Pediatric Primary Care (67 page)

b.  Classification of severity guides choice and frequency of therapy.

c.  Persistent asthma is most effectively controlled with daily anti-inflammatory medications.

d.  National Asthma Education and Prevention guidelines support aggressive therapy to achieve rapid control of symptoms and then step down to lowest level of therapy to maintain control.

e.  Goals in treatment of acute episode are:

•  Rapid reversal of acute airway obstruction.

•  Identify causes of asthma episode.

•  Adjust chronic maintenance to prevent recurrence of asthma flare.

•  Inhaled beta2-agonist is quick-relief medication for all levels of severity and treatment of choice for prevention of exercise-induced asthma.

•  Short “burst” of oral glucocorticoids is used to reduce inflammation during acute episode.

5.  Build child/family and healthcare provider partnership.

a.  Understand and address reasons for adherence problems in asthma.

b.  Explore patient/family misconceptions about asthma.

c.  Agree on goals and expectations of treatment.

d.  Jointly develop treatment plan.

H.  Follow up.

1.  Before increasing medications, investigate reasons for poor asthma control.

a.  Improper inhaler technique.

b.  Adherence issues, knowledge deficit.

c.  Environmental exposures.

d.  Exacerbation of aggravating conditions (e.g., GER, sinusitis).

2.  Many children have multiple caretakers.

a.  Each caretaker must have access to medications, appropriate devices, asthma action plan.

b.  Provide information to all caregivers including daycare providers, teachers, coaches, school nurses.

c.  Ensure reliable, immediate access to medications in all settings including school.

3.  Regular use of quick-relief medicine indicates deterioration in control of asthma and need to assess maintenance therapy.

4.  Regular follow-up visits are encouraged to achieve and maintain control with appropriate intensity of therapy.

5.  Monitor child for side effects of medications.

6.  Refer to asthma specialist for difficult-to-control asthma in children older than 5 years of age: consider at step 3; refer at step 4. (See
Figures 24-5
through
24-8
).

7.  For children younger than 5 years of age: consider referral at step 2; refer at steps 3 and 4. (See
Figures 24-5 through 24-8).

8.  Peak-flow monitoring to establish personal best: more specific than predicted value.

9.  At each encounter, reassess concerns and correct misconceptions.

10.  Monitor quality of life on regular basis.

11.  Recognize and address barriers to asthma self-management.

12.  Assess source of social support for child and family.

13.  Assess child and family satisfaction with asthma care.

14.  Yearly influenza vaccine for child and household contacts.

I.  Complications.

1.  Pneumothorax, pneumonia.

2.  Acute exacerbation requiring hospitalization, intubation, mechanical ventilation.

3.  Death.

J.  Education.

1.  Asthma education should begin at diagnosis and continue at every encounter: include child as developmentally appropriate and all caregivers.

2.  Key components.

a.  Basic asthma facts to enable child and family to understand rationale for treatment decisions and asthma self-management.

b.  Roles of medications in treating acute symptoms and achieving/maintaining asthma control.

c.  Environmental avoidance and control measures.

d.  Teach relevant skills: how to use devices such as spacers, other medication-delivery devices, peak-flow meter; have child demonstrate relevant skills at each encounter.

e.  Provide asthma action plan: daily maintenance therapy including avoidance of triggers, plan for recognizing and treating worsening asthma, and when to seek medical attention.

3.  Establish goals of therapy jointly and monitor child and family's perception of progress toward reaching goals.

VII. PNEUMONIA

A.  Etiology.

1.  Pneumonia is inflammation and infection of lung parenchyma due to infectious pathogens.

2.  It represents wide spectrum of signs/symptoms and disease severity.

3.  Pathogens vary depending on age of patient.

4.  Classification.

a.  By pathogen (bacterial, including mycoplasma or viral).

b.  By anatomic location: lobar, interstitial, bronchopneumonia.

5.  Common viral pathogens.

a.  RSV; adenovirus; parainfluenza 1, 2, 3; influenza A and B; rhinovirus.

b.  Transmission: highly contagious.

•  Transmitted by direct contact with nasopharyngeal secretions from infected person.

•  Pneumonia results from spread of infection along airways.

i.   Causes direct injury to respiratory epithelium, resulting in airway obstruction, abnormal secretion and necrotic debris in airway lumen and lymphocytic infiltrations of interstitium and lung parenchyma.

ii.  Small airways are obstructed, resulting in poor oxygenation and air trapping, which leads to ventilation and perfusion mismatch.

6.  Common bacterial pathogens.

a.  
Streptococcus pneumoniae, Mycoplasma pneumoniae, Streptococcus
(group A)
pyogenes, Staphylococcus aureus.

b.  Transmission: contagious.

•  Bacterial pathogens may be aspirated or inhaled, rarely by hematogenous spread.

•  Transmitted via person-to-person contact by large droplet aerosolization during coughing/sneezing.

•  Viral infection damages host's normal airway defense mechanisms, facilitating secondary bacterial infection.

c.  
S. pneumoniae.

•  Many have
S. pneumoniae
colonization in upper respiratory tract.

•  Gram-positive encapsulated diplococci produce local edema.

i.   Organism is distributed into adjacent areas of lung, resulting in typical focal lobar consolidation.