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CLIENT TEACHING GUIDE
ORAL THRUSH IN CHILDREN
PROBLEM Oral thrush is a white patch that coats the inside of the mouth and tongue. It mainly affects bottle-fed infants, although
breastfed infants and debilitated older children may also be affected.
CAUSE Thrush is caused by a yeast called Candida that grows rapidly on the lining of the mouth in areas abraded by prolonged
sucking. It may also occur after a course of antibiotic medication.
PREVENTION/CARE
A. Do not use large paciers and nipples.
B. Boil bottle nipples and paciers.
C. Cleanse your nipples well after breastfeeding.
TREATMENT PLAN
A. Try to remove any large plaques with a moistened cotton-tipped applicator or gauze pad.
B. Cleanse the infant’s mouth before giving medication.
C. Place the medication in the front of the mouth on each side.
D. Rub it directly on the plaques with a cotton swab.
E. Feed the infant temporarily with a cup and spoon.
F. Give a pacier only at bedtime.
Diet: Reduce sucking time until thrush clears up.
Medications: Nystatin is an oral medication used to treat thrush. Nystatin 1 mL four times a day after meals or 30 minutes before
feeding. Patches should improve within 2 to 3 days of using the medication.
You Have Been Prescribed:
You Need to Take:
You Need to Notify the Office If:
A. The child refuses to eat or drink.
B. Symptoms do not improve or thrush lasts longer than 10 days.
C. Unexplained fever occurs.
D. Secondary infection occurs in the mouth (pain, tenderness, sores).
E. Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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CLIENT TEACHING GUIDE
PHARYNGITIS
PROBLEM Pharyngitis (sore throat) is a condition that occurs when the throat becomes inamed.
CAUSE The inammation can be due to a virus, a bacterial infection, or a fungus. Other noninfectious causes include postnasal
drip, allergies, mouth-breathing, and trauma.
PREVENTION/CARE
A. Avoid sick people and crowds. Stay at home if you are sick.
B. Cover your mouth when coughing.
C. Do not share a drinking glass, kiss, or have close contact with anyone who has an upper respiratory infection.
TREATMENT PLAN
A. Hot tea, soup, and throat lozenges soothe your throat.
B. Use disposable tissues when sneezing. Use tissues when you blow your nose. If no tissue is available, do the “elbow sneeze”
into the bend of your arm (away from your open hands). Dispose of tissues and then wash your hands.
C. Avoid smoking and secondhand smoke.
Activity: If you have strep throat, do not return to school or work until you have completed a full 24 hours of antibiotic. Rest or nap
as often as possible while you are sick.
Diet: Eat a healthy diet. If swallowing is difcult, eat soft foods such as ice cream, Jell-O, pudding, and soup. Avoid salt and spicy
foods. Increase your uid intake to 10 to 12 glasses a day.
Medications: You will be prescribed antibiotics if you have a bacterial infection. If your sore throat is due to a virus, antibiotics
would not help. Do not share your prescription medications with other family members who are also sick. They need a full prescription, too. Many other medications are available over the counter, such as throat lozenges, cough suppressants, and so forth.
You Have Been Prescribed:
You Need to Take:
If you are prescribed antibiotics, complete all of the doses.
You Need to Notify the Office If:
A. You have difculty breathing because of the sore throat or enlarged tonsils.
B. Your symptoms are worse after 24 hours of antibiotics.
C. You are unable to keep down your antibiotic because of vomiting.
D. Your sick child refuses to eat or drink.
E. You develop a rash or itch after starting the antibiotic.
F. You are a diabetic and your blood glucose is high, or you have ketones in your urine.
G. Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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C H A P T E R
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RESPIRATORY GUIDELINES
Audra Malone Cave
ASTHMA
DEFINITION
A. Pathophysiologically, asthma is dened by airway
inammation, intermittent airow obstruction secondary to
increased smooth muscle tone, and bronchial hyperresponsiveness. Episodes are associated with widespread, variable,
often reversible airow obstruction and bronchial hyperresponsiveness when airways are exposed to various stimuli or
triggers. Asthma is responsible for lost school days, lost productivity, and missed days of work/school. Asthma is classied into four categories:
1. Step 1—mild intermittent: symptoms less than or equal
to twice per week; asymptomatic with normal peak expiratory ow rate (PEFR) between attacks; nighttime symptoms less than or equal to twice per month; PEFR greater
than 80% predicted with a variability of less than 20%.
