Acute asthma exacerbation (peds): Difference between revisions
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''For adult patients see [[Asthma]]''
{{Peds top}} [[asthma]]
==Background==
==Background==
*An estimated 6 million children in the US have asthma
*An estimated 6 million children in the US have asthma
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*A history of eczema or allergies maybe helpful in making a new diagnosis of asthma
*A history of eczema or allergies maybe helpful in making a new diagnosis of asthma
*Wheezing in an infant is more often [[bronchiolitis]] than asthma  
*Wheezing in an infant is more often [[bronchiolitis]] than asthma  
*Viral [[URI]], allergen exposure, and respiratory irritants (i.e. smoke) are common precipitants for pediatric asthma exacerbations
*Viral [[URI]] associated with copious rhinorrhea, allergen exposure, and respiratory irritants (i.e. smoke) are common precipitants for pediatric asthma exacerbations


==Clinical Features==
==Clinical Features==
*Wheezing
*[[Wheezing]]
*[[Cough]]
*[[Cough]]
*Accessory muscle use
*Accessory muscle use
*[[Dyspnea]]
*[[Dyspnea]]
*Prolonged expiration
*Prolonged expiration
*Severity of retractions occurs in caudal to cephalad direction
**Scalene muscle contractions more severe than subcostal and intercostal retractions
*Sign of impending ventilatory failure
*Sign of impending ventilatory failure
**Paradoxical respiration
**Paradoxical respiration
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==Evaluation==
==Evaluation==
[[File:CXR3354 IM-1609-1001.png|thumb|[[CXR]] with hyperinflated lungs consistent with broncoconstriction.]]
*Clinical diagnosis
*Clinical diagnosis
*Can consider a blood gas if there are fears that the patient is getting tired (sleepy baby vs [[hypercapnia|elevated CO2]]?)
**A CO2 >45 is abnormal in a patient hyperventilating and warrants close monitoring


===Consider [[CXR]]===
===Consider [[CXR]]===
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*Poor response to medications/treatment, if history and exam are not consistent with [[bronchiolitis]]
*Poor response to medications/treatment, if history and exam are not consistent with [[bronchiolitis]]
*Worsening symptoms
*Worsening symptoms
*Fever not explained by apparent viral illness


===Clinical Scores===
===Clinical Scores===
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''Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing''<ref>Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.</ref>
''Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing''<ref>Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.</ref>
*Nebulizer
*Nebulizer
**Intermitent: 2.5-5mg q20min, three doses are tradionally given back to back, then repeat as needed.
**Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed.
**Continuous: 0.5mg/kg/hr (max 15mg/hr)<ref>National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007; available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.</ref>
**Continuous: 0.5mg/kg/hr (max 15mg/hr)<ref>National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007; available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.</ref>
*MDI
*MDI
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===[[Ipratropium]]===
===[[Ipratropium]]===
*0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission.
*0.25-0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission.
===[[Steroids]]===
===[[Steroids]]===
''Should be given in the first hour with effects to reduce admission<ref name="Rowe">Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.</ref>''
''Should be given in the first hour with effects to reduce admission<ref name="Rowe">Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.</ref>''
*[[Dexamethasone]]
*[[Dexamethasone]]
**0.6mg/kg PO or IV (max 16mg); consider 2nd dose 24-36hrs later.  
**0.6 mg/kg PO or IV (max 16 mg); consider 2nd dose 24-36hrs later.<ref>Cross KP, et al. Single-dose dexamethasone for mild-to-moderate asthma exacerbations. Can Fam Physician. 2011 Oct; 57(10): 1134–1136.</ref><ref>Shenoi RP, Timm N; Committee on Drugs; Committee on Pediatric Emergency Medicine. Drugs used to treat pediatric emergencies. Pediatrics. 2020;145(1):e20193450. [PubMed 31871244]</ref><ref>Dexamethasone versus prednisone for children receiving asthma treatment in the paediatric inpatient population: protocol for a feasibility randomised controlled trial. BMJ Open. http://dx.doi.org/10.1136/bmjopen-2018-025630</ref>
***PO and IV have equal efficacy  
***PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
**Both 1 and 2 dose regimens as effective as [[prednisone]] in children <ref>Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273</ref>
**Both 1 and 2 dose regimens as effective as [[prednisone]] or [[prednisolone]] in children <ref>Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273</ref><ref>Cronin et al. "A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department." Annals of EM. May 2016. 67(5):593-601</ref>
*[[Prednisone]]
*[[Prednisone]]
**1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
**1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
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===[[Magnesium]]===
===[[Magnesium]]===
*Dose: 50mg/kg IV, max 2-4 g
*Dose: 50mg/kg IV, max 2-4 g over 20 mins with close blood pressure monitoring
*Smooth muscle relaxant
*Smooth muscle relaxant
*Duration of action approximately 20 min
*Duration of action approximately 20 min
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**Alleviates muscle fatigue which leads to larger tidal volumes
**Alleviates muscle fatigue which leads to larger tidal volumes
**Maximize inspiratory support
**Maximize inspiratory support
***Inspiratory pressure 10
***Delta pressure 10
***PEEP 0-5
***PEEP >4
 
