Asthma

1. BRONCHIAL
ASTHMA
A S M A S A L I M A L - S I Y A B I
P A E D I A T R I C E M E R G E N C Y
R O Y A L H O S P I T A L

2. OUTLINE
• Introduction
• Diagnosis
• Differential diagnosis
• Role of diagnostic tests
• Common medications used
• Mild – moderate asthma and Status asthmaticus
• Follow up
• When to refer
• Pitfalls
• Take home points

3. • Asthma is the most common chronic disease of childhood,
with asthma exacerbations and wheezing resulting in
more than 2 million emergency department visits per year
• According to recent data from the Centres for Disease
Control and Prevention, 1 out of 11 children in the United
States has asthma.
Moreover, 1 of 5 children with asthma presented to the
emergency department (ED) for asthma-related care in
2009

4. WHAT IS ASTHMA
• Asthma Diagnosis in Children 0-4 Years of Age
• Asthma Diagnosis in Children 5-12 Years of Age

5. ASTHMA IN 0-4 YEARS
• Consider asthma diagnosis if
• - 4 or more episodes of
• wheezing in the past year that lasted more than 1 day and affected sleep, AND who has
• either;
• a. One of the following:
– A physician’s diagnosis of atopic dermatitis
– Evidence of sensitization to aeroallergens
– A parental history of asthma
• OR
• b. Two of the following:
– Evidence of sensitization to foods
– 4% peripheral blood eosinophilia
– Wheezing apart from colds

6. ASTHMA IN 5-12YEARS
• Consider asthma if any of the following signs or symptoms is present:
• a. History of any of the following:
– Cough, worse particularly at night
– Recurrent wheeze
– Recurrent difficulty in breathing
– Recurrent chest tightness
• b. Symptoms occur or worsen at night
• c. Symptoms occur or worsen in the presence of:
• - Exercise - Animals with fur - Pollens - Aerosol chemicals - Smoke - Changes in
temperature - House dust mites - Strong emotions - Drugs (aspirin, beta blockers) -
Respiratory (viral infections )
• d. Reversible and variable airflow limitation as measured by a spirometer or a peak
expiratory flow meter

7. IMPORTANT NOTE!
Not all wheezing is due to asthma.
Not all children with asthma wheeze.

8. DIFFERENTIAL DIAGNOSIS
• Infants and young children up to 24 months
viral bronchiolitis: a common imitator of asthma and may be
difficult to distinguish, particularly since upper respiratory viral
infections are common triggers for asthma exacerbations.
Pertussis: may present with cough and respiratory distress.
Congenital conditions such as airway haemangiomas,
tumours, papillomas, vascular rings/slings, and
laryngomalacia/tracheomalacia. Typically present as
progressively worsening noisy breathing, wheezing, stridor, or
respiratory distress.

9. congestive heart failure secondary to congenital heart disease,
arrhythmias, or myocarditis
inhaled foreign body; localized or unilateral wheezing
Retropharyngeal abscess typically presents with stridor or
dysphagia, but it may also present in young children with wheezing.
These children usually present as acutely ill with fevers and decreased
neck movement.

10. • Older children and adolescents:
- Infections : viral or bacterial pneumonia may present with wheezing.
-Inflammatory processes such as hypersensitivity pneumonitis, vasculitis,
or collagen vascular disease
-Vocal cord dysfunction, psychogenic cough, and panic attack are
common causes of apparent respiratory distress and are diagnoses of
exclusion.
-Pulmonary manifestations of cystic fibrosis
-Anaphylaxis must also be considered, as it can present at any age.

11. DDX. CONT’D
-Anaphylaxis -Airway foreign body
-Pneumonia -Bronchiolitis
-Pertussis -Retropharyngeal abscess
-Congestive heart failure - Pulmonary embolism
-Cardiac arrhythmia (SVT with heart failure)
-Airway haemangioma -Mediastinal mass
-Anatomic abnormality of the airway (vascular ring, pulmonary
arterial sling)
• Acutely Life-Threatening Diagnoses

12. • Laryngomalacia/tracheomalacia
• Vocal cord dysfunction/ paralysis
• Psychogenic cough
• Panic attack/hyperventilation
• Suppurative bronchitis
• Primary ciliary dyskinesia
• Gastroesophageal reflux disease
• Allergic bronchopulmonary aspergillosis
• Alpha 1-antitrypsin deficiency
• Cystic fibrosis
• Non Acutely Life-Threatening Diagnoses

13. HISTORY
1. establish diagnosis if not done yet
2. assess severity of the disease as well as the current exacerbation.
– ?exposures to triggers, including URTI, pets, smoke, environmental allergens, changes
in weather, or exercise.
– Assessing the use of home medications (or the lack of) to determine compliance and
baseline control of the child’s asthma.
– the “rule of 2s :Children who use rescue medications more than twice per week, who
experience night time symptoms more than twice per month, or who refill their rescue
medications more than twice per year may be inadequately controlled..
– The number of ED visits
– the most recent course of systemic steroids, and the total number of steroid courses
within the last year can also help gauge the underlying level of control as well as the
severity of the child’s disease.
– ? previously required admission to the hospital (particularly to the ICU), he is more
likely to require subsequent admissions.

