A nurse who is aware of
the detail of a child's respiratory system will understand
that the younger the child, the poorer their functional
reserves. The asthmatic child can get into respiratory
difficulties quickly, and will need intervention and help
sooner. Although most children will grow out of their
asthma, some studies have suggested that decreased
lung function can occur early. Although it may not
change further with ageing (Chung 2011), it may have
an impact on the child's growth and development.
Now do time out 2.

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

This gas exchange is performed in the lungs, via the


interface between alveoli and capillary. It is important
to regulate the levels of oxygen and carbon dioxide
in the blood because changes in the concentration
of blood carbon dioxide affects the child's pH. The
body chemistry works best in a narrowly defined
pH of 7.35-7.45 (Dixon ef al 2009). Centres in
the brain regulate the rate and depth of respiration
and a fall in pH which results in a more acidotic
internal environment will trigger a breath, which will
help eliminate carbon dioxide. As carbon dioxide
is continually produced it needs to be eliminated
constantly so the cycle of breathing in health is regular
and not interrupted (Tortora and Derrickson 2009).
The asthmatic child may present with an altered
blood gas depending on the severity and duration
of the attack. When the attack begins, the natural
response to a sensation of being short of breath is to
become frightened. This can lead to hyperventilation.
Because more air is being shifted in and out of the
lungs more CO^ is washed out and the CO^ level
will initially drop, while the pH may rise (respiratory
alkalosis). The situation can deteriorate if the asthma
attack is not managed well. Because asthma causes
bronchospasm and obstruction the patient cannot
exhale completely which can result in air trapping
and hyperinflation.
To maintain ventilation, the child will need to
work hard to breathe and maintain his or her blood
gas. Eventually the child will begin to tire and start
breathing less. The CO^ will start to rise and the
pH will drop (respiratory acidosis). With respiratory
insufficiency the 0^ will drop (hypoxemia).

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

inflammatory responses, which result in an attack,


are triggered as a result of the action of cells such
as B and T lymphocytes, mast cells, eosinophils,
neutrophils, macrophages and the chemical mediators
produced by cells.
In an asthma attack the inflammation becomes
persistent and a number of changes occur in the
ainways. Oedema develops in bronchial tissue, mucus
secretion increases; epithelial cells slough off the
airway wall and mix with the mucus to form thick
plugs, which can further block the airways. The
smooth muscle contracts and, because of the diameter
of a child's ainway, even small changes can limit the
amount of air that can flow through the bronchioles.
Frequent attacks can result in permanently narrowed
airways.
Asthma can affect children of all ages although it
is hard to diagnose under the age of three (Amado
and Portnoy 2006). Babies can wheeze but because
not all wheezes are caused by asthma, parents might
experience frustration that their infant is in and out of
hospital with no diagnosis.

Asthma attack symptoms


The following are signs of respiratory distress, because
of the altered anatomy of the ainways which results in
a variable and reversible airflow obstruction:

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

Treatment and management


Because there is no cure the aim of managing asthma
is to achieve control of the condition by using the
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Continuing professional development


Side effects Parents and professionals can be anxious

Figure 3

over the long-term use of steroid therapy in children


Normal airway

and the steroid load placed on a child with asthma

Airway in asthma attack

can be a cause for concern. The effects of long-term


exposure to steroids are not fully known (Sridhar and
Widened blood vessels

McKean 2006). They may be associated with slower


growth and there are other side effects on the flora

Blood vessels

of the mouth, mood swings, heartburn or indigestion


and on adrenal function. Oral steroid therapy, such as
prednisolone, is given with caution with young children
as a rescue therapy and only under the direction and
review of a senior clinician.
Contracted
muscle

Swelling and
inflammation

Muscle

Long-acting ^ agonists (LABAs) These are an add-on


therapy for children aged more than five years and can
be used to improve symptom control. LABAs work by
relaxing smooth muscles and are taken one or twice a
day. As they do not have anti-inflammatory action
they are used in conjunction with an inhaled steroid,
such as salmeterol.