2. Step 2—mild persistent: symptoms greater than twice
per week but less than once per day; exacerbations may
affect activity; nighttime symptoms greater than twice per
month; PEFR greater than or equal to 80% predicted with
variability of 20% to 30%.
3. Step 3—moderate persistent: daily symptoms require
beta-2 agonist use; attacks affect activity; exacerbations
greater than or equal to twice per week; nighttime symptoms greater than once per week; PEFR between 60% and
80% with a variability greater than 30%.
4. Step 4—severe persistent: continuous symptoms with
limited physical activity; frequent exacerbations; frequent
nighttime symptoms; PEFR less than or equal to 60% predicted with greater than 30% variability.
INCIDENCE
A. Asthma affects 25 million people in the United States, or
300 million worldwide.
B. Asthma is the most common chronic disease of childhood,
affecting 7% to 15% of children.
C. Up to 80% of clients with asthma also suffer from persis-
tent rhinitis.
D. Asthma is often associated with other comorbid condi-
tions, including gastroesophageal reux disease (GERD) and
obesity.
E. Although asthma can present at any age, the peak age of
diagnosis is before 5 years.
PATHOGENESIS
A. Asthma arises from a complex cycle of processes initiated
by airway inammation resulting from physical, chemical,
and pharmacologic agents (e.g., environmental irritants,
allergens, furry animals, cockroaches, dust mites, pollen and
mold, cold air, viral respiratory infections, and exercise). It
progresses to airway hyperresponsiveness, bronchoconstriction, airway wall edema, chronic mucus plug formation, and
chronic airway remodeling.
PREDISPOSING FACTORS
A. In children:
1. Allergy or family history of allergy.
2. Atopy.
3. Ethnicity (Puerto Rican descent, non-Hispanic Black).
4. Sex: male during childhood.
B. In adults:
1. Family history.
2. Coexisting sinusitis, nasal polyps, and sensitivity to
aspirin (ASA) or other nonsteroidal anti-inammatory
drugs (NSAIDs).
3. Exposure in workplace to wood dust, metals, and ani-
mal products.
4. Premenstrual asthma.
5. Sex: female in adulthood.
6. Ethnicity: non-Hispanic Black for persistent asthma.
7. Occupational exposures.
8. Comorbidities in older adults.
C. In all ages:
1. Inhalation of irritants such as tobacco smoke.
2. Viral respiratory infections.
3. Gastroesophageal reux.
4. Obesity.
5. Lower socioeconomic level.
D. Triggers:
1. Allergen exposure.
2. Viral infections of the upper airways.
3. Medication (potential risk with beta-blockers,
angiotensin-converting enzyme [ACE] inhibitors, cyclooxygenase inhibitors, ASA, NSAIDs).
4. Exercise.
5. Situational factors: cold air, laughter, strong odors, air
pollution, smoke exposure, pregnancy.
6. Foods.
7. Hormones.
8. Gastrointestinal (GI) reux.
9. Stress.
10. Alternative/herbal remedies.
11. Dander/saliva from animals with fur or feathers.
12. Mold.
13. Dust mites, rodents, cockroaches.
The contributions of Mellisa A. Hall and Cheryl A. Glass to this chapter in prior editions are acknowledged here.
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9: RESPIRATORY GUIDELINES
COMMON COMPLAINTS
A. Recurrent cough (worse at night and early morning).
B. Recurrent wheezing.
C. Recurrent shortness of breath (SOB).
D. Dyspnea (less likely to be reported in the elderly).
E. Recurrent chest tightness (may worsen with moderate
activity).