**May benefit from [[ketamine]] or [[dexmedetomidine]] to mildly sedate and allow the interface
*Heliox
**60 to 80% helium is blended with 20 to 40% oxygen
**Heliox improves non laminar flow and may increases the diffusion of carbon dioxide by improving ventilation<ref>Kass JE: Heliox redux. Chest 2003; 123:673.</ref>


===[[Intubation]]===
===[[Intubation]]===
*Consider induction with [[Ketamine]]
*Push pull (bolus) [[IVF|fluids]] prior to intubation to maximize the patient's preload and ideally decrease the chance of the patient arresting
*Consider induction with [[ketamine]]
**Provides bronchodilation and sedation however it does promote secretions  
**Provides bronchodilation and sedation however it does promote secretions  
**Ketamine is the preferred induction agent for intubation in an asthmatic.  
**Ketamine is the preferred induction agent for intubation in an asthmatic.  
**Dosing 1-2mg/kg
**Dosing 1-2 mg/kg
*Ventilation of asthmatic patients requires deep sedation
*Ventilation of asthmatic patients requires deep sedation
**[[Benzos]], [[propfol]], or [[ketamine]] (1mg/kg/hr)
**[[Benzos]], [[ketamine]] (1 mg/kg/hr)
*[[Ventilation settings]]
*[[Ventilation settings]]
**Assist-control ventilation
**Assist-control ventilation
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***Start slow to avoid air-trapping and allow for longer expiration time
***Start slow to avoid air-trapping and allow for longer expiration time
***Consider I:E ratio of 1:2 or 1:3
***Consider I:E ratio of 1:2 or 1:3
**Make sure plateau pressure <30
**Plateau pressure ideally <30
**May require "permissive hypoventilation" and permissive hypercarbia and acidosis
**May require "permissive hypoventilation" and permissive hypercarbia and acidosis
***Low peak pressure/avoidance of breath stacking more important than correcting CO2 <ref> Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7 </ref>
***Low peak pressure/avoidance of breath stacking more important than correcting CO2 <ref> Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7 </ref>
**Tidal volume 6-8cc/kg ideal wt
**Tidal volume 6-8cc/kg ideal wt
**PEEP 0-5
**PEEP >4
**Flow rate 80-100L/min
**Flow rate 80-100L/min
**Keep FiO2 minimum to achieve SpO2 > 90%
**Keep FiO2 minimum to achieve SpO2 > 90%
*Use bronchodilators even when intubated
*Use bronchodilators even when intubated
*Many patients require a continuous [[neuromuscular blocking agents|paralytic]] infusion for the first 24+ hrs of intubation