Increased
mucus

Mucus

blue, ^agonists are bronchodilators with a rapid onset


of action, relaxing the smooth muscle of the bronchioles
and relieving bronchospasm. They are administered
by a metered dose inhaler (MDIs). Pocket-size breathactuated inhalers can be used for co-operative young
people, but spacers and face masks need to be used
with MDIs to deliver this medication into the airways
of young children under the age of five, children with
learning disabilities, and children with co-ordination
problems such as cerebral palsy.
Preventers For children who do not have their asthma
sufficiently well controlled with a pro re nata (PRN)
reliever, preventers can be tried. The effectiveness of
these medicines builds up with time, when compliance
is good these drugs reduce inflammation in the airways
(Asthma UK 2010). Preventers decrease the distressing
symptoms of asthma, improve lung function and reduce
airway reactivity to triggers. In the UK, preventers can
be colour-coded red, brown, beige, pink or orange.
Example medications include beclometasone and
budesonide (Asthma UK 2010).

Other treatments and add ons


Inhaled corticosteroids (ICS) Sometimes called
glucocorticoids, these are another anti-inflammatory
therapy for the treatment of a child's asthma symptoms.
They help to reduce inflammation in the ainways. They
are regarded as suitable for children under 12 years
(NICE 2007). Although the effective dosage will vary
from child to child, for most children they are effective
at low doses.
i M September 2011 | Volume 23 | Number 7

Leukotriene receptor antagonists Leukotrienes are a


group of chemicals produced by mast cells, which are
important mediators of inflammation in the upper and
the lower airways. They work by blocking the binding
of leukotrienes to the receptors on bronchial smooth
muscle. An example of this medication includes
montelukast, which was first licensed in January 1998
for use in children aged more than six years and in
January 2 0 0 1 the licence was extended to Include
children aged two to five years.
Theophylline The role of xanthines as an add on is
controversial. There is marginal evidence that it has
some good effect, but this needs to be balanced
against not inconsiderable side effects (Seddon ef al
2006).
Omalizumab This is an injectable monoclonal antibody
that binds to IgE and is available and licensed for
the treatment of severe asthma as an add on in
adolescents and children over six years of age who
have proven IgE-mediated allergic asthma. NICE
guidance does not recommend it for children under 11
years of age (NICE 2010). It is a new generation of
medicine, has a range of side effects, and should only
be prescribed for patients over 12 years and the child
should be monitored by senior doctors (NICE 2010).

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

Stepwise therapy for treating asthma in children and young people


Steps 1-5
Step 1: mild
intermittent
asthma

Adolescents and young people


aged 13 years and over

Children aged five to 12 years

Inhaled short-acting beta^ (p agonist


as required.

Inhaled short-acting ^ agonist as required.

Children aged under


five years
Inhaled short-acting
^ agonist
as required.

Step 2: regular
preventer

Add an inhaled steroid


200-800 micrograms (meg)* daily

Add Inhaled steroid 200-400mcg daily


Use other preventer drug if inhaled steroid

therapy

(400mcg is an appropriate starting


dose for many patients).

cannot be used, 200mcg is an appropriate


starting dose for many patients.

Start at dose of inhaled steroid

Start at dose of inhaled steroid appropriate


to the severity of disease.

that is appropriate to the severity


of the disease.

Add inhaled steroid


200-400mcg daily or
leukotriene receptor
antagonist if an inhaled
steroid cannot be used.
Start at dose of inhaled
steroid appropriate to
the severity of the disease.

Step 3: add-on
therapy

Add inhaled long-acting ^ agonist


(LABA),

Add inhaled LABA.

Assess control of asthma:

Good response to LABA - continue LABA,

Good response to LABA - continue


LABA,
Benefit from LABA but control still
inadequate - continue LABA and
increase steroid dose to 800mcg/day
- if not already on this dose.
No response to LABA - stop LABA
and increase inhaled steroid to
800mcg* daily. If control still
inadequate, institute trial of other
therapies, for example, leukotriene
receptor antagonist or slow release
theophylline.
Step 4:
persistent
poor control

Consider trials of;


Increasing inhaled steroid up to
2,000mcg'day,
Addition of a fourth drug, for example.

Assess control of asthma:

Benefit from LABA but control still


inadequate - continue LABA and increase
steroid dose to 400mcg/day (if patient is not
already on this dose).

In children aged two to


five years consider trial
of leukotriene receptor
antagonist.
In children under two years
consider proceeding to step
four.

No response to LABA - stop LABA and


increase inhaled steroid to 400mcg daily.
If control still inadequate, institute trial of
other therapies, for example, leukotriene
receptor antagonist or slow release
theophylline.