14. • risk factors for life-threatening exacerbations
– admission to the ICU,
– history of intubation,
– 5 additional ED visits within the last year,
– oxygen saturation < 91%,
– a longer history of asthma.

15. MANAGEMENT
• The National Asthma Education and Prevention Program has
published guidelines for the management of asthma in the
prehospital setting.
• 3 principle goals for treating asthma exacerbations:
(1) correction of significant as hypoxemia by administering
supplemental oxygen,
(2) rapid reversal of airflow obstruction, and
(3) reduction of the likelihood of recurrence of severe airflow
obstruction by intensifying therapy.

16. PHYSICAL EXAMINATION
• Oxygen saturation
• Respiratory rate
• Heart rate
• Use of accessory muscles
• Air entry and additional sounds

17. DIAGNOSTIC STUDIES
• In the acute care setting, asthma is primarily a clinical
diagnosis.
• Laboratory evaluation of children experiencing an acute
exacerbation is generally not helpful

18. CXR?
• For most patients, chest x-rays are not helpful in the emergent
assessment of asthma.
• Children with acute asthma often have abnormal chest
radiographs that show a variety of findings, including
hyperinflation, hypoinflation, atelectasis, or increased
extravascular fluid.
• These findings rarely affect patient management.
• Even among children who wheeze for the first time, chest x-
rays are generally not helpful

19. WHEN DO YOU NEED A CXR?
• persistent hypoxia
• focal abnormalities on examination,
• no family history of asthma,
• those who respond less favourably than expected to
bronchodilator therapy.
• unilateral chest pain
• differential wheezing in order to evaluate for a foreign body,
pneumothorax, or pneumomediastinum.

20. • There is evidence that an initial oxygen saturation of < 90%
predicts a substantially higher likelihood of poor outcome;
• however, most children with exacerbations have a ventilation-
perfusion mismatch and mild hypoxemia (> 90%) that is often
made temporarily worse by inhaled beta-agonist treatment.
• Regardless of oxygen saturation early in the course, experts
emphasize that serial pulse oximetry throughout the ED course
plays a vital role, as it allows children who require admission for
supplemental oxygen to be identified.

21. COMMON ASTHMA MEDICATIONS
AND THEIR RECOMMENDED DOSAGES
•

22. • salbutamol:
– First line therapy
– standard doses of 2.5 to 5 mg nebulized salbutamol(or 4-8 puffs of a metered-dose inhaler)
– For children with severe exacerbations, continuous nebulization of salbutamol(0.5 mg/kg/h
up to 20 mg/h) is more effective than intermittent treatments and results in more-rapid
improvement and fewer hospitalizations
– Oral salbutamol has not been shown to be effective in acute or chronic asthma
management.

23. • Ipratropium
– Anticholinergic
– Reduces bronchoconstriction
– 250-500 mcg + beta agonist x 1-3
– Acts synergistically with salbutamol, not as a single agent

24. • Steroids
– Reduces airway inflammation
– Prednisolone: 1-2 mg/kg/day Max dose: 60 mg/day, for 3-5 days
– Dexamethasone: 0.6-1.0 mg/kg PO, IM, IV Max dose: 16 mg, 1-2 days
– Hydrocortisone: 5-10mg/kg, for 5 days
– Methylprednisolone: 1 mg/kg divided q12h Max 1-time dose: 240 mg, for 3-5days

25. • Magnesium sulphate
– smooth muscle relaxation, bronchodilator
– 25-75 mg/kg IV over 20 min Max dose: 2 g as bolus,
– May be repeated q4-a6hrly
– Can be given as continuous infusion
– Associated with hypotension

26. CLINICAL PATHWAY FOR MANAGEMENT
OF ASTHMA IN CHILDREN
• Establish a diagnosis if not yet done
• Assess severity of current attack
• Classify as mild-moderate OR severe/ life threatening asthma

27. • Mild – moderate attack
• 1- salbutamol + ipratropium nebs x 3 q20mins
• 2- oral steroids
• 3-Review and re-assess
a .if patient is well
discharge on salbutamol puffs / steroids
follow up in 3 days
clear instructions when to review
b. still symptomatic ( distresses / persistent hypoxia)
? Magnesium sulphate bolus
refer for admission for intermittent nebulization

