Management of asthma exacerbation in children

2. Acute Asthma Exacerbation:
• Asthma exacerbations consist of acute or
subacute episodes of progressively worsening
shortness of breath, coughing, wheezing, and
chest tightness or any combination thereof.

3. • Often, asthma exacerbations worsen during sleep
(between midnight and 8 am), when airways
inflammation and hyperresponsiveness are at
their peak.
• A severe exacerbation of asthma that does not
improve with standard therapy is termed status
asthmaticus.
• The biologic, environmental, economic, and
psychosocial risk factors associated with asthma
morbidity and death can further guide this
assessment.
Acute Asthma Exacerbation:

4. Focused History
• Onset of current exacerbation
• Frequency and severity of daytime and nighttime
symptoms and activity limitation
• Frequency of rescue bronchodilator use
• Current medications and allergies
• Potential triggers
• History of systemic steroid courses, emergency
department visits, hospitalization, intubation, or
life-threatening episodes

5. Clinical Assessment
• Physical examination findings: vital signs,
breathlessness, air movement, use of
accessory muscles, retractions, anxiety level,
alteration in mental status
• Pulse oximetry
• Lung function (defer in patients with
moderate to severe distress or history of labile
disease)

6. Risk factors for asthma morbidity and
death
BIOLOGIC ECONOMIC AND PSYCHOSOCIAL
Previous severe asthma exacerbation (intensive care
unit admission, intubation for asthma)
Poverty
Sudden asphyxic episodes (respiratory failure, arrest) Crowding
Two or more hospitalizations for asthma in past year Mother <20 yr old
Three or more emergency department visits for
asthma in past year
Mother with less than high school education
Increasing and large diurnal variation in peak flows Inadequate medical care:
Use of >2 canisters of short-acting β-agonists per
month
Inaccessible
Poor response to systemic corticosteroid therapy Unaffordable
Male gender No regular medical care (only emergency)
Low birthweight Lack of written asthma action plan
Nonwhite (especially black) ethnicity No care sought for chronic asthma symptoms
Sensitivity to Alternaria Delay in care of asthma exacerbations
ENVIRONMENTAL
Inadequate hospital care for asthma
exacerbation
Allergen exposure Psychopathology in the parent or child
Environmental tobacco smoke exposure
Poor perception of asthma symptoms or
severity
Air pollution exposure & Urban environment Alcohol or substance abuse

7. Acute Asthma Exacerbation:
Assessment and Severity
• Severity range: mild  mod severe
• Treatment : outpatient, inpatient (floor or ICU)
• Severity: Clinical, PH, PEFR ( ≥ 70%, 40-69%,
< 40%)
• A chest radiograph is not recommended for
routine assessment but should be obtained for
patients suspected of having congestive heart
failure, pneumothorax/mediastinum, pneumonia.
• Other tests especially in severe cases: ABG,
other tests for DDx

8. Initial assessment of acute asthma in
children aged >2 years in A&E
Thorax 2003; 58 (Suppl I): i1-i92
Moderate
exacerbation
Severe
exacerbation
Life threatening
asthma
• SpO2 92%
• PEF 50% best/
predicted (>5 years)
• No clinical features of
severe asthma
• Heart rate:
- 130/min (2-5 years)
- 120/min (>5 years)
• Respiratory rate:
- 50/min (2-5 years)
- 30/min (>5 years)
• SpO2 <92%
• PEF <50% best/
predicted (>5 years)
• Too breathless to talk
or eat
• Heart rate:
- >130/min (2-5 years)
- >120/min (>5 years)
• Respiratory rate:
- >50/min (2-5 years)
- >30/min (>5 years)
• Use of accessory neck
muscles
• SpO2 <92%
• PEF <33% best/
predicted (>5 years)
• Silent chest
• Poor respiratory effort
• Agitation
• Altered consciousness
• Cyanosis

9. Home Management of Asthma Exacerbations
• Families of all children with asthma should have a written
action plan to guide their recognition and management of
exacerbations, along with the necessary medications and
tools to manage them.
• 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).
• A good response is characterized by: resolution of
symptoms within 1hr, no further symptoms over the next
4 hr, and improvement in PEF value to at least 80% of
personal best.

10. • The child's physician should be contacted for
follow-up, especially if bronchodilators are
required repeatedly over the next 24-48 hr.
• If the child has an incomplete response to
initial treatment with rescue medication
(persistent symptoms and/or a PEF value <
80% of personal best), a short course of oral
corticosteroid therapy (prednisone 1-
2 mg/kg/day for 4 days) in addition to inhaled
β-agonist therapy should be instituted.
Home Management of Asthma Exacerbations

11. Immediate medical attention should be
sought for: ( call 122 )
severe exacerbations,
persistent signs of respiratory distress,
lack of expected response or sustained
improvement after initial treatment,
further deterioration, or
high-risk factors for asthma morbidity or
mortality
Home Management of Asthma Exacerbations

12. Emergency Department Management
of Asthma Exacerbations
o In the emergency department, the primary goals
of asthma management include:
o correction of hypoxemia,
o rapid improvement of airflow obstruction, and
o prevention of progression or recurrence of
symptoms.
• Interventions are based on clinical severity on
arrival, response to initial therapy, and presence
of risk factors that are associated with asthma
morbidity and mortality .