Consider trials of:


Increase inhaled steroid up to
800mcg/day,

Referral to specialist
respiratory paediatrician.

leukotriene receptor antagonists.


slow release theophylline, and oral
j agonist bronchodilators.
Step 5:
continuous

Use a daily steroid tablet in the lowest


dose providing optimal control.

or frequent
use of
oral steroids

Maintain a high dose inhaled steroid


at 2,000mcg/day,
Consider other treatments to
minimise the use of steroid tablets.
Refer patients to a respiratory
specialist.

Use a daily steroid tablet in lowest dose


providing optimal control.
Maintain a high dose inhaled
steroid at 800mcg/day,
Refer patient to respiratory
paediatrician.

'Example doses: some children will have medication individually prescribed.


(Adapted from British Thoracic Society and Scottish Intercollegiate Guidelines Network 2 0 1 1 , and Scullion 2005)

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Continuing professional development


evaluated (Thomas ef al 2009), These can be
modified for use with children during the assessment
of a verbal and cognitive child whose asthma is being
reviewed or paraphrased tor use with their parents.
The three questions are:

Has the child had difficulty sleeping because ot their


asthma symptoms, for example, have the parents
heard the child coughing?
Has the child demonstrated their usual asthma
symptoms during the day, tor example cough,
wheeze, complained ot chest tightness or seemed
short ot breath?
Has asthma intertered with the child's usual daily
activities, tor example playing or school?
Now do time out 4,

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

Technique Shake the inhaler well. It the child is old


enough they can be involved with this preparation as
a game. Their involvement will help to underscore the
health message that instructions are only ettective it
followed. Fit the inhaler into the opening at the end
of the spacer, check the fit. With the child's consent,
get down to the child's level, place the mask over the
child's tace and check the seal around the nose and
mouth. Press the inhaler once and breathe with the
child, demonstrating five long slow breaths in and out ot
the spacer. It children are very young and uncooperative
an assistant or the parents might perform supportive
holding. The use of therapeutic holding is controversial
but a therapy can only be effective it administered.
However, overly restraining a child can cause emotional
distress that will create problems tor the future.
There are professional dimensions to this practice
and the reader is reterred to Jeffery (2010) for a
balanced review and the Royal College of Nursing
guidelines on restraint (2010). Remove the inhaler
and shake again. This process is repeated for each dose
of the medicine.

key role in teaching children how to use their inhalers or


nebulisers correctly.
Spacers A spacer is trequently used tor intants, young
children or those with additional needs. A spacer is a
large plastic container, with a mouthpiece at one end
and an opening tor the aerosol inhaler at the other.
Spacers only work with an aerosol inhaler. They are
usetui because they make the aerosols easier to apply
and more ettective; more medicine is inhaled and the
possibility of side effects is reduced. This equipment
needs to be kept clean. Unless the child is immunecompromised, domestically clean is sufficient. This is
achieved by washing the spacer in warm water with a
small amount of household detergent, leaving it on a
clean surface to air dry.
Apply and check the fit of the face mask on the
spacer it the child needs to use one. If the device is
new to the parents and the child, a demonstration on
teddy and a few test runs with a placebo will back up
the printed information, diagrams and discussion. It is
worth spending time in parent education as good habits
learned early might aid compliance later.

Compare and contrast


Consider the usual dauy actixities of a well
child, then compare and contrast those with
the lifestyle of a child with chronic asthma.
I A suggested answer is given on page 34.

Compliance This is improved if the administration ot


medication can be built into a child's routine. Intants
can have their drugs administered while sleeping,
it they are awake they may need to be swaddled to
prevent them squirming and knocking the inhaler and
spacer away. If the intant or child is prescribed several
puffs, it is ineffective to administer them all at one
time. This is because a higher concentration of the
drug may coalesce and result in droplets adhering to
the side of the spacer, which may result in the child
receiving less ot the drug. It is good practice, when
possible, to wash the child's face and rinse the mouth,
provide a drink or brush the teeth after administering
medication to avoid deposits ot the drug lingering on
the face or in the mouth,
Nebulisers These are small plastic devices that can
contain a prescribed drug in solution, which is then
attached to a mouth piece or mask and a compressor
which blows air or oxygen under pressure through the
solution to make a fine mist which is then inhaled.
There is evidence that multiple doses of relievers are
as good as nebuiisers (Asthma UK 2009). Although
nebulisers should ideally be used in hospital under
medical supervision they are sometimes used in GPs'
surgeries, hospital emergency departments and on
wards. Now do time out 5.

