Pediatric Asthma.ppt
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Pediatric Asthma
By Sean Robertson EMT-P, I/C
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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
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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
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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
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Sensitization to an allergenEarly-phase response upon re-
exposure to an allergenLate-phase response to an allergen
Asthmatic Cascade
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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
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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
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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.
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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,
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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
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Asthmatic Cascade
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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
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Mast Cells
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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
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Prostaglandins
Powerful vasodilators Inhibits platelet aggregation Mediates Inflammation
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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
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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
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Airway Changes
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Pathophysiology of Asthma
Note the increased number of mucous glands.
Note the hypertrophy of the muscle layer.
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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
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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.
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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?
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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?
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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
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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
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Treatment
Reassurance Get down on there level Oxygen IV (Asthmatics are almost always dehydrated) Albuterol (dose?) Epi (dose, route?) BVM Intubation
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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.
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Case Study
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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.
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Case Study
Vital signs.Pulse 150 weak at the brachialBP 90/40RR 54, laboredSpo2 80% room air
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Case Study
Treatment?O2? BVM?When is intubation considered?IV? IO?Fluids!EPI?Albuterol?
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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.
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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?
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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.
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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?
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Case Study 2
Mom states that the baby stopped taking food and fluids this morning.
This is what you find upon entering Torreon rescue
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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
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Case Study 2
WHAT NOW????
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Case Study 2
What do you want to do?What more do you want to know?How do you want to transport this
patient?
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Any Questions???
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Asthma Medications
What will they come up with next????
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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
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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.
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Advair
Generic Name: Fluticasone/Salmeterol
Combination of a corticosteroid and a long acting Beta agonist.
Taken twice daily. Used only for
prophylaxis.
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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.
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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.
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Azmacort Triamcinolone Inhaled corticosteroid Works well for asthma, but can be up to 8-
12 puffs twice daily.
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Beclovent Beclomethasone Corticosteroid Inhaled via MDI twice
daily. Not widely used
anymore
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Brethair
Terbutaline Beta agonist SQ/IM use is similar to
Epi. Can be nebulized No longer widely used
in asthma
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Bronkosol
Isoetharine Beta agonist Nebulized Not widely used
anymore
No Image Available
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Flovent
Generic Name: Fluticasone Proprianate Inhaled Corticosteroid Taken 2-4 puffs twice daily.
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Foradil Formoterol Long acting beta
agonist Brand new med.
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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.
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Maxair
Pirbuterol Short acting beta
agonist Alternative to
albuterol
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Pulmicort Budesonide Corticostero
id One of the
newer steroids
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Serevent
Salmeterol Long acting beta agonist A LOT of asthmatics are
on this drug, or Advair, which contains serevent.
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Singulair
Montelukast Leukotriene
receptor inhibitor Another next
generation asthma medication.
Appropriate for ages 12 months-Adult
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Theophylline
Numerous names Methylzanthine Acts as bronchodilater, but
also increases diaphragmatic contractility and decreases lung sensitivity to allergens and other asthma triggers
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Tilade
Nedocromil Sodium Another Mast cell
Stabilizer. MOA similar to Intal
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Xolair
Omalizumab
Binds serum free IgE, thereby blocking it from binding with Mast cells
Only available as SQ injection.
Dose is based on weight.
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Xolair
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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.
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