EPISTAXIS

I.INTRODUCTION

Epistaxis is also called nosebleed. Nosebleeds can be dramatic and frightening.

Fortunately, most nosebleeds are not serious and usually can be managed at home,
although sometimes medical intervention may be necessary.

II.DEFINITION

Epistaxis is nosebleed; haemorrhage from the nose, usually due to rupture of small
vessels overlying the anterior part of the cartilaginous nasal septum.

III.INCIDENCE

One out of every seven people will develop a nosebleed at some time in their
lives. Nosebleeds tend to occur more often during winter months and in dry, cold
climates. It can occurs at any age, but are most common in children aged 2-10
years.

IV.ETIOLOGY

I.1. Most nosebleeds do not have an easily identifiable cause Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.35" +
Indent at: 0.6"
II.2. Trauma to the nose: Nosebleeds can be caused by trauma to the
outside of the nose from a blow to the face or trauma to the inside of the
nose from nose picking
III.3. Other conditions that predispose a person to nosebleeds include:
i) Allergic Formatted: Bulleted + Level: 1 + Aligned at: 0.85" + Indent
at: 1.1"
 ii) rhinitis
iii) Nasal foreign body (object stuck in the nose)
iv) Vigorous nose blowing
v) Nasal surgery
vi) Deviated or perforated nasal septum.
IV.4. Certain medications may cause a nosebleed or make it more difficult Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.35" +
Indent at: 0.6"
to control: Topical nasal medications, such as corticosteroids and
antihistamines, may sometimes lead to nosebleeds
V.5. Liver disease, chronic alcohol abuse, kidney disease, platelet
disorders and inherited blood clotting disorders can also interfere with
blood clotting and predispose to nosebleeds
VI.6. Vascular malformations in the nose and nasal tumours are causes of
nosebleeds
VII.7. High blood pressure may contribute to bleeding, but is rarely the sole
reason for a nosebleed. It is often the anxiety associated with the nosebleed
that leads to the elevation in blood pressure.

V.TYPES

i)1. Anterior Nosebleeds Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,

3, … + Start at: 1 + Alignment: Left + Aligned at: 0.3" +
Indent at: 0.55"
Anterior Nosebleeds make up more than 90% of all nosebleeds. Anterior nosebleed
is
usually from the front and lower part of the nose. The most common site of
anterior
bleeding is in the nasal septum (bridge of the nose). Anterior nosebleeds are usually
easy to control, either by measures that can be performed at home or by a doctor.

ii)2. Posterior Nose bleeds Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,

3, … + Start at: 1 + Alignment: Left + Aligned at: 0.3" +
Indent at: 0.55"
Posterior nose bleeds are much less common than anterior nosebleeds. They tend to
occur more often in elderly people. The bleeding usually originates from an artery
in the back part of the nose. The blood usually drains down the back of the throat
instead of coming out the nostrils (nose openings). These nosebleeds are more
complicated and usually require admission to the hospital.

VI.PATHOPHYSIOLOGY

Due to etiological factor

Rupture of blood vessels

Air moving through the nose

Dry and irritate the membranes

Forming crusts

Rubbing, picking, or blowing the nose.