OTHER SIGNS AND SYMPTOMS
A. Nocturnal awakening from symptoms.
B. Variation of symptoms with seasons or environment.
C. Chest discomfort and tightness with moderate activity.
SUBJECTIVE DATA
A. Ask about the onset, duration, pattern, and course of
symptoms.
B. Inquire about sudden severe episodes of coughing,
wheezing, and SOB and whether precipitating factors can be
identied.
C. Ask whether the client has chest colds that take more than
10 days to resolve.
D. Ask if the client is a smoker, how much, and for how long
they have smoked.
E. Ask whether symptoms seem to occur during certain
seasons or during exposure to the following environmental
irritants:
1. Tobacco smoke, including e-cigarettes/vaping.
2. Perfume.
3. Household pets.
4. Fireplaces.
5. Wood-burning stoves.
6. Mold.
7. Dust mites.
8. Cockroaches.
F. Find out how often coughing, wheezing, or SOB awaken
the client.
G. Ask if symptoms are caused or exacerbated by moderate
exercise or physical activity.
H. Determine the family history of asthma, allergies, and
eczema.
I. Determine whether the client is pregnant or has medical
problems. If so, do not prescribe long-term beta-2 adrenergics
or NSAIDs. The safest medications are short-acting beta-2
agonists (SABA), cromolyn sodium, and inhaled corticosteroid (ICS).
J. Administer the asthma control test for adults or the child-
hood asthma control test for children aged 4 to 11years. This
test is for self-report (or parent-report) to determine whether
asthma symptoms are under control. Both tests are available online from www.asthma.com. A score greater than
20 points indicates the client’s asthma is well-controlled.
Scores of 5 to 19 points indicate the client’s asthma is not
well-controlled.
K. Evaluate whether the client has ever been tested for
allergies.
L. Ask whether the client has ever needed to go to the ED or
had to be hospitalized for an asthma attack.
M. Review all medications, including over-the-counter (OTC)
and herbal supplements.
PHYSICAL EXAMINATION
A. Check temperature, blood pressure (BP), pulse, respi-
rations, and pulse oximetry. Measure the client’s height
and weight to calculate body mass index (BMI) as obesity
is associated with asthma and evaluate failure to thrive if
suspected.
B. Inspect:
1. Especially in children, observe for hyperexpansion of
thorax and signs that accessory muscles are being used
(retractions, nasal aring) or stridor.
2. Note appearance of hunched shoulders and/or chest
deformity.
3. In children, inspect the nose for a foreign body.
4. In all clients, inspect ears, nose, and throat. Evaluate
the presence of enlarged tonsils and adenoids, and nasal
polyps.
5. Inspect skin for eczema, dermatitis, or other irritation
that might signal allergy.
6. Observe for allergic shiners and pebbled conjunctiva.
7. Observe for digital clubbing.
C. Auscultate:
1. Auscultate lung sounds. Note wheezing during nor-
mal expiration and prolonged expiration, which is seen
with asthma.
2. Listen to all lung elds for an asymmetric wheeze.
3. Auscultate heart.
D. Percuss:
1. Percuss the lung elds.
DIAGNOSTIC TESTS
A. Spirometry is the gold standard. Peak ow meter mea-
surements are not a substitute for spirometry. Evaluate the
forced vital capacity and forced expiratory volume in 1 second (FEV1) before and after the client inhales a short-acting
bronchodilator.
B. Evaluating chest radiograph (CXR) is not recommended
unless there is a compelling reason or suspicion of alternative
diagnosis.
C. Obtain complete blood count to assess infection or
eosinophilia.
D. Allergy testing is recommended for children with persis-
tent asthma.
E. Check PEFR after inhalation of SABA. Diagnosis is con-
rmed if:
1. There is a 15% increase in PEFR after 15 to 20 minutes.
2. PEFR varies more than 20% between arising and 12
hours later in clients taking bronchodilators (or 10% without bronchodilators).
3. There is a greater than 15% decrease in PEFR after 6
minutes of running or exercise.