28. LIFE THREATENING ASTHMA
(ANY ONE OF THE FOLLOWING FOLLOWING):
• Drowsy or confused
• Apnoea
• Inaudible breath sounds
• Paradoxical thoraco-abdominal movement
• Respiratory muscle fatigue / shallow respiration
• Cyanosis
• Bradycardia
• Silent chest

29. TREATMENT GOALS OF STATUS
ASTHMATICUS
1.Correction of significant hypoxemia with supplemental oxygen
oxygen
2.Rapid reversal of airflow obstruction with repeated or continuous
administration of an inhaled beta2-agonist; early administration of
systemic corticosteroids (e.g., oral or intravenous )
3.Reduction in the likelihood of recurrence of severe airflow
obstruction by intensifying therapy: Often, a short course of
systemic corticosteroids is helpful

30. 1.salbutamol + ipratropium
nebs x 3 q20mins
2.oral / IV steroids
IV magnesium sulphate
bolus
RE-ASSESS
MgSo4 infusion / ketamine
infusion/ NIV
RE-ASSESSINTUBATION

31. WHEN TO INTUBATE
• Poor response to therapy
• Rising CO2 (PCO2 > 50 mm Hg)
• Severe hypoxia (PO2 < 60 mm Hg)
• Waning mental status or fatigue
• Impending respiratory arrest
• Cardiopulmonary arrest

32. GOALS OF THERAPY IN GENERAL
1.Control asthma by reducing impairment through prevention of chronic
and troublesome symptoms (e.g., coughing or breathlessness in the
daytime, in the night, or after exertion)
2.Reduce the need for a short-acting beta2-agonist (SABA) for quick relief
of symptoms (not including prevention of exercise-induced
bronchospasm)
3.Maintain near-normal pulmonary function
4.Maintain normal activity levels (including exercise and other physical
activity and attendance at work or school)

33. FOLLOW UP’S
• Interval history of asthmatic complaints, including history of acute
episodes (e.g., severity, measures and treatment taken, response to
therapy)
• History of nocturnal symptoms
• History of symptoms with exercise
• Review of medications, including use of rescue medications
• Patient evaluation should include the following:
– Assessment for signs of bronchospasm and complications
– Evaluation of associated conditions (e.g., allergic rhinitis)
– Pulmonary function testing (in appropriate age group)
• Address issues of treatment adherence and avoidance of environmental
triggers and irritants

34. • Use stepwise approach to therapy; the dose, number of medications and
frequency of administration are increased as necessary and decreased when
possible to achieve and maintain control
• The level of impairment generally is judged on the most severe measure
• Regular follow up 1- 6 months interval is essential, depending on the level
of control.
• Once well-controlled asthma is achieved and maintained for 3 months, a
step-down on pharmacological therapy is recommended
• Treatment of young children is often in the form of a therapeutic trial;
therefore, it is essential to monitor the child’s response to therapy. If there is
is no clear response within 4–6 weeks, the therapy should be discontinued
and alternative therapies or alternative diagnoses considered

35. WHEN TO REFER TO A SPECIALIST
• 1.History of sudden severe exacerbations
• 2.History of prior intubation for asthma
• 3.Admission to an ICU because of asthma
• 4.Two or more hospitalizations for asthma in the past year
• 5.Three or more emergency department visits for asthma in the past year
• 6.Hospitalization or an emergency department visit for asthma within the past month
• 7.Use of 2 or more canisters of inhaled short-acting beta2-agonists per month
• 8.Current use of systemic corticosteroids or recent withdrawal from systemic
corticosteroids

36. PITFALLS
• “She is wheezing, so she definitely has asthma.”
• “He was in respiratory distress, but he wasn't wheezing, so he must not have had asthma.”
• “She couldn't have had asthma because she didn't respond to inhaled salbutamol”
• “I ordered a chest x-ray because all patients who present in respiratory distress should
have one.”
• “I was reassured because her blood gas reading was normal.”
• “I didn't prescribe corticosteroids because they are not indicated in mild exacerbations.”
• . “He couldn't tolerate oral steroids, so I gave him inhaled corticosteroids. They are just as
effective.”
• “Inhaled anticholinergics like ipratropium should be given alongside bronchodilators
throughout the hospital stay.”
• “For patients in status asthmaticus who remain in severe distress despite continuous
bronchodilators, systemic corticosteroids, and multiple other adjunct treatments such as
magnesium and/or epinephrine, intubation is the next step in management.”

37. TAKE HOME POINTS
• Asthma care components include:
– Assessment & monitoring
– Education
– Control of environmental + co-morbid conditions
– Pharmacological treatment
• Avoid diagnostic testing for acute asthma
• Consider using dexamethasone instead of prednisolone for acute
exacerbations.
• In the ED, initiate inhaled corticosteroids for daily controller therapy.
• Consider using adjunct therapies for refractory acute asthma.