1. The nose contains many small blood vessels that bleed easily. Formatted: Bulleted + Level: 1 + Aligned at: 0.25" + Indent
at: 0.5"
Nosebleeds are due to the rupture of a blood vessel within the richly
perfused nasal mucosa. Rupture may be spontaneous or initiated by trauma.
Air moving through the nose can dry and irritate the membranes lining the
inside of the nose, forming crusts. These crusts bleed when irritated by
rubbing, picking, or blowing the nose.
2. The lining of the nose is more likely to become dry and irritated from
low humidity, allergies, colds, or sinusitis. Thus, nosebleeds occur more
frequently in the winter when viruses are common and heated indoor air
dries out the nostrils. A deviated septum, foreign object in the nose, or other
nasal blockage can also cause a nosebleed.
3. The vast majority of nose bleeds occur in the anterior (front) part of
the nose from the nasal septum. This area is richly endowed with blood
vessels (Kiesselbach’s plexus). This is also known as Little's area. Bleeding
further back in the nose is known as a posterior bleed and is usually due to
rupture of the sphenopalatine artery or one of its branches. Posterior bleeds
are often prolonged and difficult to control. They can be associated with
bleeding from both nostrils and with a greater flow of blood into the mouth.
VIII. CLINICAL FEATURES
a) Dark or bright red bleeding from one or both nostrils is the most Formatted: Numbered + Level: 1 + Numbering Style: a, b, c,
… + Start at: 1 + Alignment: Left + Aligned at: 0.25" +
Indent at: 0.5"
common sign of epistaxis.
b) If the bleeding is heavy enough, the blood can fill up the affected
nostril and overflow into the nasopharynx, causing simultaneous bleeding
from the other nostril as well. Blood can also drip into the back of the throat
or down into the stomach, causing a person to spit up or even vomit blood.
c) Dizziness, weakness, confusion and fainting are the signs of epistaxis
due to excessive blood loss.

IX. DIAGNOSTIC EVALUATION

i) Health History: Past and present medical history. This may include details Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent
at: 0.45"
of any injury or present medicines are taking.
ii) Laboratory Studies: Routine laboratory studies are rarely indicated
or helpful for nosebleeds but are recommended in the presence of major
bleeding or if a coagulopathy is suspected.
1) Obtain a hematocrit count and type and cross if a history of persistent heavy Formatted: Bulleted + Level: 1 + Aligned at: 0.2" + Indent
at: 0.45"
bleeding is present.
2) Obtain a complete blood count (CBC) if a history of recurrent epistaxis, a
platelet disorder, or neoplasia is present. The bleeding time is an excellent
screening test if suspicion of a bleeding disorder is present.
3) Obtain the international normalized ratio (INR)/ prothrombin time (PT) if the
patient is taking warfarin or if liver disease is suspected.
 iii) Nasal Speculum Exam: Nasal speculum is used to look for any clots Formatted: Indent: Left: 0.24", Numbered + Level: 1 +
Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left +
Aligned at: 0.2" + Indent at: 0.45"
or swelling and also locate where the bleeding is coming from.
iv) Nasal Endoscopy: This procedure, also known as anterior Formatted: Indent: Hanging: 0.05", Numbered + Level: 1 +
Numbering Style: i, ii, iii, … + Start at: 1 + Alignment: Left +
Aligned at: 0.2" + Indent at: 0.45"
rhinoscopy, uses a scope to see the nose.
v) Angiography: This test looks for problems with arteries in the face,
especially around the nose.
iii)3. Imaging Studies: CT scanning and / or nasopharyngoscopy may be Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.3" +
Indent at: 0.55"
performed if a tumour is the suspected cause of bleeding. Sinus films are
rarely indicated for a nosebleed.
X.MANAGEMENT
1. Medical management Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 1.51" +
Indent at: 1.76", Tab stops: Not at 0.5"
Anterior Nosebleed
I.1) A minor nosebleed that has stopped may require no treatment all. Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.39" +
Indent at: 0.64"
Frequently, the body will form a clot at the site of the bleeding that stops
any further bleeding.
II.2) If the source of the bleeding is from a blood vessel that is easily seen,
a doctor may cauterize it (seal the blood vessel) with a chemical called
silver nitrate after applying a local topical anesthetic inside the nose.
Chemical cauterization is most effective when the visible bleeding
originates from the very front part of the nose.
III.3) In more complicated cases, a nasal packing may be required to stop
the bleeding. Nasal packing apply direct pressure inside the nostril to
promote clotting and stop the bleeding. Many different types of nasal
packing are available, including petroleum (Vaseline) gauze, balloon nasal
packs, and synthetic sponge packs that expand when moistened. The
decision as to which one to use is made by the doctor.
IV.4) Caregivers may directly apply medicines to nose to relieve
congestion, decrease pain, and stop bleeding. The local application of a
vasoconstrictive agent has been shown to reduce the bleeding time in
benign cases of epistaxis. The drugs oxymetazoline or phenylephrine are
 widely available in over-the-counter nasal sprays for the treatment of
allergic rhinitis, and may be used for this purpose.
V.5) Most people who receive an anterior nasal packing go home with it in
place. Because these packing block the drainage pathways of the sinuses,
antibiotics may be started to prevent a sinus infection. The packing is
usually left in place for 48-72 hours.

