Severe Asthma Children

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clinical

Asthma is the most common chronic

disease of childhood and the leading

cause of childhood morbidity from

chronic disease as measured by school

absences, emergency department visits,

and hospitalisations.1 The most recent

National Heart Lung and Blood Institute

(NHLBI) expert panel guidelines on thediagnosis and management of asthma

define asthma as a common chronic

disorder of the airways that is complex

and characterised by variable and

recurring symptoms, airflow obstruction,

bronchial hyper-responsiveness and

underlying inflammation. The interaction

of these features of asthma determines the

clinical manifestations, disease severity

and response to treatment.2 Exacerbations

of asthma are episodes of progressive

increase in shortness of breath, cough,

wheezing or chest tightness. Status

asthmaticus is a condition of progressively

worsening bronchospasm and respiratory

dysfunction due to asthma, which is

unresponsive to conventional therapy

and may progress to respiratory failure(with the need for mechanical ventilation)

or death.3 Children presenting with

severe acute exacerbations of asthma

should be referred to a hospital for further

assessment and monitoring. However,

initial emergency management will need

to be instituted in the community setting

before transfer.

Epidemiology

Asa is ird adig aus of

ospiaisaio aog pop udr 18 ars of

ag i Uid Sas of Aria.4 Ovr 2.2

iio Ausraias av urr diagosd

asa, 1416% of s ar idr. Asa

is or oo aog Idigous Ausraias

ad das ar or oo aog os ivig

i ss affu oaiis i Ausraia.5 Asa

pia gis i ar idood, wi a

arir os i as a fas.6,7 Asa is

a ifrqu aus of da durig idood.

Dad prsaio i soo kow o

av svr asa aaks is osidrd o a ajor risk faor. I so ass, svri

a av udrsiad, or saaio of

ra dad.

Pathophysiology

Asa is a roi ifaaor odiio of

airwas. Asa is ararisd rvrsi,

diffus owr airwa osruio, ausd

airwa ifaaio ad oda, roia

Adriana Yock Corrales

Manuel Soto-Martinez

Mike Starr

Management of severeasthma in children

Background

Asthma is t he most common chronic disease of childhood and the leading cause of

childhood morbidity from chronic disease. When uncontrolled, asthma can place

significant limits on daily life, and is sometimes fatal.

Objective

This article describes the initial assessment and management of status asthmaticus in

children.

DiscussionStatus asthmaticus is a medical emergency in which asthma symptoms are refractory to

initial bronchodilator therapy. Patients may report chest tightness, rapidly progressive

shortness of breath, dry cough and wheezing. Typically, patients present a few days

after the onset of a viral respiratory illness, following exposure to potent allergens or

irritants, or after exercise in a cold environment, however, they can also present with

sudden onset of symptoms with an unknown trigger. Early recognition and initiation of

therapy is vital in preventing severe complications such as respiratory failure. Aggressive

treatment with beta-agonists, anticholinergics and corticosteroids remains the gold

standard for this condition.

Keywords: child health; emergencies; asthma; respiratory tract diseases

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Management of severe asthma in childrenclinical

soo us spas, ad uus puggig.

youg idr ar pariuar suspi o

saus asaius. t pr-raiv airwa

of asai id a prid for au

osruio riggrs su as vira ifio,

arg, war ags, igar sok or

or iad irrias, gasro-osopaga

rfux, xris ad od air.810 Drug ssiivi,

pariuar o aspiri produs, a idu

pr-raiv airwas.11 howvr, xposur

o iuprof, i pais wo ar o argi o

aspiri or osroida ai-ifaaor drugs,

dos o appar o wors asa oridi ad

a aua rdu oupai visis.12,13

Risk factors

Idifig idr a risk for faa asa aaks

as prov o diffiu. Svra oriuors o

orai risk av dsrid (Table 1).howvr, up o o-ird of idr wo di fro

asa av prvious ad o id disas.

I a Ausraia sud dsriig 51 padiari

das du o asa, Rorso a14 foud

a o 39% of pais ad poia

prva faors: of s pais 68% ad

iadqua assss of, or rap for, prior

asa; 53% ad poor rap opia; ad

47% ad da i skig p. I addiio, 36%

wr judgd o av ad svr asa, 43%

wr akig rguar iad oaso

or sodiu rooga, ad 10% wr akig

rguar ora sroids. tw-wo pr ad a

prvious adissio o a isiv ar ui.14

Pais a ig risk of asa rad da d

osr osrvaio ad soud ouragd

o sk dia aio ar i au

xaraios.

