Pink Puffer Kids Final

Perpetual succour hospital Perpetual succour hospital department of family & community department of family & community

medicinemedicine

Family case presentation:Family case presentation: “ I got pink puffer kids” “ I got pink puffer kids”

LIZA D. MARIPOSQUE, M.D.LIZA D. MARIPOSQUE, M.D.

11STST Year FAMED Resident Year FAMED Resident

March 2009March 2009

GENERAL OBJECTIVE

To present a family with asthmatic children

To review the management of Bronchial asthma in pediatric age group.

Specific Objectives:

1. To present a case of a 2 year old asthmatic child.

2. To present the family dynamics and function.

3. To discuss interventions and recommendations.

INDEX CASE PROFILE

W. C., 2 Years and 6 months old, female, child from Sitio Upper La guerta, Lahug, Cebu City.

Chief Complaint: recurrence of difficulty of breathing.

PRENATAL, NATAL & POST-NATAL HISTORY

Prenatal at 3 months AOG regularly at Brgy. Lahug Health Center. Episodes of asthma attacks noted throughout the course of pregnancy.

Meds: Multivitamins and Salbutamol Delivered, Fullterm at home by a Traditional Birth

Attendant (TBA) and no complications noted. BW = 6kg BR = 3rd/4

Exclusively Breastfed up to 18 months.Weaning at 6 months.No other known medical history.No food and drug allergy. Complete primary immunization @ Brgy.

Lahug Health Center.HFD: AsthmaDevelopmental milestone:

Normal at par with age

HISTORY OF PRESENT ILLNESS

18 months PTC: Onset of nocturnal dyspnea especially at dawn. Triggers: cough & colds No fever Consult and prescribed with Salbutamol syrup and Cotrimoxazole suspension with relief. 1 month PTC:

Onset of cough and coryza with recurrent nocturnal dyspnea for 2-3 episodes/week.

- Occasional wheezing and dyspnea was noted by the mother, especially when the weather condition changes.

-More often, decoction of “Gabon” herbal plants for cough and liniments (Efficascent Oil) or Vicks was applied on the chest during asthma attacks.

PHYSICAL EXAMINATION

Examined awake, responsive, cooperative, ambulatory, not in respiratory distress

Vital Signs:BP = 90/60 mmHg Wt = 10 kgHR = 80 bpm Ht = 79cmRR = 46- 50 cpmT = 36.5C

WFA = 82.44 % (1st Degree Malnutrition) WFH = 90% (Mild Wasting)HFA = 84.04% (Severe Stunting)

Skin: no lesions, warm, good turgor HEENT: Normocephalic, anicteric sclerae,

pinkish palpebral conjunctivae, no alar flaring,

(+) clear nasal discharges (-) TPC Neck: no lymphadenopathies C/L: equal chest expansion, no chest retractions,

no rales, (+) wheeze CVS: adynamic precordium, distinct heart sounds,

normal rate, regular rhythm, no murmur

Abd: globular, normoactive bowel sounds, flabby, soft, non-tender, no masses palpated, no hepatomegaly

Ext: no edema, strong pulsesCNS: within normal limits

IMPRESSION

BRONCHIAL ASTHMA, MILD PERSISTENT, PARTIALLY CONTROLLED.

UPPER RESPIRATORY TRACT INFECTION

1st Degree Malnutrition, mild wasting, severe stunting

Childhood asthma

chronic inflammatory condition of the lung airways resulting in episodic reversible airflow obstruction when exposed to various risk factors.

The pathologic changes, linked to persistent airways inflammation and hyperresponsiveness of the lungs.

Epidemiology Increasing prevalence of childhood asthma. International study of Childhood Asthma & Allergies

prevalence in 56 countries found 20x variation (range:1.6-36.8%)

~80% asthmatics report disease onset before 6 years old.

All young children experiencing recurrent wheezing, only a minority will go on to have a persistent asthma in later childhood.

Types of Asthma by Underlying Cause or Disease Process

Allergic asthma - triggered by environmental triggers called allergens.

Non-allergic asthma- triggered by factors other than allergens, such as irritants like smoke.

Occupational asthma - triggered by irritants in the workplace ( strong fumes or chemicals).

Exercise-induced asthma - triggered by exercise or vigorous exertion.

Cough-variant asthma - main symptom is continuous coughing. There may be shortness of breath, but generally there is no wheezing.