Posterior Nosebleed
1.1) A posterior nosebleed that does not stop bleeding on its own requires Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.3" +
Indent at: 0.55", Tab stops: Not at 0.5"
admission to the hospital, as these types of nosebleeds can be very serious.
In order to control the bleeding, a posterior nasal packing will be inserted by
the doctor. Different types of packings are available, though a balloon nasal
pack is most commonly used.
1.2) Unlike anterior nasal packings, posterior nasal packings are much
more uncomfortable and frequently require sedatives and pain medications.
Furthermore, potential complications such as infection and blockage of the
breathing passages may be encountered with posterior nasal packings.
Consequently, admission to the hospital and close monitoring are required.
1.3) Posterior packings are usually left in place for 48-72 hours. If this
does not control the bleeding, arterial embolization or certain surgical
procedures may be required.
ii. Nursing management
Most people who develop nose bleeding can handle the problem without the
need of a physician if they follow the recommendations below:
1. Lean forward to keep blood from going down the back of throat, and Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.3" +
Indent at: 0.55", Tab stops: Not at 0.5"
breathe through mouth.
1.2. Pinch the lower soft part of nose tightly using thumb and index
finger for 5 to 20 minutes. This manoeuvre puts pressure on the bleeding
point on the nasal septum and often stops the flow of blood.
1.3. Sit quietly, keeping the head higher than the level of the heart. Do not
lay flat.
 1.4. Ice compress can be applied in the nose. They cause bleeding blood
vessels to constrict & bleeding stops.
1.5. After pinching nose, release it to check if there is still bleeding. If
nose is still bleeding, repeat pinching the nose and applying ice.

iii. Home Management

1.1) Advise the child to take rest with head elevated at 30 to 45 degrees. Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.3" +
Indent at: 0.55", Tab stops: Not at 0.5"
1.2) Do not blow nose or put anything into it. If child have to sneeze, open
the child’s mouth so that the air will escape out the mouth and not through
the nose.
1.3) Do not strain during bowel movements. Use a stool softener
1.4) Do not strain or bend down to lift anything heavy it will increases the
blood flow
1.5) Try to keep the head higher than the level of heart to prevent re
bleeding
1.6) Stay on a soft, cool diet. No hot liquids for at least 24 hours.
1.7) If re-bleeding occurs, try to clear the nose of clots by sniffing in
forcefully. Use temporarily a nasal decongestant spray, such as Afrin or
Neo-Synephrine. These types of sprays constrict blood vessels.
1.8) Repeat the steps above on how to stop the common nose bleed. If
bleeding persists, call the doctor and/ or visit to the emergency room.
XI.PREVENTION

Most nosebleeds occur during the winter in cold, dry climates. If a person is
prone to nosebleeds, use a humidifier in the home.

