pink puffer kids final
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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.
recommendations