Clinical presentation andassessment

mos idr wi au xaraio of asa

prs wi oug, wz, dspoa adirasd work of raig (g. apoa,

irosa rssio, suosa rraio).

Table 2ouis ora rags of rspiraor ra

pr ag group. t dgr of wz dos o

orra w wi svri of disas.15

As ra souds si s i

fa of irasd work of raig a

idia rspiraor faiur. Or fidigs of

svr asa iud disura i v

Pulmonaryfunctiontestsmaygivean

ojiv asur of svri i so ass.

t a o prford i idr ovr 6

ars of ag.19

Treatment

t ais of ra i saus asaius ar

o rvrs rooosriio, ra airwa

ifaaio, orr poxia ad oior for

opiaios.

Oxygen

A pais wi asa av viaio/prfusio

isa ad prs of poxia soud

rad urg. Suppa oxg soud

adiisrd o aiv ad aiai oxg

sauraio aov 94%.

Bronchodilator therapy

ba-agoiss ar os ipora par of

iiia ra i pais wi saus asaius

aus produ soo us raxaio.

t iiia dos of a-agois a giv

oxg driv uisr if poxia is prs,

or a prssurisd rd dos iar (mDI)

wi a spar wi ask or oupi.20 For os

idr, r is vid a mDI pus spar is

or ffii a a uisr.21,22 Sauao is

os oo usd sor aig a-agois

usd, u ors iud ruai (wi is o

suia for ougr pais).

of osiousss, iaii o spak, arkd

diiisd or as ra souds ad ra

aosis.

t iiia assss of a id wi

au asa soud iud a rif isor of

prvious pisods ad or risk faors, ad a

assss of svri aordig o naioa

Asa coui Ausraia (Table 3).16 Durig a

svr au xaraio, foowig rif

isor soud ak wi ra is

iiiad.

Historyofpreviousmedications(especially

ora/iad sroids i pas 6 os)

Historyofpreviousepisodesincluding

rg dpar visis, ospia

adissios, ad adissios o a isiv

ar ui

Thedurationofthecurrentepisodeandonset

Parentssubjectiveassessmentofseverity Associatedsymptomsandtriggers

Currentmedications(dose,route,timingofthe

as dos)

Historyofmisseddosesfromnoncompliance

or voiig.

Araiv diagoss su as iad forig

od or sruura aoraiis soud

osidrd i idr wi asa spos a

appar o rsisa o sadard rapis.

As prvious iod, assss of a

id wi a svr aak ris os o iia

osrvaios. howvr, addiioa diagosi ss

a provid addiioa iforaio i rai

siuaios. ts ar o roui ad soud o

da ra.

Chestradiographynotroutinelyindicated

xp for pais wi suspd

puoorax or puoia, os wo ar

iuad, or w or auss of wzig

ar suspd17

Arterialbloodgasmeasurementmaybe

pfu i assssig puoar gas xag

i riia i idr18

Table 1. Risk factors for near fatal asthma

History of near fatal asthma requiring intubation and mechanical ventilation38

Insufficient or poor adherence to controller therapy

Patients with severe asthma not currently using inhaled glucocorticoids 39

Patients who are overdependent on rapid acting inhaled B2 agonists, especially

those who use more than one canister of salbutamol (or equivalent) monthly40

Patients with a history of noncompliance with an asthma medication plan

Dysfunctional family unit

Table 2. Normal respiratory rate for age

Age Respiratory

rate (breaths

per minute)

Infant 3060

Toddler 2440

Preschooler 2234

School aged child 1830

Adolescent 1216

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clinicalManagement of severe asthma in children

raxaio iiiio of aiu upak.

magsiu supa a prv ospiaisaio

i idr wi svr asa w addd o

roodiaors ad sroids. Iravous mgSO4

is prfrrd.32,33

Methylxanthines

topi as wo disi aios i

airwa of pais wi asa: soo us

raxaio ad supprssio of rspos of

airwas o siui.34 topi as a arrow

rapui rag. Aiopi ( iravous

for of opi) is o idiad for idr

wi svr asa i ospia.35

t ro of wr diaios, su as

ukori iiiors, i svr asa pisods

is o drid.

Indications for hospitalisationA of foowig ar idiaios for adissio

o ospia.25

Noresponsetothreedosesofaninhaledshor

aig a-agois wii 12 ours

Tachypnoeadespitethreedosesofaninhaled

sor aig a-agois (Table 2)

Cyanosis

Childisunabletospeakordrinkoris

rass

Subcostalretractions

Oxygensaturationwhenbreathingroomair,

ss a 92%

Socialenvironmentthatimpairsdeliveryof

au ra.