1.i)Petroleum jelly (Vaseline), antibiotic ointment, or a saline nasal spray may be Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25", Tab stops: Not at 0.5"
used to keep the nasal passages moist.
1.ii) Avoid picking the nose
1.iii) Avoid blowing the nose too vigorously.
1.iv) If the nosebleed is related to another medical condition, such as liver disease
or a chronic sinus condition, follow the doctor’s instructions to keep that
problem under control.
1.v) Avoid straining while passing stools or lift anything heavy
XII. PROGNOSIS
With proper treatment, the vast majority of people recover from nosebleeds with
no long term effects. A minority of patients may experience severe bleeding,
which can rarely be life threatening.
 ASTHMA
1.I. INTRODUCTION Formatted: Numbered + Level: 1 + Numbering Style: I, II,
III, … + Start at: 1 + Alignment: Right + Aligned at: 0.25" +
Indent at: 0.5", Tab stops: Not at 0.5"
Bronchial asthma is a chronic inflammatory disease of the airways resulting
from hyper reactivity of the airways to a variety of stimuli. It is characterized by
repeated attacks of cough along with respiratory distress, which reverses either
spontaneously or with some medications like nebulized bronchodilators. The
hallmark of bronchial asthma is wheezing which is a whistling sound produced
when the flow of air from the lungs is obstructed due to narrowing of the small
airways. Wheezing may be audible without aid of stethoscope in about one-third of
the cases of asthma. 1n the remaining, use of stethoscope is required to identify
wheezing.
II. DEFINITION
Bronchial asthma is defined as a reversible, characterised by an increased
responsiveness of the airways to various stimuli, manifest by wide spread
narrowing of the airways causing paroxysmal dyspnea, wheeze or cough.
III .INCIDENCE
Globally 100 and 150 million people are affecting. World-wide, deaths from this
condition have reached over 180,000 annually. In India rough estimates indicate a
prevalence of between 10% and 15% in 5-11 years old children.
IV. ETIOLOGY
1.i)Respiratory infections: These are usually viral infections. in some patients, Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25", Tab stops: Not at 0.5"
other infections with fungi, bacteria or parasites might be responsible
1.ii) Allergens: It is anything in a child's environment that causes an allergic
reaction. Allergens can be foods, pet dander, molds, fungi, roach allergens or
dust mites, Allergens can also be seasonal, outdoor allergens for exarniale, mold
spores, pollens, grass and trees).
1.iii) Irritants: When an irritating substance is inhaled, it can cause an asthmatic
response such as Tobacco smoke, Cold air, Chemicals, Perfumes, Paint odors,
Hair sprays, Air pollutants are irritant that can cause in inflammation in the
lungs and result in asthma symptoms.
1.iv) Weather changes: Asthma attacks can be related to changes in the weather
or the quality of the air.
1.v) Exercise: In some patients, exercise can trigger asthma. Emotional factors:
Some children can have asthma attacks that are caused or made worse by
emotional upsets.
1.vi) Gastroesophageal reflux disease (GERD): It is characterized by the
symptom of heartburn. GERD is related to asthma because the presence of small
amounts of stomach acid that pass from the stomach through the food pipe
(esophagus) into the lungs can irritate the airways. In severe cases of GERD,
there may be spillage of small amounts of stomach acid into the airways
initiating asthmatic symptoms Inflammation of the upper airways (including the
nasal passages and the sinuses): Inflammation in the upper airways, which can
be caused by allergies, sinus infections or lung (respiratory) infections, must be
treated before asthma-tic symptoms can be completely controlled.
1.vii) Nocturnal asthma: Night time asthma is probablv caused by multiple
factors. Some factors may be related to how breathing changes during sleep.
1.i)Exposure to allergens during and before sleep Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25"
2.ii) Body position during sleep
3.iii) As a part of biological clock (circadian rhythm), there is reduction in the
levels of cortisone produced naturally with in the body. This may be the
contributing factor for night time asthma
Risk factors
i) Presence of allergies: Child having any allergic history there is a chance for Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25"
causing asthma
ii) Family history of asthma: family history of any asthma will leads to causing
asthma in child.
iii) Frequent respiratory infections: Frequent respiratory infections causes the
inflammation of airway that leads to asthma in child
iv) Low birth weight: Preterm infants have an increased risk of asthma compared
with term neonates. Moreover, children with a high birth weight or
body weight later are at increased risk for future asthma
V. PATHOPHYSIOLOGY

In asthma, the inflammatory process contributes to increased airway activity.

Thus, control or prevention of inflammations is the core of asthma management.
Asthma results from an airway activity. Asthma results from a complex variety
of responses in relation to trigger, process begins, mast cells, T lymphocytes,
macrophages and epithelial cells are involved in the release of inflammatory
mediators. Eosinophils and neutrophils migrate to the airway, causing injury.
Chemical mediators such as leukotrienes, bradykinin, histamine and platelet-
activating factor also contribute to the inflammatory response. The presence of
leukotrienes contributes to prolonged airway constriction. Autonomic neural
control of airway tone is affected, airway mucus secretion is increased,
mucociliary function changes, and airway smooth muscle responsiveness
increases. As a result, acute bronchoconstriction, airway edema and mucus
plugging occur.