==Outpatient Treatment==
==Outpatient Treatment==
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| align="center" style="background:*f0f0f0;"|'''Treatment (WHO 2008 Formulary)<ref>Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.</ref>'''
| align="center" style="background:*f0f0f0;"|'''Treatment (WHO 2008 Formulary)<ref>Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.</ref>'''
|-
|-
| Mild intermittent, > 80% peak flow||< 2/wk||< 2/mo||[[Albuterol]] MDI 100-200 mcg prn qid
| Mild intermittent, > 80% peak flow||< 2/wk||< 2/mo||
*[[Albuterol]] MDI 100-200 mcg PRN QID
|-
|-
| Mild persistent, > 80% peak flow||>2/wk||>2/mo||[[Albuterol]] MDI 100-200 mcg prn qid
| Mild persistent, > 80% peak flow||>2/wk||>2/mo||
PLUS
*[[Albuterol]] MDI 100-200 mcg PRN QID '''AND'''
[[Beclometasone]] 100-250 mcg bid
*[[Beclometasone]] 100-250 mcg BID
|-
|-
| Moderate persistent, 60-80% peak flow||Daily with exacerbations weekly||> 1/wk||[[Albuterol]] MDI 100-200 mcg prn qid
| Moderate persistent, 60-80% peak flow||Daily with exacerbations weekly||> 1/wk||
PLUS
*[[Albuterol]] MDI 100-200 mcg PRN QID '''AND'''
[[Beclometasone]] 100-500 mcg bid
*[[Beclometasone]] 100-500 mcg BID '''AND'''
 
*[[Salmeterol]] inhaled 50 mcg BID
PLUS
[[Salmeterol]] inhaled 50 mcg bid
|-
|-
| Severe persistent, < 60% peak flow||Continuous daily||Frequent||[[Albuterol]] MDI 100-200 mcg prn qid
| Severe persistent, < 60% peak flow||Continuous daily||Frequent||
PLUS
*[[Albuterol]] MDI 100-200 mcg PRN QID '''AND'''
[[Beclometasone]] 1mg bid (high dose)
*[[Beclometasone]] 1mg BID (high dose) '''AND'''
 
*[[Salmeterol]] inhaled 50 mcg BID '''AND'''
PLUS
*[[Theophylline]], leukotriene antagonist, or PO [[prednisolone]] with taper
[[Salmeterol]] inhaled 50 mcg bid
 
PLUS (if needed)
SR [[theophylline]], leukotriene antagonist, or PO [[prednisolone]] with taper
|}
|}


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==See Also==
==See Also==
*[[Modified pulmonary index score (MPIS)]]
*[[Asthma]]
*[[Modified pulmonary index score]]
*[[Ventilation settings]]
*[[Ventilation settings]]
*[[Deterioration after intubation]]
*[[Deterioration after intubation]]
*[[Shortness of breath]]
*[[Shortness of breath]]
*[[Asthma]]


==External Links==
==External Links==

Revision as of 18:13, 1 February 2023

This page is for pediatric patients. For adult patients, see: asthma

Background

  • An estimated 6 million children in the US have asthma
  • In 2007, asthma lead to >700,000 ED visits
  • Asthma is part of the atopy triad (asthma, allergies, eczema)
  • A history of eczema or allergies maybe helpful in making a new diagnosis of asthma
  • Wheezing in an infant is more often bronchiolitis than asthma
  • Viral URI associated with copious rhinorrhea, allergen exposure, and respiratory irritants (i.e. smoke) are common precipitants for pediatric asthma exacerbations

Clinical Features

  • Wheezing
  • Cough
  • Accessory muscle use
  • Dyspnea
  • Prolonged expiration
  • Severity of retractions occurs in caudal to cephalad direction
    • Scalene muscle contractions more severe than subcostal and intercostal retractions
  • Sign of impending ventilatory failure
    • Paradoxical respiration
      • Chest deflation and abdominal protrusion during inspiration
    • Altered mental status
    • "Silent chest"

