This document summarizes a seminar on the management of acute exacerbations of asthma. It covers the clinical manifestations of asthma exacerbations, diagnosis, and management approaches at home, in emergency departments, and during hospitalization. Key points include the use of short-acting beta agonists for milder cases, systemic corticosteroids, and oxygen supplementation. Indications for hospital admission and intensive care are also outlined.

1. SEMINAR ON MANAGEMENT OF
ACUTE EXACERBATION OF ASTHMA
PRESENTED BY; DEFENDERS;
ABDULFETAH AHMED GETASEW TEREKEG
FEYISO HUSSEIN ABRAHAM G/HIWOT
MODULATOR;
Dr. HACHALU
(PEDIATRICIAN)
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2. Outline
• Introduction
• Clinical manifestations
• Diagnosis
• Management
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3. Introduction
Asthma is a chronic inflammatory condition of the lung airways resulting in episodic
airflow obstruction.
 This chronic inflammation heightens the twitchiness of the airways—airways
hyperresponsiveness (AHR)— to common provocative exposures.
Airway narrowing that is partially or completely reversible.
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4. Epidemiology
The most common causes of childhood emergency department visits,
hospitalizations, and missed school days.
Approximately 80% of all asthmatic patients report disease onset prior to 6 yr of
age.
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5. Early Childhood Risk Factors for Persistent Asthma
Parental asthma
Allergy:
Severe lower respiratory tract infection
 Pneumonia
 Bronchiolitis requiring hospitalization
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6. Asthma predictive index(API)
Hx of ≥4 wheezing episodes ( with 1 diagnosed by a physician) with one of the
major or two the minor criteria
• Major
parental asthma
eczema
inhalant allergen sensitization
• minor
allergic rhinitis
wheezing apart from colds,
Eosinophilia ≥4%
food allergen sensitization
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7. API…
• Specificity 97%
• PPV 77%
• If positive 4-10 fold increased risk
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8. Types of Childhood Asthma:
• Based on different natural courses:
Recurrent wheezing
Chronic asthma
• Based on disease severity, Asthma is also classified as:
 Intermittent
 Persistent [mild, moderate, or severe]
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9. • Based on disease control, Asthma is also classified as:
• Well controlled
• Not well controlled
• Very poorly controlled.
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10. Management Patterns
 Easy-to-control: well controlled with low levels of daily controller therapy
 Difficult-to-control: well controlled with multiple and/or high levels of
controller therapies
 Exacerbators: despite being well controlled, continue to have severe
exacerbations
 Refractory: continue to have poorly controlled asthma despite multiple and
high levels of controller therapies
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11. Pathogenesis
In the small airways, airflow is regulated by smooth muscle encircling the
airway lumen;
bronchoconstriction of these bronchiolar muscular bands restricts or blocks
airflow.
A cellular inflammatory infiltrate and exudates can fill and obstruct the airways.
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12. Hypersensitivity or susceptibility to a variety of provocative exposures or
triggers:
Common viral infections of respiratory tract aeroallergens in sensitized
asthmatic patients
Indoor allergens
Air pollutants
Strong or noxious odors or fumes
Occupational exposures
Cold ,dry air ,exercise ,crying, laughter, hyperventilation, comorbid
conditions, druds.
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13. Etiologies & pathogenesis
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14. Asthma exacerbation
Definition
Asthma exacerbations are acute or subacute episodes of progressively worsening
symptoms and airflow obstruction
Airflow obstruction during exacerbations can become extensive
Often worsen during sleep
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15. What triggers asthma exacerbations?
Viral respiratory infections
Allergen exposure eg. Grass pollen, soy bean dust, fungal spors
Food allergy
Outdoor air pollution
Seasonal changes and/or returning to school in fall(autumn)
Poor adherence with ICS.
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16. Cont..
A severe exacerbation of asthma that does not improve with standard therapy is
termed status asthmaticus
Asthma exacerbation can be classified by their severity based on symptom, signs,
and functional assessment
Immediate management of an asthma exacerbation involves a rapid evaluation
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17. Formal Evaluation of Asthma Exacerbation
Severity in the
Urgent or EmergencyCare Setting
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20. Severity Assessment
Pulmonary Index Score (PIS):
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21.  interpretation of PIS
<7 …..mild attack
7-11……moderate attack
>12…….severe attack
can be used to assess initial severity, judge response to treatment, and facilitate
admission and discharge planning.
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22. Clinical manifestations
• HISTORY;
• Intermittent dry coughing and expiratory wheezing
• Shortness of breath and chest congestion and tightness
• Symptoms often worse at night or in the early morning
• Symptoms vary over time and intensity
• The presence of risk factors, such as a history of other allergic
conditions.