VI. CLASSIFICATION OF ASTHMA

a.1. Mild intermittent asthma: Brief episodes of wheezing, coughing or Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.2" +
Indent at: 0.45"
shortness of breath that occur no more than twice a week is called mild
intermittent asthma. Children rarely have symptoms between episodes(maybe
just one or two flare-ups per month involving mild symptoms at night). Mild
asthma should never be ignored because, even between flares, airways are
inflamed.
b.2. Mild persistent asthma: Episodes of wheezing, coughing or shortness of
breath that occur more than twice a week but less than once a day is called
mild persistent asthma. Symptoms usually occur at least twice a month at
night and may affect normal physical activity.
c.3. Moderate persistent asthma: Symptoms occurring every day and requiring
medication every day is called moderate persistent asthma. Night time
symptoms occur more than once a week. Episodes of wheezing, coughing or
shortness of breath occur more than twice a week and may last for several
days. These symptoms affect 'normal physical activity
 d.4. Severe persistent asthma: Children with severe persistent asthma have
symptoms continuously. Episodes of wheezing, coughing or shortness of
breath are frequent and may require emergency treatment and even
hospitalization. Many children with severe persistent asthma have frequent
symptoms at night and can handle only limited physical activity.
VII.CLINICAL FEATURES
Classical triad : It includes cough, wheeze and breathlessness. These symptoms
may not present in all the patients.

i) Wheezing Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,

… + Start at: 1 + Alignment: Left + Aligned at: 0.3" + Indent
at: 0.55"
1.a. wheezing is when the air flowing into the lungs makes a high-pitched
Formatted: Indent: Left: 0.05", Numbered + Level: 1 +
whistling sound. Numbering Style: a, b, c, … + Start at: 1 + Alignment: Left +
Aligned at: 0.2" + Indent at: 0.45"
2.b. Mild wheezing occurs only at the end of a breath When the child is breathing Formatted: Numbered + Level: 1 + Numbering Style: a, b, c,
… + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent
out (expiration or exhalation). at: 0.45"

3.c. More severe wheezing is heard during the whole exhaled breath. Children
with even more severe asthma can also have wheezing while they breathe in
(inspiration or inhalation). However, during a most extreme asthma attack,
wheezing may be absent because almost no air is passing through the
airways.
4.d. Asthma can occur without wheezing and be associated with other symptoms
such as cough, breathlessness, chest tightness. So, wheezing is not necessary
for the .diagnosis of asthma. Also, wheezing can be associated with other
lung disorders such as cystic fibrosis.
5.e. In asthma related to exercise (exercise-induced asthma) or asthma that
occurs at night (nocturnal asthma), wheezing may be present only during or
after exercise (exercise-induced asthma) or during the night, especially during
early part of morning (nocturnal asthma).
ii) Coughing Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0.3" + Indent
at: 0.55"
Cough may be the only symptom of asthma, especially in cases of exercise-
induced or nocturnal asthma. Cough due to nocturnal asthma (night time
asthma)usually occurs during the early hours of morning, from 1am to 4 am
 usually, child does not cough anything up so there is no phlegm or mucus. Also,
coughing may occur with wheezing.

