Clinical Features and Description.
Bronchial asthma is a disease of the chest characterised by episodes of breathlessness accompanied by wheezing (noisy breathing, especially when breathing out) and cough. It is caused by a narrowing of the airways carrying air to and from the air sacs in the lungs. These airways are called bronchioles. In asthma, the resistance to the flow of air through these bronchioles is variable which in turn leads to variable symptoms. Asthma therefore tends to occur in acute attacks with complete or relative normality in between, although a small number of children with severe asthma may have persisting symptoms
In asthma there is an increased responsiveness (hyper-reactivity) of the bronchioles to various stimuli such as viral infections, allergens (eg the housedust mite), pets, exercise and changes in air temperature. The reaction of the over-responsive airway is inflammation, swelling and thickening of the walls of the bronchioles, which may be associated with excessive production of thick, sticky mucus; and contraction of the muscle tissue of the bronchi themselves. All this causes diffuse narrowing of the airways and obstruction to airflow.
Asthma usually begins in childhood but may develop at any age. During an attack the affected child coughs, wheezes and becomes breathless and may become distressed. The symptoms vary from day to day and during sleep. This variability is due to the changes in the size of the airways and the production of excessive mucus. The narrowed airways can revert to normal spontaneously, following removal of one of the stimuli mentioned above, or as a result of treatment with drugs which either dilate the bronchioles or diminish the inflammatory response. Some children with mild asthma may not experience such attacks of breathlessness, but instead parents notice that they have a persistent cough.
Not all attacks of wheeziness are due to asthma. In many children they are associated with a minor infection such as a cold, and the child will be well and free from symptoms for many months at a time without the need for regular treatment. Approximately 1 in 7 children between the ages of 2 and 15 years have symptoms of asthma requiring some form of regular treatment. In the majority of children, attacks become less frequent and less severe as the child gets older. In a small number of children the disease may be difficult to manage: such children are usually cared for at specialist hospital clinics.
Care Needs.
Assistance with Treatment
(i) All children with recurrent wheeziness will, at some time or other, be treated with inhaled drugs. Two types of drug may be used: relievers (bronchodilators) and preventers (anti-inflammatories). Bronchodilators relax the muscles in the airways leading to the lungs, whilst anti-inflammatory drugs (usually steroids, but sometimes sodium cromoglycate) reduce the inflammation and hence the amount of sticky mucus in the bronchi. In children with only mild and infrequent asthma, an inhaled bronchodilator may only be needed during attacks and then it may be required up to four times a day. In those with rather more frequent attacks, it may be necessary for the child to take inhaled anti-inflammatory drugs twice daily on a regular basis. These children will also need to have bronchodilator treatments during acute attacks. In those whose asthma is rather more severe, the regular inhalation of both bronchodilators and steroids may be required. In the most severely affected children, courses of steroid tablets may be required during particularly bad attacks. Courses of antibiotics are rarely necessary since most of the infections which give rise to wheeziness are due to viruses.
(ii) The needs of the child with asthma vary according to the child's age, the severity of the condition, and the frequency at which inhaled medication needs to be taken. A variety of devices are available to make the process of inhaling the required dose as easy and as effective as possible. Below the age of five, it is likely that most children will require help with treatment. Over the age of eight it is to be expected that the child will have become proficient at managing the technicalities of taking the correct dose of inhaled medication. Between these ages, the needs will depend on the circumstances of the case. For example, the need for help is likely to persist longer if a mask needs to be used in conjunction with the inhalation device.
(iii) Until relatively recently many young children used to receive their inhaled drugs by means of a nebuliser. This is a special machine which produces a fine spray of a solution of the drug, which is then inhaled through a mask. Most such children require help to use a nebuliser. With recent developments in the design of inhalation devices, almost all children, regardless of age or severity of asthma, can receive the appropriate dosage without the use of a nebuliser.
(iv) In order to evaluate response to treatment, and detect any warning of deterioration, children aged 6 or older are now instructed in the use of a portable mini peak flow meter into which they blow hard after taking a deep breath in. This gives an indirect measure of the degree of obstruction in the airways. Measurements are usually done in the morning and at bedtime. Children under about 8 years of age cannot be expected to carry this out regularly and reliably without assistance from an adult. The attention required is likely to take a significant amount of time. Older children should be able to use the mini peak flow meter unassisted. When the child is symptom free, regular checks by an adult that this is being done properly may be required only once or twice a month.
Variability.
The time devoted to treatment administration and gauging response to it will depend on the severity of the disorder and on the frequency with which episodes of increased wheeziness occur. During the early years following diagnosis the child with established moderate to severe disease is likely to improve with modern treatment; periods of disability causing extensive attention needs will generally become shorter in duration and less frequent.
Attention to Bodily Functions.
A child with infrequent episodes of wheezing, or whose wheeziness is well controlled by regular treatment with anti-inflammatory drugs should be able to pursue all the normal activities expected of a child of the same age. During acute attacks of wheezing breathlessness, the child's physical activity is limited and attention substantially in excess of that normally given to a child of the same age may be needed by day or at night. However in all but the most severely affected children a series of acute attacks is unlikely to last more than a few weeks.
Supervision/Watching-Over Needs.
Supervision will not usually be required for most of the time during the day except in young children suffering acute attacks. Similarly watching-over at night, though frequently undertaken by anxious parents, is not really necessary for the very great majority of asthmatic children, Exceptions will be the occurrence of acute attacks. Because of the increased awareness of the potential dangers of poorly managed asthma in children, acute attacks of wheezing breathlessness which do not respond to therapy necessitate in-patient management. It would be most unusual for there to be no history of hospital admissions in an asthmatic child in whom frequent severe attacks are said to occur by day and night.
Mobility Considerations.
Most acute attacks of wheezing and breathlessness will occur in children aged under 5 years. Acute attacks which are treated appropriately are unlikely to last for more than 12-24 hours at a time: during this short period the child's ability to walk will be restricted, but will then recover as the attack resolves.
Further Evidence.
A factual report from the GP, and the school in school age children, may greatly assist in determining the severity and frequency of attacks and whether they occur by day or night, or both. When there is a history of frequent hospital admissions a factual report from the hospital may be useful in documenting the severity of the condition and its response to treatment. A hospital report may also help to clarify the situation where it is claimed that the child requires nebuliser treatment.