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23. c/m…
• Sign;
allergic rhinitis, conjunctivitis
General signs of respiratory distress: tachypnea, nasal flaring, lower chest wall
in-drawing (subcostal retractions)
Wheezing
Silent chest
Reduced air entry, particularly in bases
Rhonchi and crackles ( rales)
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24. dx
• Pulmonary function testing
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25. • Radiograph
Often appear to be normal
subtle and nonspecific findings of hyperinflation and peribronchial thickening
can help identify abnormalities that are hallmarks of asthma masqueraders
Complications
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26. Management of
Asthma Exacerbation
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27. CHILDREN 6 YEARS AND OLDER
VS
CHILDREN 5 YEARS AND YOUNGER
• HOME/SELF-MANAGEMENT OF EXACERBATIONS
• EMERGENCY DEPARTMENT MANAGEMENT OF ASTHMA
EXACERBATIONS
• PRIMARY CARE OR HOSPITAL MANAGEMENT OF
ASTHMA EXACERBATIONS
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28. HOME/SELF-MANAGEMENT OF ASTHMA
EXACERBATIONS
• written asthma action plans
• Inhaled reliever medication (ICS-formoterol or SABA)
• Combination low dose ICS (budesonide or beclometasone) with
formoterol maintenance and reliever regimen
• Leukotriene receptor antagonists
• Oral corticosteroids
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29. Home Management of Asthma Exacerbations
Families of all children with asthma should have a written Asthma
Action Plan
A written home action plan can reduce the risk of asthma death by
70%
The NIH guidelines recommend immediate treatment with “rescue”
medication (inhaled SABA, up to 3 treatments in 1 hr)
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32. Initial treatment at home for children 5 yrs
and younger
• Inhaled SABA via a mask or spacer, and review response
• Family/carer-initiated corticosteroids
• Leukotriene receptor antagonists
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33. A good response is characterized by;
resolution of symptoms within 1 hr
 no further symptoms over the next 4 hr
improvement in PEF value to at least 80% of personal best
If the child hasn’t respond a short course of OCS therapy (prednisone,
1-2 mg/kg/day [not to exceed 60 mg/day] for 4 days) should be
instituted
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34. For patients with severe asthma and/or a history of life-threatening
episodes
 an epinephrine autoinjector
 portable oxygen
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35. For mild to moderate exacerbation, repeated administration of
inhaled SABA(up to 4-10 puffs every 20 minutes for the first hr)
The dose of SABA required varies from 4-10 puffs every 3-4 hrs up to
6-10 puffs evry 1-2 hrs.
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36. Albuterol nebulizer
<5 Years of Age 1.25–2.5 mg up to every 20 min with face mask for
≤3 doses, then every 2–4 h as needed
5–11 Years of Age 1.25–2.5 mg up to every 20 min for
≤3 doses, then every 2–4 h as needed
≥12 Years of Age 2.5–5 mg up to every 20 min for ≤3 doses, then
every 2–4 h as needed
Albuterol MDI (90 µg/puff) 2-8 puffs up to every 20 min for 3 doses as
needed, then every 1-4 hr as needed
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37. cont
The most adverse drug reactions with SABA are
CVS: Tachycardia, diastolic hypotension, arrhythmias, and prolonged
QTc interval.
Tremors,
Nausea
Hypokalemia.
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38. Emergency Department Management of Asthma
Exacerbations
primary goals:
correction of hypoxemia
rapid improvement of airflow obstruction
prevention of progression or recurrence of symptoms
Interventions are based on:
clinical severity on arrival,
response to initial therapy, and
presence of risk factors associated with asthma morbidity and
mortality
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39. Indications of a severe exacerbation
breathlessness, dyspnea, retractions, accessory muscle use,
tachypnea or labored breathing, cyanosis, mental status
changes,
 a silent chest with poor air exchange, and
severe airflow limitation (PEF or FEV1 value <50% of personal
best or predicted values).
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40. Initial treatment includes
supplemental oxygen,
inhaled β-agonist therapy every 20 min for 1 hr
Epinephrine (for anaphylaxis)
systemic corticosteroids
Inhaled corticosteroids
Other treatments
In the ED, single oral, IV, IM dose dexamethasone (0.6 mg/kg,
maximum 16 mg) has been found to be an effective
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41. Albuterol nebulizer
<5 Years of Age 0.15 mg/kg (minimum, 2.5 mg) every 20 min for 3
doses, then 0.15–0.3 mg/kg up to 10 mg every 1–4 h as needed or 0.5
mg/kg/h via continuous nebulization
5–11 Years of Age 0.15 mg/kg (minimum, 2.5 mg) every 20 min for 3
doses, then 0.15–0.3 mg/kg up to 10 mg every 1–4 h as needed or
0.5 mg/kg/h via continuous nebulization
≥12 Years of Age 2.5–5 mg every 20 min for 3 doses, then 2.5–10 mg
every 1–4 h as needed or 10–15 mg/h via continuous nebulization
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42. Inhaled ipratropium may be added
an IM injection of epinephrine or other β-agonist [in severe cases]
Oxygen should be administered and continued for at least 20 min after
SABA administration
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43. Reviewing response and F/U
Monitor
clinical status,
hydration,
Oxygenation
The patient may be discharged home if:
 symptoms improved,
 normal physical findings,
 PEF >70% of predicted,
Oxygen saturation >92%
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46. Hospital Management of Asthma Exacerbations
Assessing exacerbation severity
• If the patient shows signs of a severe or life-threatening
exacerbation,
• treatment with SABA,
• controlled oxygen and
• systemic corticosteroids
• urgent transfer to an acute care facility.