Differential Diagnosis

Pediatric Wheezing

Evaluation

CXR with hyperinflated lungs consistent with broncoconstriction.
  • Clinical diagnosis
  • Can consider a blood gas if there are fears that the patient is getting tired (sleepy baby vs elevated CO2?)
    • A CO2 >45 is abnormal in a patient hyperventilating and warrants close monitoring

Consider CXR

  • 1st wheezing episode
  • Asymmetric lung auscultation findings, after treatment with albuterol
  • Poor response to medications/treatment, if history and exam are not consistent with bronchiolitis
  • Worsening symptoms
  • Fever not explained by apparent viral illness

Clinical Scores

  • Diagnosis and treatment can be guided by clinical scores
    • Modified Pulmonary Index Score (MPIS - Utilized at CCMC)
    • Pediatric Asthma Score (PAS)
    • Pulmonary Score (PS)
    • Pediatric Respiratory Assessment Measure (PRAM)

Modified Pulmonary Index Score (MPIS)

Age <3 Years
Points SpO2 Acces Musc Use I:E Wheeze HR RR
0 >95% None 2:1 None; Good Aeration ≤120 ≤30
1 93-95% Mild 1:1 End Exp 121-140 31-45
2 90-92% Moderate 1:2 Insp/Exp; Good Aeration 141-160 46-60
3 <90% Severe 1:3 Insp/Exp; Poor Aeration >160 >60
Age 3-6 Years
Points SpO2 Acces Musc Use I:E Wheeze HR RR
0 >95% None 2:1 None; Good Aeration ≤100 ≤30
1 93-95% Mild 1:1 End Exp 101-120 31-45
2 90-92% Moderate 1:2 Insp/Exp; Good Aeration 121-140 46-60
3 <90% Severe 1:3 Insp/Exp; Poor Aeration >140 >60
Age ≥6 Years
Points SpO2 Acces Musc Use I:E Wheeze HR RR
0 >95% None 2:1 None; Good Aeration ≤100 ≤20
1 93-95% Mild 1:1 End Exp 101-120 21-35
2 90-92% Moderate 1:2 Insp/Exp; Good Aeration 121-140 36-50
3 <90% Severe 1:3 Insp/Exp; Poor Aeration >140 >50
  • MPIS <7 - Mild exacerbation
  • MPIS 7-10 - Moderate exacerbation
  • MPIS ≥10 - Severe exacerbation

Management

Albuterol

Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing[1]

  • Nebulizer
    • Intermittent: 2.5-5mg q20min, three doses are traditionally given back to back, then repeat as needed.
    • Continuous: 0.5mg/kg/hr (max 15mg/hr)[2]
  • MDI
    • 4-8 puffs q20min given in first hour, then q1-4hr as needed

Ipratropium

  • 0.25-0.5mg q20min, given with the first three doses of albuterol, it is shown to reduce admission.

Steroids

Should be given in the first hour with effects to reduce admission[3]

  • Dexamethasone
    • 0.6 mg/kg PO or IV (max 16 mg); consider 2nd dose 24-36hrs later.[4][5][6]
      • PO and IV have equal efficacy. Giving the IV form by mouth is typically better tolerated by young children (same dosing)
    • Both 1 and 2 dose regimens as effective as prednisone or prednisolone in children [7][8]
  • Prednisone
    • 1-2mg/kg/day (60mg max) in one or two divided doses for 3-5 days
  • Methylprednisolone
    • 1mg/kg IV q 4–6hr
    • Only use IV if cannot tolerate PO since equal effectiveness between dosing routes[9]

Magnesium

  • Dose: 50mg/kg IV, max 2-4 g over 20 mins with close blood pressure monitoring
  • Smooth muscle relaxant
  • Duration of action approximately 20 min
  • In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2[3]

Beta-agonist

  • Epinephrine
    • 1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed
  • Terbutaline
    • Given SQ, usual dose 0.01mg/kg up to 0.3mg.
    • Longer-acting beta2-agonist promoting bronchodilation