13. • Indications of a severe exacerbation include:
• 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).
Emergency Department Management
of Asthma Exacerbations

14. • Initial treatment includes:
• supplemental oxygen,
• inhaled β-agonist therapy every 20 min for 1 hr, and,
• systemic corticosteroids given either orally or
intravenously.
• Inhaled ipratropium may be added to the β-agonist
treatment if no significant response is seen with the 1st
inhaled β-agonist treatment.
• Oxygen should be administered and continued for at least
20 min after SABA administration to compensate for
possible ventilation-perfusion abnormalities caused by
SABAs.
• Close monitoring of clinical status, hydration, and
oxygenation are essential elements of immediate
management.
Emergency Department Management
of Asthma Exacerbations

15. • The patient may be discharged to home if there
is sustained improvement in symptoms, normal
physical findings, PEF >70% of predicted or
personal best, an 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 plus a 3-to
7-day course of an oral corticosteroid.
• Optimizing controller therapy before discharge is
also recommended.
Emergency Department Management
of Asthma Exacerbations

16. • A poor response to intensified treatment in the
1st hour suggests that the exacerbation will not
remit quickly.
• The addition of ICS to a course of oral
corticosteroid in the emergency department
setting reduces the risk of exacerbation
recurrence over the subsequent month.
• An intramuscular injection of epinephrine or
other β-agonist may be administered in severe
cases.
Emergency Department Management
of Asthma Exacerbations

17. Hospital Management of Asthma
Exacerbations
• For patients with moderate to severe
exacerbations that do not adequately improve
within 1-2 hr of intensive treatment,
observation and/or admission to the hospital,
at least overnight, is likely to be needed.
• Other indications for hospital admission
include high-risk features for asthma
morbidity.

18. • Admission to an intensive care unit is
indicated for patients with:
• severe respiratory distress,
• poor response to therapy, and
• concern for potential respiratory failure and
arrest.
Hospital Management (ICU)of Asthma
Exacerbations

19. • the conventional interventions for children
admitted to the hospital for status
asthmaticus are:
• Supplemental oxygen,
• frequent or continuous administration of an
inhaled bronchodilator, and
• systemic corticosteroid therapy
• Patients requiring cardiac monitoring &
oximetry.
Hospital Management of Asthma
Exacerbations

20. • SABAs can be delivered frequently (every 20 min to 1 hr) or
continuously (at 5-15 mg/hr).
• When administered continuously, significant systemic
absorption of β-agonist occurs and, as a result, continuous
nebulization can obviate the need for intravenous β-
agonist therapy.
• Inhaled ipratropium bromide is often added to albuterol
every 6 hr if patients do not show a remarkable
improvement.
• In addition to its potential to provide a synergistic effect
with a β-agonist agent in relieving severe bronchospasm,
ipratropium bromide may be beneficial in patients who
have mucous hypersecretion or are receiving β-blockers.
Hospital Management of Asthma
Exacerbations

21. • Short-course systemic corticosteroid therapy is
recommended for use in moderate to severe asthma
exacerbations to hasten recovery and prevent
recurrence of symptoms.
• Studies in children hospitalized with acute asthma have
found corticosteroids administered orally to be as
effective as intravenous corticosteroids.
• Accordingly, oral corticosteroid therapy can often be
used, although children with sustained respiratory
distress who are unable to tolerate oral preparations or
liquids are obvious candidates for intravenous
corticosteroid therapy.
Hospital Management of Asthma
Exacerbations

22. Nelson Textbook of Pediatrics, 20th edition, page 1114.
According to Nelson Textbook of
Pediatrics, 20th edition 2016
 The addition of ICS to a course of oral corticosteroid
in the emergency department setting , reduces the
risk of exacerbation recurrence over the
subsequent month.

23. Use of ICS*, either alone or in addition to systemic steroids, to treat acute asthma has
the potential benefit of reducing side effects, directly delivering medication to the
airway and reducing airway reactivity and edema more effectively
 Patients treated with ICS* are less likely to be admitted, whether they recieved
systemic steroids or not
 Patients treated with ICS* have early improvement in outcomes (less than 3 hours)
because of topical effects
Richard M, et al. Asthma. Rosen's Emergency Medicine- Concepts and Clinical Practice. Marx, Hockberger,
wallas. 8th edition, Saunders 2014 . Chapter 73, page 950.
According to Rosen's Emergency Medicine - Concepts and Clinical
Practice