• Milder exacerbations
• can usually be treated in a primary care setting, depending on resources
and expertise
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47. Hospital Management of Asthma Exacerbations
Indication for hospital admission
1. Those who do not adequately improve within 1-2
hr of intensive treatment
2. high-risk features for asthma morbidity or death
3. Children who require beta 2-agonist therapy more often than
every two to three hours
4. Have not improved after administration of systemic
glucocorticoids
5. Those who require supplemental oxygen
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48. 6. A history of rapid progression of severity in the past exacerbations
7. Poor adherence with outpatient medication regimen
8. Inadequate access to medical care
9. Poor social support system at home
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49. Admission to an intensive care unit (ICU)
severe respiratory distress,
poor response to therapy,
concern for potential respiratory failure and arrest.
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50. Conventional interventions for children admitted to the hospital for
status asthmaticus
supplemental oxygen (because of hypoxemia),
inhaled bronchodilator (SABAs can be delivered
frequently,
systemic corticosteroid therapy
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51. Oxygen Administration
 to maintain a SpO2 level of ≥92%.
The preferred therapy is with Nebulised albuterol/salbutamol
Given based on age
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52. <5 Years of Age 0.15–0.3 mg/kg up to 10 mg every 1–4 h as needed
or 0.5 mg/kg/h via continuous nebulization
5–11 Years of Age 0.15–0.3 mg/kg up to 10 mg every 1–4 h as needed
or 0.5 mg/kg/h via continuous nebulization
≥12 Years of Age 2.5–10 mg every 1–4 h as needed or 10–15 mg/h
via continuous nebulization
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53. Inhaled ipratropium is often added to albuterol
Short-course systemic corticosteroid therapy is recommended(oral and
IV )
Patients with persistent severe dyspnea and high-flow oxygen
requirements
require additional evaluation
Further complicating this situation is the association of increased
antidiuretic hormone secretion with status asthmaticus
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54. Despite intensive therapy, some asthmatic children remain critically ill
and at risk for respiratory failure, intubation, and mechanical
ventilation
patients with severe status asthmaticus Several therapies, including
parenteral β-agonists,
magnesium sulfate,
inhaled heliox have demonstrated some benefit as adjunctive
therapies
Parenteral epinephrine or terbutaline sulfate
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57. Mechanical ventilation in severe asthma exacerbations
a severe asthma exacerbation in a child results in respiratory failure
requires the careful balance of enough pressure
should be managed in a pediatric ICU
Elective tracheal intubation with rapid-induction sedatives and
paralytic agents is safer than emergency intubation
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58. Endotracheal Intubation
Indications for intubation in patients with acute severe asthma include:
Hypoxemia despite provision of high concentrations of oxygen or
noninvasive positive pressure ventilation (NPPV; partial pressure
of oxygen [pO2] <60 on 100 percent oxygen or NPPV)
Severe and unremitting increased work of breathing (eg, inability
to speak)
Altered mental status
Respiratory or cardiac arrest.
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59. Discharge if:
sustained improvement in symptoms
 normal physical findings
 PEF >70% of predicted or personal best
 oxygen saturation >92% while the patient is breathing room air for 4 hr.
Discharge medications include administration of an inhaled β-agonist up to
every 3-4 hr
+
a 3-7 day course of an oral corticosteroid
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60. Monitoring
Clinical status and response to therapy must be monitored frequently during
treatment for acute asthma exacerbation.
A variety of tools are used for this purpose in children:
1. Clinical assessment: vital signs, sign symptom for respiratory distress
and pulse oximetry.
2. Asthma scores: the score is the sum of numeric ratings for five
parameters: respiratory rate, accessory muscle use, air exchange,
wheeze, and inspiratory: expiratory ratio.
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62. 3. Pulmonary function:
PFTs are used to characterize disease, assess severity and follow response to
therapy.
Peek Expiratory Flow Rate (PEFR): is the maximum flow rate generated
during a forced expiratory maneuver.
Compare a patient’s PEFR to the “previous personal best” and the normal
predicted value.
Diurnal variation in PEF >20% is consistent with asthma
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63. 4. Spirometry: is the plot of airflow versus time.
is usually performed before and after a bronchodilator to assess
response to therapy or after bronchial challenge to assess airway
hyperreactivity:
Forced Vital Capacity (FVC): FVC < 15ml/kg may be an indication
for ventilatory support.
Forced Expiratory Volume in 1 second (FEV 1): It is the single best
measure of airway function.
 Forced Expiratory Flow (FEF25 – 75%): Measuring exhaled nitric
oxide (FENO)
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64. References
Nelson textbook of pediatrics,21th ed
Up to date
Global Initiative for Asthma (GINA) program 2022
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65. Thank you
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