iii) Chest tightness Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0.3" + Indent
at: 0.55"
The child may feel like the chest is tight or would not expand when breathing in.
FEATURES OF LIFE THREATENING ASTHMA.
i) Cyanosis, silent chest or feeble respiratory effort Formatted: Bulleted + Level: 1 + Aligned at: 0.1" + Indent
at: 0.35"
ii) Fatigue or exhaustion
iii) Agitation or reduced level of consciousness
VIII. DIAGNOSTIC EVALUATIONS
a)1. History collection:includes the following- Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0" +
Indent at: 0.25"
i) History of breathing problems
Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
ii) Family history of asthma, allergies, skin conditioncalled eczema, or other lung … + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25"
disease.
iii) History of cough, wheezing, shortness of breath, chest pain
b)2. Physical Examination: During the physical examination, the doctor has to Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0" +
Indent at: 0.25"
listen for abnormal heart and lungs.
c)3. Laboratory and Diagnostic Tests: These studies commonly ordered for the
assessment of asthma include the following:
1.i) Pulse oximetry: Oxygen saturation may be significantly decreased or normal Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25"
during a mild exacerbation
2.ii) Chest X-ray: Usually reveals hyperinflation
3.iii) Blood gases: Might show carbon dioxide retention and hypoxemia
4.iv) •Pulmonary function tests (PFT): Can be very useful in determining the
degree of disease but are not useful during an acute attack. Children as young as
5 or 6 years might he able to comply with spirometry
5.v) Peak expiratory flow rate (PEER): It is decreased during an exacerbation
6.vi) Allergy testing: Skin test or RAST can determine allergic triggers for the
asthmatic child.
IX. MANAGEMENT
1.Medical Management
Developing an effective medication plan to control a child's asthma can take a little
time and trial-and-error. Different medications work more or less effectively for
different kinds of asthma, and some medication combinations work well for some
children but not for others.
There are two main categories of asthma medications
a) Quick-relief medications (rescue medications) Formatted: Numbered + Level: 1 + Numbering Style: a, b, c,
… + Start at: 1 + Alignment: Left + Aligned at: 0" + Indent
at: 0.25"
b) Long-term preventive medications (controller medications).
Drug therapy helps in promoting bronchodilation , reducing inflammation and
removing secretions.
1.i)Aminophylline: Given intravenously, is limited to use in acute episodes of Formatted: Numbered + Level: 1 + Numbering Style: i, ii, iii,
… + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent
at: 0.45", Tab stops: Not at 0.5"
asthma that requires hospitalization. The dosage of thiophylline which is low
in 10-16 mg/ kg/day and high dose m18-28 mg/kg/day.
1.ii) Isoproterenol: The dosage of the drug is 0.2 to 0.3 ml in 2. 5 ml saline by
aerosol and is inhaled B-adrenergic stimulants. It acts quickly and short
duration which produces bronchospasm. Asthalin solution by nebulizer as per
recommended.
1.iii) Metaproteremol: The dosage of the drug is 0.2-0.3 ml in 2.5 ml
saline by inhalation.
1.iv) Corticosteroids (Methyl prednisolone): The dosage of the drug is 2
mg /kg/ intravenously, the exact mechanism of action of corticosteroids it
may reduce inflammatory response.
1.v) Cromolyn sodium: It blocks the release of chemical mediators from the
mast cells. It produces indirect vasodilation. It is used to prevent attacks and
is the most effective in children with extrinsic asthma.
2. NURSING MANAGEMENT Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 1.51" +
Indent at: 1.76", Tab stops: Not at 0.5"
1. Providing emotional support and education : The child who had an acute
Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
episode of asthma is anxious, frightened and uncomfortable due to respiratory 3, … + Start at: 1 + Alignment: Left + Aligned at: 0.2" +
Indent at: 0.45", Tab stops: Not at 0.5"
distress, frequent coughing and loss of sleep, etc. Nurses need to allay the
anxiety and minimize emotional trauma, by addressing the child calmly and
 quietly. External stimuli should be minimized. Teach the child and his
parents about the use of metered dose inhalers and spacers, etc.
1.2. Administer intravenous fluids during the acute attack. Large amounts of
food or fluids may be discouraged as it might initiate vomiting in children
who receive theophylline or who use abdominal muscles for respiration. Give
oral fluids as the child improves. Offer small amount frequently.
1.3. Theophylline infusion: Theophylline can help to relieve breathlessness by
relaxing muscles in airways so they open up, and the air can flow through
more easily.
1.4. Provide Rest and Comfort : Child needs to be provided uninterrupted rest
because they are usually exhausted due to breathing efforts. The child’s head
should be raised with pillows as this position helps in breathing. If the child
feels more comfortable in leaning forward, provide cardiac table and pillow
to the child.
1.5. Evaluate respiratory status and facilitate breathing:
Observe the child for presence of cyanosis, use of accessory muscles of
respiration and intensity of wheezing. Administer humidified oxygen to the
child. Younger children can be placed in oxygen hood and for older children
nasal cannula can be used. Nurses should monitor the child’s response to
oxygen therapy. Also provide frequent mouth care and nasal care to the child.
X. PREVENTION OF ASTHMA
a. Encourage breastfeeding at least for 6 months Formatted: Numbered + Level: 1 + Numbering Style: a, b, c,
… + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent
at: 0.45"
b. Identify the allergens, if possible, such as:
- Outdoor and indoor allergens, e.g. trees, shrubs, weeds, grass, molds, pollens,
spores, dust mites, cockroach antigens, etc.
- Irritants-Strong odors, e.g. sprays, paints, smoke, etc.
- Changes in weather
- Cold air, certain medications (aspirin)
- Emotions (anger, fear, laughing, crying)
- Infections
 c. Though food may cause asthma, it is generally unusual. Keep the bedroom Formatted: Numbered + Level: 1 + Numbering Style: a, b, c,
… + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent
at: 0.45"
and house clean and dust free
d. Wet mopping is preferred over dry dusting
e. Avoid floor carpets and stuffed furniture as it attracts lots of dust.
f. Clean the wall hangings, furniture and books frequently.
g. Discourage close contacts with pet animals.
h. Advise to avoid active and passive smoking
i. Avoid strong odors, e.g. paints, disinfectants.