F. Consider a bronchial provocation test with histamine or
methacholine for nondiagnostic spirometry.
DIFFERENTIAL DIAGNOSES
A. In infants and children:
1. Asthma.
2. Pulmonary infections:
a. Pneumonia.
b. Respiratory syncytial virus (RSV).
c. Viral bronchiolitis.
d. Tuberculosis (TB).
3. Allergic rhinitis and sinusitis.
4. Foreign body in the nose, trachea, or bronchus.
5. GERD.
6. Cystic brosis (CF).
7. Bronchopulmonary dysplasia.
8. Vocal cord dysfunction.
9. Enlarged lymph nodes or tumors.
ASTHMA
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213
B. In adults:
1. Asthma.
2. Chronic obstructive pulmonary disease (COPD).
3. GERD.
4. Congestive heart failure (CHF).
5. Cough secondary to medications such as ACE inhibi-
tors or beta-blockers.
6. Pneumonia, including aspiration pneumonia in the
elderly or postcerebrovascular accident.
7. Pulmonary embolism.
8. Laryngeal dysfunction.
9. Benign and malignant tumors.
10. Vocal cord dysfunction.
PLAN
A. General interventions:
1. Review proper medication dosages. Short- and
long-term agents come in several formulations, such as
nebulizer, metered-dose inhaler (MDI), and a dry powder inhaler (DPI). Young children should have medication via a nebulizer using an appropriate-sized face mask.
The “blow-by” technique is not an appropriate means of
administering medication.
2. Demonstrate correct use of inhalers, spacers, and neb-
ulizers. If the client does not use correct technique when
using these devices, medication does not get delivered to
the bronchioles, and therefore the client may believe that
the medication does not work. Most often, the medication
works well when delivered to the bronchioles correctly.
3. Stress the importance of using a peak ow monitor at
home to monitor progress of the disease.
4. For rescue from acute symptoms, use SABA.
5. The use of a SABA more than twice a week for symp-
tom relief would indicate the client has inadequate asthma
control and needs an ICS as controller therapy.
6. Stress the need for an asthma action plan.
B. Client teaching: See Client Teaching Guides for this chapter,
"Asthma," "Asthma: Action Plan and Peak Flow Monitoring," and
"Asthma: How to Use a Metered-Dose Inhaler."
C. Pharmaceutical therapy:
1. Drugs are prescribed in a stepwise fashion for the type
of asthma. The amount of medication used depends on
the severity of the asthma (steps 1–6 in the following list).
Before any medication/dosage changes, monitor the client’s compliance (Table 9.1).
2. The following treatments are recommended for chil-
dren aged 5 years and older and for adults:
a. Step 1: mild:
i. No long-term preventive medications are
needed.
ii. Use SABA as rescue medication. It may be used
up to four times a day to treat exacerbations.
iii. For adults and adolescents over 12 years old,
use low-dose ICS/formoterol as needed.
b. Step 2: mild to moderate:
i. Low-dose ICS are used daily as a long-term pre-
ventive medication.
ii. Only budesonide inhalation suspension is
approved by the Food and Drug Administration for
use in infants and children younger than 4 years.
iii. Alternative medications include an ICS plus
either a leukotriene modier or long-acting beta-2
agonist (LABA) for adults and adolescents over
12 years.
c. Step 3: moderate:
i. Consider referral to an asthma specialist at
step3.
ii. Use low-dose ICS plus a LABA for maintenance
and rescue therapy; SABA can also be added for rescue/reliever therapy.
iii. Use ICS plus either a leukotriene modier or a
sustained-release theophylline.
iv. LABA is not recommended for children under
5 years old.
v. An alternative therapy to maintain control may
include medium-dose ICSand immunotherapy.
d. Step 4: moderate to severe:
i. Rescue:
1) Low-dose ICS/formoterol with SABA as an
alternative.
ii. Control:
1) Low-dose ICS/formoterol, medium- to
high-dose ICS plus either a LABA or montelukast; also consider adding long-acting antimuscarinic antagonist.