Conclusion
This CPD has introduced the developmental origins
of the respiratory systems and considered aspects
of the normal growth and physiology of the airways.

September 2011 | Volume 23 | Number 7

NURSING CHILDREN AND YOUNG PEOPLE

It has reviewed asthma at a basic level for students


and junior staff. It can also be used as a resource for
mentors to enhance their awareness of the academic
level of those they mentor. It has reviewed common
therapy and it is hoped enthused the reader to engage
with this opportunity to enhance their portfolio and to
continue to seek more information to help develop and
enhance their knowledge and skill base.

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?

Asthma UK Materials to Help You and Your Patients.


http://tiny.cc/4xynu
British Guideline on the Management of Asthma
National Ciinicai Guideline 101. http://tiny.cc/lqtdh
The Childhood Asthma Test http://tiny.cc/z25zq
Patient.co.uk Inhalers for Asthma.
http://tiny.cc/08gau
British Thoracic Society Nebuliser Treatment Best
Practice Guideline, http://tiny.cc/ilp5b

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.

Chung H (2011) Asthma in childh(xxl: a


complex, heterogeneous disease. Korean .loumal
of Paediatrics. 34. 1, 1-5.

McComnck MC et a;(2011) Prematurit>^ an


overview and public health implications. Annual
Review of Public Health. 32. .April 21, 367-379.

Anderton J. Broady J (1999) Improving schools'


asthma policies and procediores. Nursing
Standard. 14, (1, :i4-38.

Disability Alliance (2010) Disability Alliance


Response R67. ww-vv.disabiiit>alliancc.org/r67.htm
(Last accessed: April 2011.)

Malik G et al (2010) Changing trends in asthma


in 9-12 year olds between 1964 and 2009.
Archives of Disease in Childhood. 96, 3. 227-231

Asthma UK (2010) Schook and Earty Years.


www.asthma.org. iik/how_we_help/schools_early_
years/index.html (Last accessed: .luly 8 2011.)

Dixon M et al (Eds) (2009) Nursing the


High Dependency Child and Infant. Oxford.
Wiley-Blackwell, Oxford.

Asthma UK (2009) Asthma Facte.


www.as thma.org. iik/alLabout_asthma/factfUes/
index.html (Lastaccessed: July8 2011.)

Edgecomhe K et al (2010) Health experiences


of adolescents with uncontrolled seyere asthma.
Archives of Disease in Childhood. 95,12.985-991.

McKean M. Furness J (2009) Paediatric


respirator^' nursing posts in secondary care
reduce asthma morbidity', but provision is
variable. Archives of Disease in Childhood. 94,
8. (44.

Bacharier L el a/(2008) Diagnosis and treatment


of asthma in childhood: a PR.ACTALL consensus
report. Allergy. G'i. 1, 5-34

Escobar GJ ef al (2010) Recurrent wheezing


in the third year of life among children bom
at 32 weeks' gestation or later relationship
to laboratory-confirmed, medically attended
infection with respirator> s>iic>tial virus during
the first year of life. Arclii\'es of Pdiatrie and
Adolescent Medicine. 164,10, 915-922.

Bal T (2010) Evidence for airway remodeling in


chronic asthma. Carrent Opinion in Allergy and
Clinical Immunology. 10.1.82-86.
Bracken M et al (2009) The importance of
nurse-led hoine \1sits in the assessment of
children with problematic asthma. Archives of
Disease in Childhood. 94, 10, 780-784.
British Thoracic Society. Scottish
Intercollegiate Guidelines Network (2011)
Briti'ih Guideline on the Management of Asthma.
BTS. London, SIGN, Edinburgh, wu-w.sigaac.uk/
guidelines/fuUtext/lOl
BurchardI T (2006) Changing Weights and
Measures: Disability and Child Poverty, www.
cpag.org.uk/info/Povert>articles/Povertyl23/
disability.htm (Last accessed: July 8 2011.)

Frost S. Daly W (2010) Nurse-led asthma


services for children and young people: a survey
of GPs' views. Paediatric Nursing. 22, 8, 32-36.
Iley K (2008) The impact of asthma on children's
lives: a social perspective. Primary Health Care.
17.8,25-29.
Jeffcry K (2010) Supportive holding or restraint:
terminology and practice. Paediatric Nursing.
22. 6. 24-28.
MacGregor J (2008) Anatomy and Physiology of
Children. Second edition. Routledge. London.

