Managing the paediatric patient with an acute asthma exacerbation

Question 1

What is the lifetime prevalence of asthma in Canadian children?

Answer 1

11-16%

Question 2

What is an asthma exacerbation?

Answer 2

an acute or subacute deterioration of symptom control that causes distress or risks health to the extent that a visit to a health care provider or treatment with systemic corticosteroids becomes necessary

Question 3

What are the most common triggers for asthma AE?

Answer 3

Viral respiratory tract infections (most)
Exposure to allergens
Suboptimal baseline control

Question 4

What are ED management objectives for acute asthma exacerbations ?

Answer 4

1. An immediate and objective assessment of their severity.
2. Prompt and effective medical intervention to decrease respiratory distress and improve oxygenation.
3. Appropriate disposition of the patient after emergency management.
4. Arranging proper follow-up.

Question 5

What is the definition of mild asthma exacerbation?

Answer 5

Normal mental status
Normal activity and exertional dyspnea
Normal speech
Minimal intercostal retractions
Moderate wheeze
SpO2 >94% RA
Peak flow vs. personal  best >80%

Question 6

What is the definition of moderate asthma exacerbation?

Answer 6

Might look agitated
Decreased activity or feeding (infant)
Speaks in phrases
Intercostal and substernal retractions
Loud pan-expiratory and inspiratory wheeze
SpO2 91-94% RA
Peak flow vs. personal best 60-80%

Question 7

What is the definition of severe asthma exacerbation?

Answer 7

Usually agitated
Decreased activity infant, stops feeding
Speaks in words
Significant respiratory distress, usu. all accessory muscles involved and may display nasal flaring and paradoxical thoraco-abdominal movement. Wheezes might be audible without stethoscope
Peak flow vs. personal best <60%

Question 8

What is the definition of impending respiratory failure?

Answer 8

Drowsy or confused
Unable to eat
Unable to speak
Marked respiratory distress at rest. All accessory muscles involved, including nasal flaring and paradoxical thoraco-abdominal movement.
The chest is silent (absence of wheeze)
SpO2 <90% on RA
Unable to perform peak flows

Question 9

What assessment should occur in an asthma exacerbation?

Answer 9

1. Signs and symptoms of respiratory distress and airway obstruction incld. full set of vital signs esp. pulse oximetry
2. A focused medical history recording previous medications and risk factors for ICU admission and death:
   a) previous life-threatening events,
   b) admissions to ICU,
   c) intubation,
   d) deterioration while already on systemic steroids.
3. A focused P/E:
   a) use of accessory muscles
   b) air entry in both lungs
   c) wheezing
   d) level of alertness
   e) ability to speak in full sentences
   f) activity level
4. Spirometry should be used or peak flow metre in older children
5. Ancillary tests are not routinely recommended:
   a) CXR only is concern re: complications (i.e. pneumothorax), bacterial pneumonia, presence of foreign body or if fail to improve w/ max conventional therapy
   b) blood gases not required unless patient has no clinical improvement w/ maximal aggressive therapy. Normal cap CO2 despite persistent resp distress –> impending resp distress

Question 10

What is the initial treatment recommendation for mild exacerbation?

Answer 10

1. Keep SpO2 > 94%
2. Salbutamol q20min x 1-3 doses
3. Consider ICS

Question 11

What is the initial treatment recommendation for moderate exacerbation?

Answer 11

1. Keep SpO2 > 94%
2. Salbutamol q20min x 3 doses
3. Oral steroids
4. Consider ipratropium x 3 doses in 1h

Question 12

What is the initial treatment recommendation for severe exacerbation?

Answer 12

1. Keep SpO2 > 94%, consider 100% O2
2. Salbutamol and ipratropium x 3 doses
3. Oral steroids
4. Consider IV methylprednisolone
5. Consider continuous aerosolized beta-2-agonists
6. Consider IV MgSO4
7. Keep patient NPO

Question 13

What is the initial treatment recommendation for severe to impending respiratory failure?

Answer 13

1. Keep SpO2 > 94%, NRB mask with 100% O2
2. Continuous aerosolized salbutamol and ipratropium x 3 doses
3. Keep NPO and start IV access
4. Continuous CRM and O2 sat monitor
5. IV methylprednisolone
   Consider:
6. IV MgSO4
   or 2. IV aminophylline
   or 3. IV salbutamol
7. Gas and lytes
8. Consider SC epinephrine
9. If deteriorating RSI
   Call PICU MD

Question 14

What are the side effects of salbutamol?

Answer 14

1. Tachycardia
2. Hyperglycemia
3. Hypokalemia
4. Reversible arrhythmias in adults

Question 15

Which patients should one be cautious to use ipratropium in?

Answer 15

Children with soy allergy

Question 16

What are some side effects of MgSO4?

Answer 16

1. Hypotension

2. Bradycardia

Question 17

What complications are associated with ETT and ventilation for impending respiratory failure?

Answer 17

26% have complications

1. Pneumothorax
2. Impaired venous return
3. Cardiovascular collapse due to increased intrathoracic pressure
4. Increased risk of death

Question 18

What alternative treatment options are available in severe asthma with maximized therapy?

Answer 18

1. IV salbutamol infusion
2. IV aminophylline
3. Heliox

Question 19

What should admission be considered?

Answer 19

1. An ongoing need for supplemental oxygen
2. Persistently increased work of breathing
3. ß2-agonists are needed more often than q4 h after 4 to 8 h of conventional treatment
4. The patient deteriorates while on systemic steroids.
5. Consider if comorbid conditions such as anaphylaxis
6. Distance from home

Question 20

When should ICU admission or referral to a tertiary care centre be considered?

Answer 20

The patient requires continuous nebulized salbutamol and fails to improve on this therapy. Call a tertiary care centre PICU specialist to discuss patient management and transport.

Question 21

What are the discharge criteria from the ED?

Answer 21

1. Needing ß2-agonists less often than q4 h after 4 to 8 h of conventional treatment
2. A reading of SpO2 94% on room air
3. Minimal or no signs of respiratory distress
4. Improved air entry.

Question 22

What is the recommended discharge plan?

Answer 22

1. Complete a 3- to 5-day course of oral steroids, depending on the severity of the illness at presentation.
2. Continue to use a short-acting ß2-agonists such as salbutamol (200 µg [0.3 puffs/kg to a maximum of 10 puffs] every 4 h) until exacerbations resolve and then as needed, with directions to see a health care professional if therapy is needed more often than every 4 h.
3. Prepare a written asthma action plan.
4. Review techniques for using inhaled asthma medications as well as for cleaning/maintaining the inhaler device.
5. Encourage follow-up with the patient’s primary care physician or a local asthma clinic to review asthma control, environmental history and symptom recognition. Every effort should be made to ensure proper follow-up and to implement a long-term plan with the patient’s primary care physician within two to four weeks of discharge from the ED. If severe or frequent exacerbations lead to further treatment in the ICU, referral to an asthma specialist, such as a paediatric allergist or respirologist, is strongly recommended.

Question 23

What ICS options are available?

Answer 23

1. Beclomethasone dipropionate HFA (QVAR)
2. Budesonide (Pulmicort)
3. Ciclesonide (Alvesco)
4. Fluticasone (Flovent)