2) Medium-dose ICS plus either a leukotri-
ene modier or a low-dose sustained-release
theophylline.
iii. Immunotherapy.
iv. For children under 5 years old, refer to aspecialist.
e. Step 5: severe:
i. Rescue: low-dose ICS/formoterol or SABA as
needed.
ii. Control: High-dose ICS plus LABA; consider
alternatives such as oral corticosteroids (CS).
iii. Refer to specialty; consider alternatives such as
tiotropium, azithromycin, anti-immunoglobulin E,
anti-IL-55/R, and anti-IL-4R alpha.
f. Step 6: severe:
i. High-dose ICS plus LABA plus oral CS and con-
sider omalizumab for clients who have allergies.
g. Exercise-induced bronchospasm:
i. Short-acting inhaled beta-2 agonist: Two inhala-
tions shortly before exercise are effective for 2 to 3
hours.
ii. LABA: Two inhalations are effective for 10 to 12
hours. There is no immediate effect.
h. Hypertension and asthma:
i. The drug of choice is a calcium channel blocker.
Asthmatics also tolerate diuretics well.
i. Theophylline can cause cardiac arrhythmias; there-
fore, use it with caution and always follow up with theophylline levels.
j. Vaccinations:
i. Inhaled u vaccine is not used in clients with
asthma. Inactivated inuenza vaccine is safe,
including in children with severe asthma.
ii. Pneumococcal vaccines are recommended for
children and adults with asthma.
3. Goal of asthma therapy:
a. Minimal to no chronic symptoms, including
nighttime symptoms.
b. Minimal exacerbations.
c. No ED visits.
d. Minimal use of SABA.
e. No limitations of activities.
f. Peak expiratory ow maintained in normal range.
g. Minimal adverse effects of medications.
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9: RESPIRATORY GUIDELINES
TABLE 9.1 MEDICATIONS FOR ASTHMA AND COPD (BY CLASS/ALPHABETICAL ORDER)
Brand Generic Drug Classification Availability
SABA, for Rescue/Fast-Acting Rescue
AccuNeb Albuterol Beta-2 agonist Nebulizer
Albuterol Albuterol sulfate Beta-2 agonist Inhaler, solution
Nebulizer
Syrup
Combivent Ipratropium + albuterol Combination anticholinergic +
beta-2 agonist
Fenoterol Ipratropium + fenoterol Beta-2 agonist Inhaler, MDI, and oral syrup
Maxair Autohaler Pirbuterol acetate Beta-2 agonist MDI
ProAir HFA inhaler Albuterol Beta-2 agonist MDI
Proventil HFA inhaler Albuterol Beta-2 agonist MDI
Terbutaline sulfate Brethine Beta-2 agonist Tablet
Ventolin HFA Albuterol sustained-release Beta-2 agonist MDI
Vospire ER Albuterol Beta-2 agonist Extended-release tablet
Xopenex Levalbuterol tartrate Beta-2 agonist HFA inhaler
LABA, for Maintenance/Long-Acting Control
Advair Diskus Fluticasone + salmeterol Combination steroid + LABA Dry powder Diskus
Arcapta Indacaterol LABA Nebulizer
Brovana Arformoterol Beta-2 agonist Nebulizer
Foradil Aerolizer Formoterol fumarate LABA Nebulizer
MDI
Concentrate solution for nebulizer
MD–HFA inhaler
Perforomist Formoterol solution Beta-2 agonist Nebulizer
Serevent Diskus Salmeterol LABA Dry powder Diskus
Striverdi Respimat Olodaterol LABA MDI
ICS Anti-Inflammatory, for Maintenance or Long-Term Control
Aerobid and Aerobid M Flunisolide ICS MDI
Aerospan Flunisolide ICS MDI
AirDuo
RespiClick
Alvesco Ciclesonide ICS MDI
Arnuity Ellipta Fluticasone furoate ICS DPI
ArmonAir
RespiClick
Asmanex Mometasone ICS Twisthaler dry powder
Dry powder Diskus
MDI with menthol