NURSING CHILDREN AND YOUNG PEOPLE

National Institute for Health and Clinical


Excellence (2000) Guidance on the Use of Inhaler
systems Devices) in Children under the Age of 5
Years with Chronic .Asthma. TAIO. NICE, Londoa
National Institute for Health and Clinical
Excellence (2002) Inhaler De\ices for Routine
Treatment of Chronic Asthma in Older Children
(aged 5-15 years). TAIIS. NICE Londoa
National Institute for Heaith and Clinical
Excellence (2007) Inhaled Corticosteroids for the
Treatment of Chronic Asthma in Children under
the Age of 2 years. TA l.il. NICE, London.
National Institute for Health and Clinical
Excellence (2010) Omaliiumab for the
Treatment of Severe Permtent Allergic Asthma in
Children aged 6to 11 Years. NICE. London.
Preston G (Ed) (2006) A Route Out of Poverty?
Disabled People, Work and Welfare Reform.
Chapter 4. Living with a Disability: a Message
from Disabled Parents. Child Poverty Action
Ciroup, London.

Royal College of Nursing (2010) Restrictive


Physical Intervention and Therapeutic Holding for
Children and Young People: Guidance for Nursing
Staff. RCN, London.
ScuUion J (2005) A proactive approach to
asthma. Nursing Standard. 20 . 9, 57-6S.
Seddon F et al (200(>) Oral xanthines as
maintenance treatment for asthma in children.
Cochrane TMabase of .Systemic Reviews Issue I.
Sridhar A. McKean M (2006) Nedocromil
sodium for chronic asthma in children Cochrane
Database of Systematic Reviews. Issue 3.
Stoelting R. Miller R (2007) Basics in
Anaesthesia. Fifth edition. Elsevier Health
Sciences, Philadelphia PA.
TilUe-Lehlond 1 et a/(2008) Airway retnodelling
is correlated with obstruction in children with
severe asthma. Allergy. 63, 5. 533-541.
Thomas M et al (2009) A.ssessing asthma control
in routine clinical practice: u.se of the Royal
College of Physicians '3 Questions'. Primary
Care Respirator)' Journal. 18, 2, 83-88.
Tortora G. Derrickson B (2009) Principles of
.Anatomy and Physiology. Twelfth edition. Wiley
Publishers, New York, NY.
Vuillermin P e( af (2010) An.xiet> is more
common in children with asthma. Archives
of Disease in Childhood. 95. 8, 624-629.

September 2011 | Volume 23 | Number 7

Continuing professional development


Suggested answers to time out activities
Time outs 1 and 2:
answers can be found in the text and Box 1.
Time outs 3 and 4:
see tables below.
Time out 5:
Under normal, less acute, circumstances,
children's nurses can enable successful
and open communication by using
strategies such as: making the overture,
setting the context, questioning, active
listening, summeirising, reflecting,
paraphrasing and bringing the interaction

Time out 3

to an acceptable closure. Good


communication skills help to reassure the
child, relieve anxiety, and make the child
feel valued and importcint.
The child with asthma may not have
the breath or the energy to participate in
a lengthy two-way interaction.
Strategies that could be used include:
closer observation and taking more
cues from body language, keeping the
questions closed so the child only has to
say 'yes' or 'no', or phrasing them in such
a way that the questions only require a
short answer.

Additionally, giving the child more time


to answer, which alleviates the need to rush
in to fill the pauses in the conversation,
could be employed The children's nurse
might consider providing the answer and
asking the child to nod or shake the head
if they agree. Computer keyboards could
be used, or recourse to a pad of paper for
children who are cognitively advanced.
Another idea is to engage and agree simple
signs. Asthma may make a child temporally
aphasie because they are so breathless but
that child still has communication needs
and wants to be heard.

nal range values and indicators of concer

Age

Example range of heart rates


depend on the age of the
child, state of arousal and
level of health and fitness

Example range of respiratory rates


depend on the age of the child,
state of arousal and level of health
and fitness

If tachypnoeic, the nurse should have


a lower threshold of concern because
children have lower respiratory rates
when at rest or asleep

(Beats per minute)

(Breaths per minute)

(Breaths per minute)

Three months

90-160

30-40

More than 60

Nearly a year old

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

*Weil-trained athletes may have very low heart rates

Time out 4

}aily activities of a well child and a child with chronic asthma

Normal child

Chronic asthma and not well controlled

Child awakes feeling refreshed. Enjoys breakfast


before school.