24. Data suggest that addition of inhaled budesonide to
systemic corticosteroids following an emergency
department visit, leads to improved symptoms and
decreased relapse rate
lUGOGO N, et al. Asthma: Clinical Diagnosis and Management. Murray & Nadel's Textbook of
Respiratory Medicine. V.Courtney Broaddus. 6th edition, Saunders 2015 . Chapt er 42, page 749.
In Murray & Nadel's Textbook of
Respiratory Medicine- 2015

25. Patients with persistent severe dyspnea and high-
flow oxygen requirements require additional
evaluations, such as
complete blood cell counts,
measurements of arterial blood gases and serum
electrolytes, and
chest radiograph,
to monitor for respiratory insufficiency, co-
morbidities, infection, and/or dehydration.
Hospital Management of Asthma
Exacerbations

26. • Hydration status monitoring is especially important in
infants and young children, whose increased respiratory
rate (insensible losses) and decreased oral intake put them
at higher risk for dehydration.
• Further complicating this situation is the association of
increased antidiuretic hormone (ADH) secretion with status
asthmaticus.
• Administration of fluids at or slightly below maintenance
fluid requirements is recommended.
• Chest physical therapy, spirometry, and mucolytics are not
recommended during the early acute period of asthma
exacerbations as they can trigger severe
bronchoconstriction.
Hospital Management of Asthma
Exacerbations

27. • Despite intensive therapy, some asthmatic
children remain critically ill and at risk for
respiratory failure, intubation, and mechanical
ventilation.
• Complications (air leaks) related to asthma
exacerbations increase with intubation and
assisted ventilation; every effort should be
made to relieve bronchospasm and prevent
respiratory failure.
Hospital Management of Asthma
Exacerbations

28. • Several therapies, including parenterally administered
• epinephrine,
• β-agonists,
• methylxanthines,
• magnesium sulfate (25-75 mg/kg, maximum dose 2.5 g, given
intravenously over 20 min), and
• inhaled heliox have demonstrated some benefit as adjunctive
therapies in patients with severe status asthmaticus.
• Administration of either methylxanthine or magnesium sulfate
requires monitoring of serum levels and cardiovascular status.
• Parenteral (subcutaneous, intramuscular, or intravenous)
epinephrine or terbutaline sulfate may be effective in patients with
life-threatening obstruction that is not responding to high doses of
inhaled β-agonists, because in such patients, inhaled medication
may not reach the lower airway.
Hospital Management of Asthma
Exacerbations

29. • Rarely, a severe asthma exacerbation in a child results in respiratory
failure, and intubation and mechanical ventilation become
necessary.
• Mechanical ventilation in severe asthma exacerbations requires the
careful balance of enough pressure to overcome airways
obstruction while reducing hyperinflation, air trapping, and the
likelihood of barotrauma (pneumothorax, pneumomediastinum).
• To minimize the likelihood of such complications, mechanical
ventilation should be anticipated, and asthmatic children at risk for
the development of respiratory failure should be managed in a
pediatric intensive care unit (ICU).
• Elective tracheal intubation with rapid-induction sedatives and
paralytic agents is safer than emergency intubation.
Hospital Management of Asthma
Exacerbations

30. • Volume-cycled ventilators, using
• short inspiratory and long expiratory times,
• 10-15 mL/kg tidal volume,
• 8-15 breaths/min,
• peak pressures < 60 cm H2O, and without positive
end-expiratory pressure are starting mechanical
ventilation parameters that can achieve these
goals.
Hospital Management of Asthma
Exacerbations

31. • As measures to relieve mucous plugs, chest percussion and airways
lavage are not recommended because they can induce further
bronchospasm.
• One must consider the nature of asthma exacerbations leading to
respiratory failure; those of rapid or abrupt onset tend to resolve
quickly (hours to 2 days), whereas those that progress gradually to
respiratory failure can require days to weeks of mechanical
ventilation.
• Such prolonged cases are further complicated by muscle atrophy
and, when combined with corticosteroid-induced myopathy, can
lead to severe muscle weakness requiring prolonged rehabilitation.
• This myopathy should not be confused with the rare occurrence of
an asthma-associated flaccid paralysis (Hopkins syndrome), which
is of unknown etiology but prolongs the intensive care stay.
Hospital Management of Asthma
Exacerbations

32. • In children, management of severe exacerbations in
medical centers is usually successful, even when extreme
measures are required.
• Consequently, asthma deaths in children rarely occur in
medical centers; most occur at home or in community
settings before lifesaving medical care can be administered.
• A follow-up appointment within 1 to 2 wk of a child's
discharge from the hospital after resolution of an asthma
exacerbation should be used to monitor clinical
improvement and to reinforce key educational elements,
including action plans and controller medications.
Hospital Management of Asthma
Exacerbations

33. © Global Initiative for Asthma
Managing exacerbations in acute care settings
GINA 2014, Box 4-4 (1/4)

34. THANKS FOR YOUR
ATTENTION