Asthma–acute asthma exacerbation in children–managing

Question 1

What are the 3 pathologic features that constitute an asthma condition?

Answer 1

Bronchial hyperresponsiveness, airflow obstruction, and underlying inflammation

Question 2

What occurs to the airflow during an asthma exacerbation?

Answer 2

The airways narrow and slow the speed of the air moving into the lungs.

Question 3

How can a peak flow meter be useful for asthma exacerbations?

Answer 3

Peak flow meters can show narrowing of the airways before an exacerbation happens

Question 4

When should a peak flow be used in a person with asthma?

Answer 4

A peak flow meter should be used twice daily at the same time each day and with early signs of an asthma exacerbation.

Question 5

What are the 3 zones that can help family members monitor and manage an asthma exacerbation?

Answer 5

Green zone
Yellow zone
Red zone

Question 6

What are the features of a green zone for child with acute asthma?

Answer 6

There is no acute exacerbation, patient is doing well no symptoms of cough, wheezing, chest tightness, or shortness of breath. Has normal activities. And peak flow is 80 to 100% of the highest reading.

Question 7

What are the salient features of a yellow zone for child with acute asthma?

Answer 7

Symptoms of cough, wheezing, chest tightness, breathing difficulties, or awakening at night due to coughing with some limitations to usual activities. Peak flows are 50 to 80% of the highest reading

Question 8

What are the salient features of a red zone for a child with acute asthma?

Answer 8

Severe symptoms including shortness of breath, quick relief medications do not help, or symptoms are the same or worse after 24 hours in the yellow zone. Peak flow < 50% highest reading. This is an emergency.

Question 9

What are the quick relief medications used for an asthma exacerbation?

Answer 9

Albuterol or levalbuterol are the short acting beta agonists or SABAs
And short acting muscarinic antagonists (SAMA) usually given in combination with SABAs

Question 10

SABAs, What is their mechanism of action and onset of action and effective duration?

Answer 10

They are bronchodilators that work within minutes and may be effective for 4 to 6 hours. They are given generally for children in the yellow or red zone.

Question 11

What are the 4 long-term controller medications used as maintenance for asthma control?

Answer 11

1. Inhaled corticosteroids
2. Leukotriene modifiers
3. Long-acting beta agonists AKA LABAs
4. Long-acting muscarinic antagonists or LAMAs

Question 12

What are the common inhaled corticosteroids and how do they work and for how long should they be used?

Answer 12

They include fluticasone, budesonide, mometasone, beclomethasone, ciclesonide, and are anti-inflammatory which reduce swelling in the airways they may be used for weeks to months before getting maximum benefit.

Question 13

What are the leukotriene modifiers and how do they work and how long do they last?

Answer 13

Montelukast, zafirlukast, zileuton, block the effects of leukotrienes, that are immune system molecules that cause asthma symptoms. These meds prevent symptoms for up to 24 hours.

Question 14

What are the long-acting beta agonist medications, how to they work and for how long do they last?

Answer 14

They include salmeteral and formoterol which are bronchodilators and reduce swelling for at least 12 hours and use to control moderate to severe asthma and prevent nighttime symptoms. And that they last longer than the SABA’s

Question 15

What is the long-acting muscarinic antagonist and how is used and in what setting?

Answer 15

+Tiotropium are bronchodilators and use to control severe asthma when a LABA cannot be used.

Question 16

What are the 5 medications used for severe asthma exacerbations?

Answer 16

1. Ipratropium
2. Oral glucocorticoids including prednisolone or methylprednisolone
3. Terbutaline as a beta agonist and is fast acting bronchodilator
4. Magnesium sulfate relaxes smooth muscles in the bronchioles
5. Inhaled epinephrine is an alpha and beta adrenergic agonist that relaxes airway muscles to control bronchospasms

Question 17

Discussed green zone management for an acute asthma exacerbation at home or at school?

Answer 17

Continue taking long-term controller medications

Question 18

Discussed yellow zone management for acute asthma exacerbation at home or at school?

Answer 18

Asthma is getting worse with peak flow between 50 and 75% of best flow reading, repeat administration of the SABAs, 2 puffs with spacer every 4 hours and continue long-term control medications.

Question 19

Discussed red zone management for acute asthma exacerbation at home or school?

Answer 19

Peak flow is less than 50%, this is a medical alert, repeated administration of the SABAs, 4 to 8 puffs with a spacer every 15 minutes x 3 while on the way to the ED. High-dose inhaled corticosteroids are not effective for red zone management.

Question 20

How is an acute mild asthma exacerbation managed in the office setting or ED?

Answer 20

Give SABAs via nebulizer or metered-dose inhaler x3 doses every 20 minutes.
Give oral glucocorticoids if there is no improvement after 1 inhalation treatment or if there is a history of severe or recurrent exacerbations
Note that there is transient hypoxia due to ventilation/perfusion mismatch.

Question 21

How is in a moderate asthma exacerbation managed in the ED?

Answer 21

Give nebulized albuterol plus ipratropium x3 doses every 20 minutes or continuously for 1 hour
Give oral corticosteroids within 30 to 60 minutes of ED arrival

Question 22

What are the symptoms that constitute a mild exacerbation?

Answer 22

They include normal alertness, tachypnea, expiratory wheezing, accessory muscle use, and O2 sats greater 95%.

Question 23

What are the symptoms that constitute a moderate asthma exacerbation?

Answer 23

Symptoms may include normal alertness, tachypnea, wheezing either expiratory plus or minus inspiratory, accessory muscle use, and O2 saturations in the 92 to 95% range.

Question 24

What are the symptoms that constitute a severe asthma exacerbation?

Answer 24

Symptoms include inability to repeat a short phrase, extreme tachypnea, wheezing expiratory and inspiratory, heavy use of accessory muscles, and O2 saturations less than 92% on room air

Question 25

How is a severe asthma exacerbation managed in the emergency department or office?

Answer 25

Give continuous nebulized albuterol and ipratropium for the first hour then consider transition to continuous albuterol
Give IV methylprednisolone as soon as IV is accessed
Consider IM/IV terbutaline or epinephrine for very poor inspiratory flow
Consider giving IV magnesium sulfate which has been shown to reduce the risk of hospitalization

Question 26

What are the symptoms of impending respiratory failure?

Answer 26

They include inability to maintain respiratory effort, cyanosis, inability to speak, altered mental status, PA CO2 greater than or equal to 42 mmHg, respiratory acidosis and oxygen saturations less than 90%.

Question 27

How is an impending respiratory failure from an asthma exacerbation managed?

Answer 27

Do not delay intubation once deemed necessary
Give IV terbutaline and continuous nebulized albuterol
IV methylprednisolone once IV is established
Consider giving IM/IV epinephrine
Consider giving IV magnesium sulfate
Ventilatory support using noninvasive positive pressure ventilation, be cautious with intubation which can lead to increased airflow obstruction due to the exaggerated bronchial responsiveness.