1. What factors may trigger an asthmatic episode?

Allergens (indoor and outdoor), irritants (tobacco smoke), exposure to chemicals,

exercise, cold air, changes in weather or temperature, new environment (school,
home, city), cols and infections, animals, medications (NSAIDs, aspirin, antibiotics,
beta-blockers), strong emotions, medical conditions (gastroesophageal reflux), food
additives, foods, and endocrine factors (menses, pregnancy, thyroid disease).
Textbook p. 737

2. What are the clinical manifestations of a child experiencing an exacerbation of

asthma?
Cough that is hacking, irritative, and nonproductive initially, then becomes rattling
and produces frothy, clear, gelatinous sputum. Shortness of breath, prolonged
expiratory phase, audible wheeze, course breath sounds, crackles, lips that are
deep, dark red color, may have malar flush (butterfly rash covering the bridge of the
nose & cheekbones) and red ears, restlessness, prominent sweating as attack
progresses, and speaking that is short & panting. May progress to cyanosis of nail
beds or circumoral cyanosis and older children will have tripod positioning. Textbook
p. 738

3. Explain the progression of asthma that is nonresponsive to treatment.

Status asthmaticus is a medical emergency that is marked by continued respiratory
distress that is nonresponsive to initial therapeutic measures such as albuterol.
Patients often present a few days after the onset of a viral respiratory illness, following exposure to a
potent allergen or irritant, or after exercise in a cold environment. Frequently, patients have underused or
have been underprescribed anti-inflammatory therapy.
Within minutes of exposure to an allergen, mast cell degranulation is observed along with the release of
inflammatory mediators. These substances cause airway smooth muscle contraction, increased capillary
permeability, and mucus secretion characterized by bronchoconstriction. The release of inflammatory
mediators primes adhesion molecules in the airway epithelium and capillary endothelium, which then
allows inflammatory cells, such as eosinophils, neutrophils, and basophils, to attach to the epithelium and
endothelium and subsequently migrate into the tissues of the airway. This interaction promotes further
airway hyperresponsiveness in asthma.
Bronchospasm, mucus plugging, and edema in the peripheral airways result in increased airway
resistance and obstruction. Air trapping results in lung hyperinflation, ventilation/perfusion (V/Q)
mismatch, and increased dead space ventilation. The lung becomes inflated near the end-inspiratory end
of the pulmonary compliance curve, with decreased compliance and increased work of breathing.
The increased pleural and intra-alveolar pressures that result from obstruction and hyperinflation, together
with the mechanical forces of the distended alveoli, eventually lead to a decrease in alveolar perfusion.
The combination of atelectasis and decreased perfusion leads to V/Q mismatch within lung units. The V/Q
mismatch and resultant hypoxemia trigger an increase in minute ventilation.

In the early stages of acute asthma, hyperventilation may result in respiratory alkalosis. This is because
obstructed lung units (slow compartment) are relatively less numerous than unobstructed lung units (fast
compartment). Hyperventilation allows carbon dioxide removal via the fast compartment. However, as the
disease progresses and more lung units become obstructed, an increase in the slow compartments
occurs, resulting in decreased ability for carbon dioxide removal and eventually causing hypercarbia.
Medscape, Status Asthmaticus

4. Discuss the pathophysiology of asthma.

Inflammatory response to stimuli, airway edema and accumulation and secretion of
mucus, spasm of the smooth muscle of the bronchi and bronchioles which
decreases the caliber of the bronchioles, and airway remodeling which causes
permanent cellular changes. Textbook p. 737

5. Actions, side effects, contraindications, nursing implications

Albuterol- bronchodilator, relaxes smooth muscle
Side effects: palpitations, tachycardia, hypokalemia
Contra: tachydysrhythmias, severe cardiac disease
Nursing: When given via nebulizer, O2 flow of 6-10L/min; assess respiratory function
Nebulizer: (Child 2- 12) 0.1 to 0.15 mg/kg/dose tid-qid; 1.25mg dose (10-15kg) tidqid; 2.5mg dose (>15kg) tid-qid

Atrovent (Ipratropium)- bronchodilator, anticholinergic, relaxes smooth muscle

SE: Palpitations, dizziness, anxiety
Contra: Sensitivity to atropine, bromide, soybean or peanut products
Nursing: Access respiratory status, deliver solution in nebulizer with mouthpiece
rather than face mask
Nebulizer: 250-500mcg q 20min up to 3hrs (for this SIM we give twice after giving 1
neb of albuterol)

