ASTHMA Flashcards
List 10 DDx
Angioedema
Anaphylaxis
Foreign Body
Croup
Bacterial Tracheitis
Epiglottitis
Diphtheria
Lemierre Syndrome
Ludwig Angina
Mononucleiosis
Peritonsillar Abscess
Retropharyngeal Abscess
Uvulitis
Pneumonia
Asthma
CHF
DDx Wheezing
Asthma (>2)
Bronchiolitis (<2)
GERD (with feedings)
FBA
CHF
History & Physical
Questions to ask:
History of coughing and wheezing, chest tightness
Number of days with symptoms per week
Altered sleep patterns, night cough, number of episodes
Triggers
Nasal symptoms
Fever
Previous admissions, intubations, ICU admission
Current medication and puffers - dose and frequency
Additional questions to ask in children under 2:
Noisy breathing
Retractions
Trouble feeding
Changes in respiratory rate
Apnea
Additional questions to ask children over 2:
Shortness of breath
Fatigue
Decreased physical activity
Missed days at school
Triggers:
Cold air
Exercise
Viral illness
Allergens
Smoking
Sulphites in foods
Beta blockers
NSAIDS
Strong emotions
Calculate Pram Score
PRAM: What are the components?
PRAM (Pediatric Respiratory Assessment Measure)
O2 Saturation on room air: >/95%, 92 - 94%, <92%
Suprasternal retraction: Present or Absent
Scalene muscle contraction: Present or Absent
Air entry: normal, decreased at the base, decreased at the apex and base, minimal or absent
Wheezing: Absent, expiratory, inspiratory, audible without stethoscope or silent chest
Mild: 0-3
Moderate: 4-7
Severe: 8-12
Investigations
Peak Expiratory Flow Rate if > 7 / reliable enough
CXR if indicated
CXR if suspected underlying pneumonia
Management of Mild Asthma Exacerbation (PRAM 0-3):
< 20 kg and > 20 kg
Salbutamol - MDI 100 mcg / puff
< 20 kg: 5 puffs x 1 with spacer, reassess, then 5 puffs q 1 hr PRN
> 20 kg: 10 puffs x 1 with spacer, reassess, then 10 puffs q 1 hr post-treatment
Reassess HR, RR, BP, Sp02 and PRAM score 1 hr post treatment
If PRAM score greater than or equal to 4, treat according to moderate treatment plan
Management of Moderate Asthma Exacerbation (PRAM 4-7):
< 20 kg and > 20 kg
Salbutamol - MDI 100 mcg / puff
< 20 kg: 5 puffs q 20 min x 3 with spacer, reassess, then 5 puffs q 1 hr
> 20 kg: 10 puffs q 20 min x 3 with spacer, reassess, then 10 puffs q 1 hr
Dexamethasone 0.15 - 0.6 mg / kg / dose; max 10 mg / dose
Predisone / Prednisolone 1-2 mg / kg / dose; max 60 mg / dose
Reassess HR, RR, BP, Sp02 and PRAM score post-treatment, then q30-60 min
If PRAM score is unchanged or <3 point improvement consider Ipratroprium Bromide
If PRAM score >/ 8, treat according to Severe treatment plan
Management of Severe Asthma Exacerbation (PRAM 4-7): < 20 kg
Salbutamol - MDI 100 mcg / puff
5 puffs q 20 min x 3 with spacer, reassess, then 5 puffs q 1 hr
OR
Sabultamol-Nebulizer:
2.5 mg in 0.9% NaCl in total 3 ml by neb x 3 continuous; then 2.5 mg in 0.9% NaCl total 3 mL Neb q 1 h
Iprotropium Bromide: 250 mcg by nebulizer x 3 continuous mixed with first 3 salbutamol treatments
Dexamethasone PO 0.3 - 0.6 mg / kg / dose; max 20 mg / dose
Predisone / Prednisolone 1-2 mg / kg / dose; max 60 mg / dose
Reassess HR, RR, BP, Sp02 and PRAM score post-treatment, then q30-60 min
Magnesium Sulfate IV 25-50 mg / kg / dose over 20 min; max 2000 mg / dose
Management of Severe Asthma Exacerbation (PRAM 8-12): > 20 kg
Salbutamol - MDI 100 mcg / puff:
10 puffs q 20 min x 3 with spacer, reassess, then 10 puffs q 1 hr
OR
Sabultamol-Nebulizer:
5 mg in 0.9% NaCl in total 3 ml by neb x 3 continuous; then 5 mg in 0.9% NaCl total 3 mL Neb q 1 h
Iprotropium Bromide: 500 mcg by nebulizer x 3 continuous mixed with first 3 salbutamol treatments
Dexamethasone PO 0.3 - 0.6 mg / kg / dose; max 20 mg / dose
Predisone / Prednisolone 1-2 mg / kg / dose; max 60 mg / dose
Reassess HR, RR, BP, Sp02 and PRAM score post-treatment, then q30-60 min
Magnesium Sulfate IV 25-50 mg / kg / dose; max 2000 mg / dose
Disposition: Admission
Ongoing need for supplemental oxygen
Persistent increased work of breathing
B2 agonists are needed more than q4 hr after 4-8 hrs of conventional treatment
Deterioration while on systemic steroids
Disposition: When should referral to ICU or a Tertiary Center be Considered?
The patient requires continuous neblized salbutamol and fails to improve on this therapy
Call PICU at tertiary center to discuss management and transport
Disposition: What are discharge criteria from the ED?
Needing B2 agonists less often than q4hr after 4 to 8 h of conventional treatment
A reading of Sp02 94% on RA
Minimal or no signs of respiratory distress
Improved air entry
What are your discharge instructions?
Discharge all patients with salbutamol and spacer to be used q 4 hr for the next 48 hrs then PRN (<20 kg 5 puff, >20 kg 10 puff)
Moderate to severe: Single dose dex 0.6 mg / kg with a second dose at 36 hr
Prescribe low dose inhaled steroid to continue for min 12 weeks
Outpatient Treatment in children 6-11
- SABA PRN WITH low dose ICS PRN
- Daily low dose ICS with PRN SABA
- Daily Symbicort with PRN SABA
- Increase sode of Symbicort
Outpatient treatment age > 12
PRN Symbicort
Then Maintenance and PRN Symbicort
Second line is LTRA (Leukotriene receptor antagonist) but black box warning for suicidality
Increase dose of ICS
Add LABA
Add LTRA
Add Biologics (Resilzumab, Benralizumab)