C. CYSTIC FIBROSIS

1.I. DEFINITION Formatted: Numbered + Level: 1 + Numbering Style: I, II,

III, … + Start at: 1 + Alignment: Right + Aligned at: 0.25" +
Indent at: 0.5", Tab stops: Not at 0.5"
Cystic fibrosis is a less common respiratory alteration. It is an inherited autosomal
recessive genetic disorder that affects the exocrine glands of the body. Children
with Cystic fibrosis have an abnormality in the function of a cell protein called the
cystic fibrosis transmembrane regulator (CFTR). This cell protein controls the flow
of water and certain salts in and out of the body’s cells. As the movement of salt
and water in and out of cells is altered, mucous becomes thickened. The thickened
mucous can affect many organs and body systems including:

Respiratory system: sinuses and lungs

Digestive system: pancreas, liver, gall bladder and intestines

Reproductive system: In males, sperm carrying ducts become clogged

II.ETIOLOGY
The gene responsible for cystic fibrosis is chromosome 7. Mutations of the gene
cause CF.
III.PATHOPHYSIOLOGY
CF is an exocrine gland dysfunction characterized by abnormal levels of sodium
and chloride, increased viscosity of mucus gland secretions, elevation of sweat
electrolytes, abnormal autonomous nervous system function and changes in the
constituents of saliva. Increased viscosity of mucus gland secretion is responsible
for the clinical manifestations. Thick secretion of mucus gland causes obstruction in
small ducts of gland. Blockage of pancreatic duct may lead to pancreatic iibrosis
and it prevents the entry of pancreatic enzymes into the duodenum causing
impairment in digestion and absorption causing stetorrhea (bulky stool with
undigested fat) and azotorrhea (foul-smelling stools with putrefied proteins).
Endocrine function of pancreas remains unaltered in the beginning but as the
disease progresses, insulin production is also affected, causing greater incidence of
diabetes mellitus in children with cystic fibrosis. Gastro intestinal and pulmonary
complications are common among these children. Alterations in the reproductive
system lead to sterility both in male and females. The growth and development of
the child is affected.
CLINICAL MANIFESTATIONS
1. Abnormalities in the glands that produces sweat and mucous. This may cause
loss of salt that may cause an upset in the balance of minerals in the blood,
abnormal heart rhythm and possibly shock
2.Earlier manifestations observed in newborns are due to meconium ileus:

i. Abdominal distension

ii. Vomiting

iii. Failure to pass stools

iv. Dehydration
3. Thick mucous that accumulates in the lungs and intestines may lead to por
growth, frequent respiratory infections, breathing difficultiesand or lung disease.
4. Diarrhoea may occur which does not go away. The stools are foul smelling and
greasy
5. Deficiency of fat soluble vitamins A, D, E and K
6.Increased appetite in the beginning and later as disease progresses, loss of appetite
7.Pancreatitis
8..Dry cough (non-productive) :cough may be dry, hacking first but over a period of
time becomes loose and productive. As lung involvement progresses, brochiolitis
develops and wheezing occurs.
9.