Fluticasone propionate/salmeterol ICS + LABA DPI
Fluticasone propionate ICS DPI
(continued)
ASTHMA
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TABLE 9.1 MEDICATIONS FOR ASTHMA AND COPD (BY CLASS/ALPHABETICAL ORDER) (CONTINUED)
Brand Generic Drug Classification Availability
Beclovent Beclomethasone dipropionate ICS Dipro powder inhaler
Breo Ellipta Fluticasone furoate/vilanterol ICS + LABA DPI
Dulera Mometasone furoate + formoterol Combination CS + LABA MDI
215
Flovent HFA Fluticasone ICS MDI (also available as a DPI as
Pulmicort Budesonide ICS Flexhaler and respules
QVAR Beclomethasone ICS MDI
Symbicort Budesonide + formoterol Combination CS + LABA MDI
Leukotriene Modifiers: Nonsteroidal Anti-Inflammatory
Accolate Zafirlukast Leukotriene modifier Tablet
Singulair Montelukast Leukotriene modifier Chew tablet
Zyflo Zileuton Leukotriene modifier Filmtab
Interleukin-5 agonist
Cinqair Reslizumab Interleukin-5 agonist Intravenous infusion
Dupixent Dupilumab Interleukin-5 agonist Subcutaneous injection
Fasenra Benralizumab Interleukin-5 agonist Subcutaneous injection
Nucala Mepolizumab Interleukin-5 agonist Subcutaneous injection
Anticholinergics
Atrovent HFA Ipratropium Antimuscarinic/antispasmodic MDI and nebulized
Flovent Diskus)
Tablet granules
DuoNeb Ipratropium + albuterol Combination antimuscarinic/
antispasmodic + beta-2 agonist
Spiriva with HandiHaler Tiotropium Antimuscarinic/antispasmodic Dry powder Diskus
Mast Cell Stabilizer
Intal Cromolyn sodium Mast cell stabilizer MDI
Tilade Nedocromil Mast cell stabilizer MDI
Methylxanthine
Aminophylline Theophylline Methylxanthines respiratory
smooth muscle relaxant
Theo-24 Theophylline sustained-release Methylxanthines respiratory
smooth muscle relaxant
Anti-IgE (IgE Blocker) Monoclonal Antibody
Xolair Omalizumab IgE blocker-immunomodulator Subcutaneous injection
Systemic CS: Used As a Short-Term “Burst” for Control
Deltasone Prednisone Systemic CS Tablet
Medrol Methylprednisolone Systemic CS Tablet
Prelone Prednisolone Systemic CS Tablet
Nebulizer
Tablet
Tablet
(continued)
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TABLE 9.1 MEDICATIONS FOR ASTHMA AND COPD (BY CLASS/ALPHABETICAL ORDER) (CONTINUED)
Brand Generic Drug Classification Availability
PDE4
Ariflo Cilomilast Selective PDE4 Tablet
Daliresp Roflumilast Selective PDE4 Tablet
COPD, chronic obstructive pulmonary disease;CS, corticosteroid; DPI, dry powder inhaler; HFA, hydrofluoroalkanes; ICS, inhaled corticosteroid; IgE, immunoglobulin E;
LABA, long-acting beta-2 agonist; MDI, metered-dose inhaler; PDE4, phosphodiesterase-4 inhibitors;SABA, short-acting beta-2 agonist.
9: RESPIRATORY GUIDELINES
FOLLOW-UP
A. After acute episodes, follow up within 1 to 2 hours or next
day to monitor improvement until client is stable.
B. For clients with mild intermittent or mild persistent asthma
under control for at least 3 months, assess and follow up at
least every 6 months to provide education and reinforce positive behaviors. Gradually reduce medication dosage. If control
is not achieved, consider increasing the dosage after reviewing
medication technique, compliance, and environmental control.
CONSULTATION/REFERRAL
A. Consider hospitalization in clients with acute episodes
who do not completely respond to treatment within 1 to 2
hours.
