Acute asthma exacerbation (peds): Difference between revisions

(Text replacement - "==Diagnosis==" to "==Evaluation==")
(changes to background, ddx, cleaned up wording in other sections)
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''For adult patients see [[Asthma]]''
''For adult patients see [[Asthma]]''
==Background==
==Background==
*One of the most common complaints that brings patients to pediatric ER
*An estimated 6 million children in the US have asthma
*Need to establish history of asthma or reactive airway disease
*In 2007, asthma lead to >700,000 ED visits
*Quickly establish severity of current presentation and history of severe exacerbations (e.g. need for ICU, [[intubation]], etc)
*Asthma is part of the atopy triad (asthma, allergies, eczema)
*Identify any treatable precipitant (e.g. [[pneumonia]], [[URI]], [[GER]]D, esposure to irritants)
*A history of eczema or allergies maybe helpful in making a new diagnosis of asthma
*Need to establish history of asthma or reactive airway disease (most wheezing in patients <3 y/o is not asthma)
*Wheezing in an infant is more often [[bronchiolitis]] than asthma
*Viral [[URI]], allergen exposure, and respiratory irritants(ie smoke)are common precipitants for pediatric asthma exacerbations
 


==Clinical Features==
==Clinical Features==
*Dyspnea, wheezing, and cough
*Wheezing
*Cough
*Accessory muscle use
*Dyspnea
*Prolonged expiration
*Prolonged expiration
*Accessory muscle use
*Sign of impending ventilatory failure
*Sign of impending ventilatory failure
**Paradoxical respiration
**Paradoxical respiration
***Chest deflation and abdominal protrusion during inspriation
***Chest deflation and abdominal protrusion during inspiration
**Altered mental status
**Altered mental status
**"Silent chest"
**"Silent chest"


==Differential Diagnosis==
==Differential Diagnosis==
{{SOB DDX}}
*Upper Airway diseases
**Allergic rhinitis and [[sinusitis]]
 
*Large Airway Obstruction
**[[Foreign body]] aspiration
**Vascular ring or laryngeal webs
**Laryngotracheomalacia
**Enlarged lymph node or tumor
**Vocal cord dysfunction
 
*Small Airway Obstruction
**Viral [[bronchiolitis]]
**[[Cystic Fibrosis]]
**[[Bronchopulmnary dysplasia]]
**Cardiac Disease 
 
*Other causes
**[[GERD]]
**[[Anaphylaxis]]
 


==Evaluation==
==Evaluation==
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**Pediatric Respiratory Assessment Measure (PRAM)
**Pediatric Respiratory Assessment Measure (PRAM)


===Consider [[CXR]] if===
*[[Fever]] > 102.2
*Worsening symptoms
*Poor response to medications/treatment
*1st wheeze
*[[Chest pain]]


{{Modified Pulmonary Index Score}}
{{Modified Pulmonary Index Score}}
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==Management==
==Management==
===[[Albuterol]]===
===[[Albuterol]]===
''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 x3, then 2.5-10mg q1-4hr as needed OR
**Intermitent: 2.5-5mg q20min, three doses are tradionally 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>
**If child using intermitent nebs at home PTA, start on continuous
 
*MDI
*MDI
**4-8 puffs q20min up to 4h, then q1-4hr as needed
**4-8 puffs q20min given in first hour, then q1-4hr as needed
 
''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>
===[[Ipratropium]]===
===[[Ipratropium]]===
*0.5mg q20min x3
*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]]
**As effective as prednisone especially in children <ref>Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273</ref>
**0.6mg/kg PO or IV (max 16mg); 2nd dose 24-36hrs later.  
**Study found only applicable in mild/moderate exacerbations<ref>Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-227</ref>
***PO and IV have equal efficacy
**0.6mg/kg IV or PO (max 16mg); 2nd dose 24hr later. PO and IV have equal efficacy
**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>
*[[Prednisone]]
*[[Prednisone]]
**40-60mg/day in one or two divided doses x5d
**1-2mg/kg/day(60mg max) in one or two divided doses for 3-5 days
*[[Methylprednisolone]]
*[[Methylprednisolone]]
**1mg/kg IV q 4–6hr
**1mg/kg IV q 4–6hr
**Only use IV if cannot tolerate PO since equal effectiveness between dosing routes<ref>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</ref>
**Only use IV if cannot tolerate PO since equal effectiveness between dosing routes<ref>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</ref>
===[[Magnesium]]===
===[[Magnesium]]===
*Dose: 50mg/kg IV, max 2-4 g
*Smooth muscle relaxant
*Smooth muscle relaxant
*Dose: 50mg/kg IV, max 2-4 g
*Duration of action approx 20 min
*Duration of action approx 20 min
*In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2<ref name="Rowe"></ref>
*In patients with moderate to severe asthma there is a decreased rate of admission with an NNT of 2<ref name="Rowe"></ref>


===Parenteral beta-agnonist===
====[[Epinephrine]]====
====[[Epinephrine]]====
*1:1000 0.01mg/kg (max 0.3mg) IM Q20min x 3
*1:1000 0.01mg/kg (max 0.3mg) IM, repeat as needed


====[[Terbutaline]]====
====[[Terbutaline]]====
*Given SQ, usual dose 0.01mg/kg up to 0.3mg.
*Longer-acting beta2-agonist promoting bronchodilation
*Longer-acting beta2-agonist promoting bronchodilation
*Given SQ, usual dose 0.01mg/kg up to 0.3mg.