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.

Walks, cycles or ains to school with fnends.

Has car ride to school with parent.

Runs in school playground. Participates in games


and sports.
Cleans out school hamster cage.

Has no breath or energy to run in the playground or participate fully

Secure in the friendships of peers. Has a positive


body image.

in games and sports.


Unable to take a turn to clean out school hamster cage. Has allergy to fur and
dander.
Stands out as little as possible. Poor body image and lack of confidence.

Eats school dinners, drinks a range of cordials and

Eats packed lunch. In the past, has had allergic reactions to muesli bake, lentil curry,

can share some peanut brittle with some friends.

and kiwi fruit yogurt. This has made staff and parents anxious.

Rushes through homework before playing football

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.

September 2011 | Volume 23 | Number 7

NURSING CHILDREN AND YOUNG PEOPLE

Continuing professional development

Practice profile
What do I do now?

'n Using the information in section 1 to guide


you, write a practice profile of between
750 and 1,000 words - ensuring that you
have related it to the article that you have
studied. See the examples in section 2.
_ Write 'Practice Profile' at the top of your
entry followed by your name, the title
of the article, which is: understanding
childhood asthma and the development
of the respiratory tract, and the article
number, which is NCYP8.

(Ampete all of the requirements of the


cut-out form provided and attach it securely
to your practice profile. Failure to do so will
mean that your practice profile cannot be
considered for a certificate.

You are entitled to unlimited free entries.

Using an A4 envelope, send for your free


assessment to: Practice Profile, RCN
Publishing Company, Freepost PAM
10155, Harrow, Middlesex H A l 3BR
by July 2012. Please do not staple your
practice profile and cut-out slip - paper-clips
are recommended. You can also email
practice profiles to practiceprofile@
rcnpublishing.co.uk. You must also provide
the same information that is requested on
the cut-out form. Type 'Practice Profile' in
the email subject field to ensure you are
sent a response confirming receipt.

You will be informed in writing of your


result. A certificate is awarded for successful
completion of the practice profile.

that she will sit next to her patients when


talking to them. She makes a conscious
decision to pay attention to her own body
language, posture and eye contact, and
notices that communication with patients
improves. This forms the basis of her
practice profile.

Feedback is not provided: a certificate


indicates that you have been successful.
Keep a copy of your practice profile and
add this to your professional profile copies are not returned to you.

1. Framework for reflection

Study the checklist (section 3).


What have I learnt from this article?

Example 2 After reading a CPD article on


'Wound care', Amajit, a senior staff nurse
on a surgical ward, approached the nurse
manager about her concerns about wound
infections on the ward. Following an audit
which Amajit undertook, a protocol for
dressing wounds was established which
led to a reduction in wound infections
in her ward and across the directorate.
Amajit used this experience for her
practice profile and is now taking part in
a region-wide research project.

- To what extent were the intended learning


outcomes met?

What do I know, or can I do, now,


that I did not/could not before reading
the article?

What can 1 apply immediately to my


practice or client/patient care?
Is there anything that I did not
understand, need to explore or read about
further, to clarify my understanding?
What else do I need to do/know to
extend my professional development in
this area?

3. PortfoUo submission

Checklist for submitting your practice profile

What other needs have I identified in


relation to my professional development?
How might I achieve the above needs?
(It might be helpful to convert these to
short/ medium/long-term goals and draw
up an action plan.)

2. Excunples of practice profile entries

Example 1 After reading a CPD article on


'Communication skills', Jenny, a practice
nurse, reflects on her own communication
skills and re-arranges her clinic room so

Have you related your practice profile to


the article?
Have you headed your entry with: the title
'Practice Profile'; your name; the title of

the article; and the article number?


Have you written between 750 and

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?

Continuing professional development: practice profile


Please complete this form using a ballpoint
pen and CAPITAL letters only, then cut out
and send it in an envelope no smaller than
9x6 inches to:

Full title and date of article:

Job title:
Place of work:
Address

Practice Profile
RCN Publishing Company
Freepost PAM 10155
Harrow, Middlesex HAl 3BR

September 2011 | Volume 23 | Number 7

Article number:
First name:

Postcode

Surname:

Daytime tel:

NURSING CHILDREN AND YOUNG PEOPLE

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