B. If all therapies fail—including a short burst of predni-
sone—refer the client to an asthma specialist.
C. Consult with a physician when the client is pregnant or
has other medical problems, or when standard treatment is
ineffective.
D. Refer if the client presents with atypical symptoms.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Risks of uncontrolled asthma far outweigh risks to the
mother or fetus from drugs used to control the disease.
2. Most drugs used to treat asthma and rhinitis, with the
exception of brompheniramine and epinephrine, pose little increased risk to the fetus.
3. Classes of drugs that do cause risk include deconges-
tants, antibiotics (tetracycline, sulfonamides, and cipro-
oxacin), live virus vaccines, immunotherapy (if doses
are increased), and iodides. Always weigh benets against
risks because adequate fetal oxygen supply is essential.
4. If CS are necessary, recommend aerosolized forms due
to their lower systemic effects. Prednisone or methylprednisolone is preferred and should be prescribed at minimum effective doses.
5. Do not prescribe inhaled triamcinolone because it is
teratogenic.
6. Inhaled budesonide is the preferred ICS for treat-
ment of asthma during pregnancy. Ipratropium is generally considered less effective than ICS and is therefore
a second-line agent in pregnancy (acaai.org/asthma/
who-has-asthma-and-why/pregnancy-and-asthma).
7. Drugs recommended during pregnancy:
a. A SABA, such as albuterol, is preferred; two inha-
lations Q4H as needed. Regular daily use suggests a
need for additional medications. If a daily LABA is
needed, budesonide is preferred.
b. Ipratropium: Two inhalations QID may be used in
step therapy.
c. Regular inhaled budesonide is considered a rst-line
agent if an inhaled glucocorticoid is needed.
d. The leukotriene modiers montelukast or zaf-
irlukast may be considered as add-ons to inhaled
glucocorticoids.
e. Oral prednisone if all other therapies fail; 1week
of 40 mg/d, followed by 1 to 2 weeks of tapering.
Recommend obstetric consult before prescribing.
B. Geriatrics:
1. Asthma in the elderly is often associated with other
comorbidities such as COPD, cardiac conditions, or
dementia.
2. Half of elderly clients with asthma have the rst onset
after 65 years of age. Respiratory viruses are a common
trigger.
3. Recurrent episodes of SOB may be the primary
symptom.
4. Treatment is the same as with younger clients, with
inhaled SABA as needed and step therapy with daily inhaled
steroids. Oral steroids are reserved for severe episodes. The
elderly have more adverse effects from inhaled ICS.
5. If steroids are prescribed, carefully monitor the client
for complications, including cataracts, increased intraocular pressure, hyperglycemia, and accelerated loss of bone
mass.
6. Inhaled anticholinergics and LABAs are second-line
treatments.
7. The elderly may have difculty with inhaling med-
ications or activating inhaler devices and may require a
nebulizer.
8. Theophylline is rarely effective in the elderly. Asthma
medications may have increased adverse effects in the
elderly or may aggravate coexisting medical conditions,
requiring medication adjustments. Also consider drug
interactions and drug and disease interactions.
C. Pediatrics:
1. Spacing chambers are recommended to assist in proper
delivery of medication.
RESOURCES
Asthma Control Tests: www.asthma.com
American Lung Association: www.lung.org
Asthma & Allergy Foundation of America: www.aafa.org
National Heart Lung and Blood Institute (NHLBI): www.nhlbi.nih.gov
BIBLIOGRAPHY
Barnes, P. J. (2015). Asthma. In D. L. Kasper, A. S. Fauci, S. L. Hauser, D. L.
Longo, & J. L. Jameson (Eds.), Harrison’s principles of internal medicine
(19th ed., pp. 1669–1680). McGraw-Hill. http://accessmedicine.mhme
dical.com/book.aspx?bookid=1130
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BRONCHIOLITIS: CHILD
DEFINITION
A. Bronchiolitis is a narrowing and inammation of the bron-
chioles, causing wheezing and mild to severe respiratory distress. Infants are affected most often due to their small airways
and insufcient collateral ventilation. It is one of the most common causes of acute hospitalizations in infants, especially in the
fall and winter. A small decrease in a bronchiole’s already small
airway will lead to a fourfold increase in airway resistance and
accounts for this pathologic manifestation in this age group.