===[[Non-invasive ventilation]]===
===Consider [[CXR]]===
*Consider as alternative to intubation
*1st wheezing episode
*Alleviates muscle fatigue which leads to larger tidal volumes
*Asymmetric lung auscultation findings, after treatment with albuterol
*Maximize inspiratory support
*Poor response to medications/treatment, if history and exam are not consistent with [[bronchiolitis]]
**Inspiratory pressure 10
*Worsening symptoms
**PEEP 0-5
 
===Assisted Ventilation===
*[[Non-invasive ventilation]]
**Consider as alternative to intubation
**Alleviates muscle fatigue which leads to larger tidal volumes
**Maximize inspiratory support
***Inspiratory pressure 10
***PEEP 0-5


===Heliox===
*Heliox
*60 to 80% helium is blended with 20 to 40% oxygen
**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>
**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]]===
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==Disposition==
==Disposition==
*'''Discharge''' - if symptoms resolve, remember patient will often have decreased O2 saturations after treatment due to V/Q mismatch, look for resolution of symptoms and subjective improvement.
*'''Discharge'''  
**Often, patients will still have mild wheezing, but should have complete resolution of tachypnea, hypoxia, and work of breathing if being discharged
**Often, patients will still have mild wheezing, but should have complete resolution of tachypnea, hypoxia, and improved work of breathing  
***'''Discharge versus admit based on physician judgment if some symptoms persist and adequate home support'''
**A short course of glucocorticoids decreases chance of relapse <ref>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</ref>)
**A short course of glucocorticoids (prednisone in adults or dexamethasone in children (0.6mg/kg) decreases change of relapse <ref>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</ref>)
**Patient should generally continue albuterol at home q6hrs for at least the first 24hrs after discharge
*'''Admit''' - if symptoms persist or are severe
**A spacer should be prescribed to be used with the MDI to improve medication delivery to the lungs
*Classically disposition is based on peak flow measurements, such results are often not available in the ED
*'''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
**Predicted = (30 x age (yrs)) + 30
**PEF >70% predicted → high likelihood of successful discharge
**PEF >70% predicted → high likelihood of successful discharge

Revision as of 13:52, 23 July 2016

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, allergen exposure, and respiratory irritants(ie smoke)are common precipitants for pediatric asthma exacerbations


Clinical Features

  • Wheezing
  • Cough
  • Accessory muscle use
  • Dyspnea
  • Prolonged expiration
  • Sign of impending ventilatory failure
    • Paradoxical respiration
      • Chest deflation and abdominal protrusion during inspiration
    • Altered mental status
    • "Silent chest"

Differential Diagnosis

  • Upper Airway diseases
  • Large Airway Obstruction
    • Foreign body aspiration
    • Vascular ring or laryngeal webs
    • Laryngotracheomalacia
    • Enlarged lymph node or tumor
    • Vocal cord dysfunction


Evaluation

  • Clinical diagnosis
  • 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

  • Nebulizer
    • Intermitent: 2.5-5mg q20min, three doses are tradionally given back to back, then repeat as needed.
    • Continuous: 0.5mg/kg/hr (max 15mg/hr)[1]
  • MDI
    • 4-8 puffs q20min given in first hour, then q1-4hr as needed

Favor continuous nebulization to decrease the chance of admission when compared to intermittent dosing[2]

Ipratropium

  • 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
    • 0.6mg/kg PO or IV (max 16mg); 2nd dose 24-36hrs later.
      • PO and IV have equal efficacy
    • Both 1 and 2 dose regimens as effective as prednisone in children [4]
  • 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[5]

Magnesium

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

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

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

Assisted Ventilation

  • Non-invasive ventilation
    • Consider as alternative to intubation
    • Alleviates muscle fatigue which leads to larger tidal volumes
    • Maximize inspiratory support
      • Inspiratory pressure 10
      • PEEP 0-5
  • 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[6]

Intubation

  • 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 1-2mg/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
    • Make sure plateau pressure <30
    • May require "permissive hypoventilation" and permissive hypercarbia and acidosis
      • Low peak pressure/avoidance of breath stacking more important than correcting CO2 [7]
    • Tidal volume 6-8cc/kg ideal wt
    • PEEP 0-5
    • Flow rate 80-100L/min
    • Keep FiO2 minimum to achieve SpO2 > 90%
  • Use bronchodilators even when intubated

Outpatient Treatment

Severity Day Sx Night Sx Treatment (WHO 2008 Formulary)[8]
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

PLUS Beclometasone 100-250 mcg bid

Moderate persistent, 60-80% peak flow Daily with exacerbations weekly > 1/wk Albuterol MDI 100-200 mcg prn qid

PLUS Beclometasone 100-500 mcg bid

PLUS Salmeterol inhaled 50 mcg bid

Severe persistent, < 60% peak flow Continuous daily Frequent Albuterol MDI 100-200 mcg prn qid

PLUS Beclometasone 1mg bid (high dose)

PLUS Salmeterol inhaled 50 mcg bid

PLUS (if needed) SR theophylline, leukotriene antagonist, or PO prednisolone with taper

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 [9])
    • 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. ↑ 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.
  2. ↑ Camargo CA et al. Continuous versus intermittent beta- agonists for acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 14583926.
  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. ↑ Keeney, et al. Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis. Pediatrics. 2013-2273
  5. ↑ 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
  6. ↑ Kass JE: Heliox redux. Chest 2003; 123:673.
  7. ↑ Darioli, et al. Mechanical Controlled hypoventilation in status asthmaticus. Am Rev Respir Dis. 1984; 129 (3) 385-7
  8. ↑ Stuart MC et al. WHO Model Formulary 2008. http://www.who.int/selection_medicines/list/WMF2008.pdf.
  9. ↑ 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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