Epinephrine- Adrenergic agonist bronchodilator

SE: Cerebral hemorrhage, palpitations, tachycardia
Contra: Hypersensitivity, nonanaphylactic shock during general anesthesia
Nursing: Assess cardiac status (BP and pulse), continuous ECG during administration
IV: 0.01 mg/kg up to 0.5mg q20mins x 3 doses (1:10,000 solution available in 1mg/
10mL)

Prednisolone- Corticosteroid, decreases inflammation

SE: Circulatory collapse, GI hemorrhage, thrombocytopenia, embolism
Contra: Psychosis, thrombocytopenia, glomulernephritis, fungal infections, measles,
varicella, Cushings Syndrome
Nursing: Assess for adrenal insufficiency, edema, potassium levels, BP, monitor for
crackles, behavioral changes
PO: 1mg/kg/day over 2 divided doses

Prednisone- Corticosteroid, anti-inflammatory

SE: Circulatory collapse, GI hemorrhage, thrombocytopenia, embolism
Contra: Psychosis, thrombocytopenia, glomulernephritis, fungal infections, TB,
measles
Nursing: Assess for adrenal insufficiency, edema, potassium levels, BP, monitor for
crackles, behavioral changes
PO: 0.05 - 2mg/kg/day over 1-4 divided doses (Michelles pathway says 2mg/kg to a
max of 60mg in the ER)

Solumedrol (methylprednisolone)- Corticosteroid, anti-inflammatory for severe

inflammation
SE: Circulatory collapse, GI hemorrhage, thrombocytopenia, embolism
Contra: Cushings syndrome, measles, varicella, fungal infections
Nursing: Assess for edema, hypertension, behavioral changes, potassium depletion
(dysrhythmias, weakness), adrenal insufficiency
PO/IV: 1mg/kg in 2 doses (60mg max); IV infusion over 10-20 mins

Magnesium sulfate- potent muscle relaxer

SE: Flaccid paralysis, circulatory collapse, respiratory depression
Contra: Heart block, myocardial damage
Nursing: Have calcium gluconate available
IV: 25-50mg/kg diluted in D5W and given over 10- 20min; max 2mg/dose

Sodium bicarbonate- Relieves bronchospasm; Also corrects metabolic acidosis

brought on by work of breathing
SE: Tetany, seizures, cardiac arrest
Contra: Metabolic/respiratory alkalosis, hypochloremia, hypocalcemia
Nursing: Assess respiratory and cardiac function, watch for fluid overload, evaluate
blood pH and PO2
IV: 2-5 mEq/kg over 4-8hrs, monitor CO2 and pH; not to exceed 50mEq/hr

6. Treatment modalities and note when each is indicated:

Aerosolized medications by nebulizer- Changes medication from a liquid to a mist so that it can be more
easily inhaled into the lungs. Particularly effective in delivering asthma medications to infants and small
children and to anyone who has difficulty using an asthma inhaler. It is also convenient when a large dose
of an inhaled medication is needed. MedScape- Nebulizers

Metered-dose inhaler- Used to deliver asthma medications via inhalation; can be

used with rescue medications such as albuterol and long term control medications
such as corticosteroids
Oxygen- First line treatment for acute asthma exacerbation to keep oxygen sats
above 90%; delivered via face mask
Heliox therapy- A breathing gas mixture (delivered via non-rebreather) of helium
and oxygen that is less dense than air or oxygen, so it provides a less resistant flow when passing
through obstructed airways and requires less mechanical energy to ventilate the lungs. Useful in severe
asthma attacks to reduce work of breathing and respiratory distress in greatly constricted airways until
Beta-agonist and IV corticosteroid therapy take effect.

BiPap- Bilevel positive airway pressure, continuous positive airway pressure (CPAP)
with pressure support breaths. It is used during noninvasive positive pressure
ventilation. It delivers a preset inspiratory positive airway pressure (IPAP) during
inspiration and expiratory positive airway pressure (EPAP).

7. Discuss consent for treatment of a minor. How does the nurse proceed if the
parent is unreachable?
If the child was brought into the ER by another care provider other than the parents
that care provider may give consent by proxy if the parents allow for it. In
emergencies, the nurse should document any efforts made to obtain consent, and
appropriate care should be given.