B. The average length of illness with bronchiolitis is 12 days.
INCIDENCE
A. Respiratory infection is seen in one-third of children
younger than 12 months, with 1 in 10 requiring hospitalization.
B. Bronchiolitis occurs most often in infants and children
aged 1 to 2 years. Approximately 2% to 4% of adults with
respiratory illnesses, comorbidity of immunosuppression,
and the elderly will also be diagnosed with bronchiolitis.
PATHOGENESIS
A. The pathology results in obstruction of bronchioles from
inammation, edema, and debris, leading to hyperination of
the lungs, increased airway resistance, atelectasis, and ventilation–perfusion mismatching.
B. Respiratory syncytial virus (RSV) is the most common
cause (50%–80%) of bronchiolitis.
C. Human metapneumovirus (HMPV) is the second most
common cause (3%–19%).
D. Other causes include parainuenza virus, adenovirus,
inuenza Chlamydia pneumoniae, Mycoplasma pneumoniae, and
human bocavirus (HBoV).
PREDISPOSING FACTORS
A. Low birth weight, particularly in premature infants.
B. Chronic lung disease (CLD; formerly bronchopulmonary
dysplasia).
C. Parental smoking.
D. Congenital heart disease.
E. Immunodeciency.
F. Lower socioeconomic group.
G. Crowded living conditions and day care.
H. Sex: Bronchiolitis occurs in males 1.25 times more fre-
quently than in females.
COMMON COMPLAINTS
A. Initially subtle clinical manifestations.
B. Infants who become increasingly fussy.
C. Difculty feeding during the 2- to 5-day incubation period.
This is because infants prefer to breathe through their nose
(obligate nasal breathing) as opposed to their mouths; signicant nasal edema and/or rhinorrhea may force mouth breathing and disturb feedings.
D. Low-grade fever (usually less than 101.5°F).
E. Cough.
F. Tachypnea.
G. Wheezing.
H. Retractions.
I. Nasal aring and grunting.
OTHER SIGNS AND SYMPTOMS
A. Coryza.
B. Irritability.
C. Lethargy.
D. Respiratory distress.
E. Nasal aring and grunting.
F. Hypothermia (infants younger than 1 month).
SUBJECTIVE DATA
A. Determine the onset, course, and duration of illness.
Typically starts with a 3- to 5-day prodrome of respiratory
symptoms similar to common upper respiratory infections
(URIs) (fever, cough, rhinitis).
B. Are breathing problems affecting the ability to eat and
drink? Is the baby able to be breastfed?
C. Evaluate a history of fever, nausea, vomiting, or diarrhea.
D. Does the client or any family members have asthma?
E. Are there any other family members who are ill?
F. Are there smokers in the family environment or exposures
to other types of inhaled toxins?
PHYSICAL EXAMINATION
A. Check temperature, blood pressure, and respirations:
1. Count respirations for 1 full minute.
2. Respirations greater than 70 breaths per minute in an
infant may be associated with risk of severe disease and
warrant further evaluation for pneumonia.
3. Tachypnea at any age is a concern for severe lower
respiratory illness.
B. Inspect:
1. Observe overall appearance.
2. Note respiratory pattern and nasal aring.
3. Note the use of accessory muscles for breathing. May
note retractions.
4. Check for tachypnea, which differentiates bronchiolitis
from URI and bronchitis.
5. Examine the eyes, ears, and throat, noting other poten-
tial infections.
6. Inspect the nose for nasal aring.
C. Auscultate:
1. Heart.
2. Lungs. On examination there are ne inspiratory crack-
les and/or high-pitched expiratory wheezes. A prolonged
expiration phase is seen with bronchiolitis.
D. Palpate:
1. Liver and spleen.
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