5.Respiratory infection by pseudomonas

6.Atelectasis
7.As the condition worsens, cyanosis is present with clubbing of fingers and toes. .
DIAGNOSTIC EVALUATION
1. Family history Formatted: Picture bulleted + Level: 1 + Aligned at: 0" +
Indent at: 0.25", Tab stops: Not at 0.5"
2. Pulmonary function test
Sweat chloride test is positive. Normal: Less than 40 mEq/ L
3. Sweat sodium level: More than 60 mEq/ L (abnormally high sodium in the
sweat is seen)
1. Radiography reveals atelectasis or obstructive emphysema Formatted: Picture bulleted + Level: 1 + Aligned at: 0" +
Indent at: 0.25", Tab stops: Not at 0.5"
Newborn screening for DNA, identification of mutant gene.
COMPLICATIONS
1.Meconium ileus
2. Diabetes mellitus
3.Distal intestinal obstruction Gum-like masses obstru causing a partial or
complet
4.Pulmonary complications
5.Malabsorption syndrome
6. Growth retardation.
MANAGEMENT
1. Antibiotic Therapy: The common microbial agents causing pulmonary Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.2" +
Indent at: 0.45", Tab stops: Not at 0.5"
problem” staphylococcus aureus, H. influenza,Pseudomonas, Mycoplasma,
Mycobacterium Virus, aspergillus, etc.
Common antibiotics
Fluroquinolone, aerosolized gentamicin, tobramicin,
For pseudomonas infection: Ceftazidine, Cefoperazone, Piperacillin, Imipenam
with an aminoglycoside.
2. Mucolytic agents: N-acetyl cystein is used to reduce the viscosity of airway
secretion
3. Recombinant human DNase (deoxyribo nuclease) which is given as aerosol
(2.513% OD or BD) increases mucociliary clearance and reduces incidence of
respiratory infection.
4.Management of pulmonary problem: It includes airway clearing techniques
such as
1.1) Postural drainage Formatted: Numbered + Level: 1 + Numbering Style: 1, 2,
3, … + Start at: 1 + Alignment: Left + Aligned at: 0.1" +
Indent at: 0.35", Tab stops: Not at 0.5"
1.2) Chest clapping
1.3) Flutter therapy
1.4) Positive expiratory pressure
Flutter mucus clearance device is a small hand-held plastic pipe with a
Stainless of ball in the inside that facilitates removal of mucus.
Another method to remove secretion is to wear a mechanical vest device which
provides high frequency chest wall oscillation.
Chest physiotherapy is the corner stone of pulmonary therapy
5.Bronchodilators and inhalation steroid therapy
About 25-50% of patients with CF require these drugs to open bronchi for easier
expectorations. Usually, it is administered before physiotherapy.
6. Management of gastrointestinal problems
Replace pancreatic enzymes with meals. It is available in enteric-coated capsule
form (will not be neutralized b gastric acids). 1-5 capsules are administered within
30 minutes of eating. Capsules should not be broken, crushed or chewed as
destruction of enteric coating leads to inactivation of the enzymes and excoriation
of oral mucosa.
Meconium ileus and constipation are common among those children who are
treated with stool softness, laxatives and gastrograffin (rectally).
7. Nutritional management: Provide a well balanced, high-protein, high-calorie
diet. Calories may be increased up to 50% during acute infections..
8.Management of endocrine problems: Monitor blood glucose levels and
administer oral hypoglycemic agents or injection insulin.
9.Diet and exercise management
10.Administer growth hormone.