Assisted Ventilation

  • Non-invasive ventilation
    • Consider as alternative to intubation
    • Alleviates muscle fatigue which leads to larger tidal volumes
    • Maximize inspiratory support
      • Delta pressure 10
      • PEEP >4
    • May benefit from ketamine or dexmedetomidine to mildly sedate and allow the interface

Intubation

  • Push pull (bolus) fluids prior to intubation to maximize the patient's preload and ideally decrease the chance of the patient arresting
  • Consider induction with ketamine
    • Provides bronchodilation and sedation however it does promote secretions
    • Ketamine is the preferred induction agent for intubation in an asthmatic.
    • Dosing 1-2 mg/kg
  • Ventilation of asthmatic patients requires deep sedation
  • Ventilation settings
    • Assist-control ventilation
    • Resp rate
      • Start slow to avoid air-trapping and allow for longer expiration time
      • Consider I:E ratio of 1:2 or 1:3
    • Plateau pressure ideally <30
    • May require "permissive hypoventilation" and permissive hypercarbia and acidosis
      • Low peak pressure/avoidance of breath stacking more important than correcting CO2 [10]
    • Tidal volume 6-8cc/kg ideal wt
    • PEEP >4
    • Flow rate 80-100L/min
    • Keep FiO2 minimum to achieve SpO2 > 90%
  • Use bronchodilators even when intubated
  • Many patients require a continuous paralytic infusion for the first 24+ hrs of intubation

Outpatient Treatment

Severity Day Sx Night Sx Treatment (WHO 2008 Formulary)[11]
Mild intermittent, > 80% peak flow < 2/wk < 2/mo
Mild persistent, > 80% peak flow >2/wk >2/mo
Moderate persistent, 60-80% peak flow Daily with exacerbations weekly > 1/wk
Severe persistent, < 60% peak flow Continuous daily Frequent

Disposition

  • Discharge
    • Often, patients will still have mild wheezing, but should have complete resolution of tachypnea, hypoxia, and improved work of breathing
    • A short course of glucocorticoids decreases chance of relapse [12])
    • Patient should generally continue albuterol at home q6hrs for at least the first 24hrs after discharge
    • A spacer should be prescribed to be used with the MDI to improve medication delivery to the lungs
  • Admit
    • If symptoms do not significantly improve or for severe exacerbations
  • Peak flow measurements maybe helpful when deciding disposition
    • Predicted = (30 x age (yrs)) + 30
    • PEF >70% predicted → high likelihood of successful discharge
    • PEF <40% predicted → should be admitted

See Also

External Links

References

  1. ↑ Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.
  2. ↑ National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma,” Clinical Practice Guidelines, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 08-4051, prepublication 2007; available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
  3. ↑ 3.0 3.1 Rowe BH et al. Magnesium sulfate for treating exac- erbations of acute asthma in the emergency depart- ment. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650.
  4. ↑ Cross KP, et al. Single-dose dexamethasone for mild-to-moderate asthma exacerbations. Can Fam Physician. 2011 Oct; 57(10): 1134–1136.
  5. ↑ Shenoi RP, Timm N; Committee on Drugs; Committee on Pediatric Emergency Medicine. Drugs used to treat pediatric emergencies. Pediatrics. 2020;145(1):e20193450. [PubMed 31871244]
  6. ↑ Dexamethasone versus prednisone for children receiving asthma treatment in the paediatric inpatient population: protocol for a feasibility randomised controlled trial. BMJ Open. http://dx.doi.org/10.1136/bmjopen-2018-025630
  7. ↑ Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273
  8. ↑ Cronin et al. "A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department." Annals of EM. May 2016. 67(5):593-601
  9. ↑ Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. Jul 1992;10(4):301-10
  10. ↑ Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7
  11. ↑ Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.
  12. ↑ Chapman K. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. NEJM. 1991;324(12):788
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