Intubation and mechanicalventilation

Iuaio of pais wi svr asa is

o roui rodd, ad i a iras

risk of aroraua ad aggrava

rooosriio. Asou idiaios for

iuaio iud:

cardiopulmonaryarrest severehypoxia

rapiddeteriorationinthechildsmentalstate.

If disio of iuaio is ad, kai

soud iduio ag aus of is

roodiaor aio.36,37

Conclusion

I suar, asa oius o a ig

prva disas i o dvopig ad

Doss of ipraropiu roid ar:16

24puffs(childrenyoungerthan6years)

48puffs(children6yearsorolder).

ts doss ar giv vr 20 ius for r

doss i firs our ad vr 46 ours

if rquird.

Steroids

Sroids ar par of firs i ra

for au asa xaraios. t p

oro airwa ifaaio odifig

ifaaor rspos, rsorig disrupd

piiu, drasig uus srios,

ad dowrguaig produio of pro-

ifaaor okis.29

Ora or parra sroids ar qua

ffiaious, aoug parra sroids ar

prfrrd for riia i idr ad os wi

voiig. t adiisraio of sroids is os

ffiv w giv ar i xaraio.30,31

Appropria doss of sroids ar:

prednisolone12mg/kgperdayfor35days

is of suffii methylprednisolone1mg/kgintravenously

vr 6 ours iiia.16

If s diaios ar o avaia, us

aor ssi sroid of a quiva dos,

g. drooriso 24 g/kg.

Magnesium sulphate

t ais of aio of agsiu supa

(mgSO4) is ivd o soo us

Iravous a-agoiss soud

osidrd i pais ursposiv o ra

wi oiuous uisaio as w as os i

wo uisaio is o possi (g. iuad

pais or os wi poor air r).

Advrs ffs of s diaios

iud aardia, arria, prsio or

posio, ad pokaaia.23 howvr, r

is o sigifia risk of ardia oxii.24

Appropria doss ar:16,25

6puffsMDIviaspacer(childrenyoungerthan

6 ars) = 2.5 g sauao

12puffsMDIviaspacer(children6yearsor

odr) = 5 g sauao

ts doss soud giv vr 20 ius

for r doss i firs our. If pai

iprovs, u sauao is rquird agai wii

3-4 ours, furr doss soud giv. If

id ds sauao or frqu,

soud rfrrd o ospia.

If id as svr asa, us oiuous

uisd sauao wi ig fow oxg ad

arrag urg rasfr o ospia.26

Anticholinergics

Aioirgi ags ar usua adiisrd

via iad rou ad os oo is

ipraropiu roid. Sudis suggs a

addiio of iad ipraropiu roid (g.

Arov) o a a-agois for odra o svr

asa iprovs ouo ad drass

ospiaisaio ras.27,28

Table 3. Initial assessment of acute asthma in children16

Symptoms Mild Moderate Severe and life

threatening*

Altered consciousness No No Agitated/confused/drowsy

Oximetry on

presentation (S02)

94% 9490%


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Management of severe asthma in childrenclinical

dvopd ouris wi sigifia oridi

i idr. Idifig a id a risk of a svr

aak rais agig. ear rogiio

ad iiiaio of rap is via i prvig

svr opiaios, su as rspiraor faiur.

Aggrssiv ra wi a-agoiss,

aioirgis ad oriosroids rais

god sadard for is odiio.

Key points

Patientsathighriskofasthmarelated

da d os osrvaio ad soud

ouragd o sk dia aio ar i

a au xaraio.

Absentbreathsounds(silentchest)inthe

fa of irasd work of raig a

idia rspiraor faiur.

Initialmanagementincludesabeta-agonistvia

mDI pus spar or uisr. Theadditionofinhaledipratropiumbromide

iprovs ouo ad drass

ospiaisaio ras.

Steroidsarealsouseful,particularlywhen

giv ar i a xaraio.

AuthorsAdriaa yok corras mD, is Padiari

erg Fow, Dpar of erg

mdii, Roa cidrs hospia, mour,

Vioria. [email protected]

mau Soo-mariz mD, is Rspiraor Fow,

Dpar of Rspiraor mdii, Roacidrs hospia, mour, Vioria

mik Sarr mbbS, FRAcP, is a padiariia,

ifious disass psiia, osua i r-

g dii ad Diror, Padiari Psiia

traiig, Roa cidrs hospia, mour,

Vioria.

cofi of irs: o dard.

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Severe Asthma Children