Medication-induced asthma - NSAIDS

Asthma Classifications by Severity

ASTHMA SEVERITY

DAYS W/ SYMPTOMS

NIGHTS W/ SYMPTOMS

LUNG FUNCTION

Mild Intermittent

<3 per week < 3 months FEV1 or PEF ≥80 of predicted;

PEF Variability <20%

Mild Persistent ≥3 per week 3-4 months FEV1 or PEF ≥80 of predicted;

PEF Variability 20-30%

Moderate

Persistent

Daily symptoms, daily use of short acting ß-agonist

>1 time per week FEV1 or PEF >60 & ≤80% of predicted;

PEF Variability >30%

Severe Persistent Continual symptoms, limited physical activity, frequent exacerbations

frequent FEV1 or PEF ≤60 of predicted;

PEF Variability >30%

Behrman, Kliegman, Jenson, et.al.Nelson Textbook of Pediatrics,17th Edn. p767

PathogenesisAsthma Triggers

Airway Obstruction

Airway Inflammation, Hyperresponsiveness, & Remodelling

Status Asthmaticus

Early phase:15-30mins

Late Phase:4-12hr after allergen exposure

Clinical Manifestations ..

Diagnostic tools ..

Good asthma management

1. Maintain normal activity- Attend school regularly.- Participate fully in the sport of their choice.

2. Sleep well without disturbance due to asthma.3. Experience little to no adverse effects from asthma

pharmacotherapy5. Prevent chronic asthma symptoms.6.Maintain normal lung function.7. With early intervention, stay safe by keeping asthma

exacerbations from becoming severe.

Four Components of Optimal Asthma Management:

1. Regular assessment & monitoring.- check-ups q 2-4wks until good control is achieved.- 2-4 per year to maintain good control.- lung function monitoring.

2. Control of factors contributing to asthma severity.- eliminate or reduce problematic environmental exposures.- treat co-morbid conditions.- Annual Influenza vaccination

3. Patient education

4. Asthma pharmacotherapy

- Quick-relief medications (“relievers”)

a. short-acting ß-agonists

b. inhaled anticholinergics

c. short-course systemic glucocorticoids

Long-term-control medications (“controllers”)

- Nonsteroidal anti-inflammatory agents.

- Inhaled glucocorticoids ..

- Sustained-release theophylline

- Long-acting inhaled ß-agonist

- Leukotriene modifiers

- Oral glucocorticoids.

Inhalers for Asthma

Reliever Inhalers:- bronchodilator.- as needed and for acute attack.- if needed 3x a week or more to ease symptoms, a preventer inhaler is usually advised.

Long-Acting Bronchodilator Inhalers- MOA is same with 'relievers', but work for up

to 12 hours.- salmeterol and formoterol.

Pressurised MDIs (Metered Dose Inhalers)

- contains a pressurized inactive gas that propels a

dose of drug in each 'puff'.

- easy to use, small & hand-carry.

- recommended for children ≥5 years old. Breath-activated MDIs

- ß-2 agonist.

- Alternatives to the standard MDI.- require less co-ordination than the standard MDI.

- recommended for children ≥5 years old

Spacer devices- used with pressurized MDIs.- Decrease risk of fungal infection.- Recommended for ≤4 years old.- 50% decrease delivery to the lungs due to

electrostatic charge to the plastic which attracts the aerosol.

Dry Powder Inhalers (DPI)- Recommended for ≥4 years old.- Not be used for children in severe attacks w/ greatly reduced inspiratory flow.

Nebulizers

- No need any co-ordination to use, justbreathe in and out.

- used mainly in hospital for severeattacks of asthma when large doses of

inhaled drugs are needed

Stepwise Approach for Managing Asthma in terms of Severity

ASTHMA SEVERITY

QUICK RELIEF MEDICATION

LONG-TERM CONTROL MEDICATION

EDUCATION

Step 1: Mild Intermittent

Short acting ß-agonist - prn

No daily medication needed Use of MDI & spacer, environmental control measures

Step 2: Mild Persistent

Short acting ß-agonist - prn

Anti-inflammatory: low dose inhaled glucocorticoids, cromolyn, leukotriene modifier, nocromil.

Alternative: sustained release theophylline

Step 1 + group education & monitoring

Step 3: Moderate persistent

Short acting ß-agonist - prn

Anti-inflammatory: low-medium dose inhaled glucocorticoids, & either LABA, Leukotriene

Step 1 + group education & monitoring

Step 4: Severe Persistent

Short acting ß-agonist - prn

Anti-inflammatory: high-dose inhaled glucocorticoids + LABA, either leukotriene modifier, sustained release theophylline. Oral glucocorticoid

Step 1 + group education & monitoring + referral

Behrman, Kliegman, Jenson, et.al.Nelson Textbook of Pediatrics,17th Edn. p767

Levels of asthma control according to the Global Initiative for Asthma (GINA).

Characteristic Controlled(All of the following)

Partly controlled(Any measure present in any

week)

Uncontrolled

Daytime symptoms None (twice or less/week)

More than twice/week

Three or more features of partly

controlled asthma present

in any week

Limitations of activities

None Any

Nocturnal symptoms/awakening

None Any

Need for reliever/rescue

treatment

None (twice or less/week)

More than twice/week

Lung function (PEF or FEV1)‡

Normal <80% predicted or personal best (if

known)

Exacerbations None One or more/year* One in any week†

FEV1 = forced expiratory volume in 1 second; PEF = peak expiratory flow.

*Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.

†By definition, an exacerbation in any week makes that an uncontrolled asthma week.

‡Lung function is not a reliable test for children 5 years and younger.

Probable Reasons for Poor Asthma Control

Incorrect choice of inhalerPoor technique use of inhalerNon-adherence to treatment Individual variation in response to treatmentSmokingCo-morbid rhinitis

Family dynamics

Family Profile

Mother : M. L., 24 years old, common law partner, unemployed, asthmatic

- educational attainment: Grade III

Father : W. C. Sr., 27 years old, common law partner, breadwinner (panday-mason), who earned only ~Ƥ800/wk., occasional alcoholic drinker.

- educational attainment: 2nd year High school

SIBLINGS:

1. Winmar. L. - 7 years old, male, 1st child,

grade 1 in Lahug Elementary school.

2. Winnie C. Jr. - 5 years & 10 months old, male, 2nd

child, asthmatic

3. Winjel C. - Index Patient, 2 years & 6 months old,female, 3rd child, asthmatic

4. Winnie Rose C. - 10 months old, female, 4th child

Marissa, Winnie Rose,Winnie Jr., Winjel

House of Betty, the sister

SITUATIONAL ANALYSIS

Lapuz-Caparida’s Hause

Bedroom

Dining area

Deep well

Smilkstein’s Cycle of Family Function

FAMILY IN EQUILIBRIUM

STREESFUL LIFE EVENTS:Asthma attacks & no permanent work

CRISIS:Inadequate family income

EXTRA-FAMILIAL RESOURCES:Free medical check-upsFree medicinesCan borrow money from older sister

Permanent work

Impact of Illness

Stage I – Onset of Illness

Stage II – Reaction to Diagnosis (Impact phase)

Stage III – Major Therapeutic efforts

Stage IV – Early Adjustment to Outcome (Recovery)

Stage V – Adjustment to the Permanency of the

Outcome

Family Assessment Tools

1. Family Genogram

2. Family Circle

3. Family APGAR

4. Clinical Biography and Life Events

5. SCREEM

Family genogramFamily genogramlapuz-caparida familylapuz-caparida family

january 13, 2009january 13, 2009

Entiquino, 49

@x† Francisca36,

Ѿ

@

Carmen 39

Betty 30

Rosela 27

Renante25

Marissa 24,

Roger 23

Jenny 22

Remarck 16

Queeny 10

Winnie Sr.27,

Winmar,7

@Winnie Jr. 5

@ Winjel, 2

Winrose, 10 mos.

1988

I

ii

III

@Rostica 59,

Alejandro60

Generoso42

Dita 36

Rita

45 Ronnie 29

Amay28

Benvienido 25

LEGENDS:@ - Asthmatic

Index Patient† or X deceased

recurrent urticarial rashes 5 months pregnant

Ѿ

Abella-Lapuz Jimenes-Caparida

male female

FAMILY CIRCLE

MARISSA

WINMAR

WINROSE

WINNIE SR.

WINJEL

WINNIE JR.

BETTY

FAMILY APGAR iINFORMANT: MARISSA CAPARIDA & betty

Almost always

Some of the time

Hardly ever

A I am satisfied that I can turn to my family for help when something is troubling me.

√

P I am satisfied with the way my family talks over things with me and shares problems with me.

√

G I am satisfied that my family accepts and supports my wishes to take on new activities and direction.

√

A I am satisfied with the way my family expresses affection and responds to my emotions.

√

R I am satisfied with the way my family and I share time together.

√

Total 9

screemResource/ Strength Pathology/Weakness

Social Interacts with neighbors and relatives. No known enemies.

Nobody can help the wife in attending the 4 children

Cultural Herbal medicine Using herbal medicine & linements

Religious Prays at home. Attends mass occasionally during fiesta, Christmas.

Economic The father works as a construction worker Inadequate monthly income.

Educational Primary education Learns at home

Medical Can borrow money from the eldest sister in case of emergency. Medical check-up with the family physician

Limitations in finances for medical check-up & medicine.

FAMILY DIAGNOSISNuclear type of family with young children,

highly Functional, Lower Class Stage IV of the Family Illness Trajectory.Father is the breadwinner; mother is the

primary care giver; patriarchalHealth status of kids: poorReligious practices: poor

interventions

Preventive measures & environmental sanitation.

Hypoallergenic diet Medical advices Family planning.

Medical check-up.Follow – up check-up regularly. Giving some free medicines. Referred to pediatric

pulmonologist for consult.

To continue the medical center. constructed by the PSH-Dept. of Family & Community Medicine.

To propose a nebulizer machine in the community center.

To propose a free medicines from the Brgy. Health Center & Bry. Lahug.

To suggest a vehicle from the Brgy. Lahug for emergency purposes.

To propose a free mass wedding in the community.

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