Asthma exacerbation in a 13 year old childLYNDON WOYTUCKMBBS4 PROGRAMME AT ST GEORGE’S UNIVERSITY OF LONDON DELIVERED BY THE UNIVERSITY OF NICOSIASHEBA MEDICAL CENTER AT TEL HASHOMER

R.R.

Male, 13 years and 9 months Presented to the paediatric ER on the night of Jan 11 complaining of an

asthma attack Consisted of difficulty breathing (dyspnoea) and dry cough Worsening began Jan 10 and perpetuated; was not managed by relieving

medications at home (Ventolin) Diagnosed with asthma at age 3 Has a history of attending hospital about once per week over last 2 years

due to asthma exacerbation; absent 100/200 school days last year

What is your differential?

Asthma differential

Bronchiolitis (RSV, parainfluenza) Episodic (viral) wheeze Inhaled foreign body Recurrent aspiration (GORD,

pneumonitis) Cardiac failure Cystic fibrosis Primary ciliary dyskinesia

Persistent bacterial bronchitis (H. influenza or S. pneumoniae)

Hyperventilation Physiologic exertional dyspnoea

What is the next step?

Action

First – triaged and determine if moderate or greater exacerbation

Give treatment promptly Take brief history and exam Assess lung function if not in

extremis Take labs as needed

Immediate Management

Management in older children is generally similar to adults, whereas infants with exacerbation are much higher risk

Oxygen administration by mask (may use nasal cannula) with oxygen saturation monitor until a clear response to bronchodilator therapy occurred

Inhaled β2-agonist treatment (Albuterol given) the most effective means of reversing airflow obstruction. In the ED, three doses administered every 20 to 30 minutes is a safe strategy for initial therapy. After, frequency according to patient improvement in airflow obstruction and associated symptoms.

About 60% to 70% of patients will respond sufficiently to the initial three doses to be discharged, and most of these will demonstrate a significant response after the first dose – and can be administered continuously in severe exacerbation (<40% PV)

Consider nebulizer therapy in children due to necessity versus MDI with valve chamber Oral corticosteroids speed the resolution of airflow obstruction and reduce the rate of post-ED

relapse

Defining 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.” - American Thoracic Society

This is different from poor asthma control: diurnal variability in airflow may not change in exacerbation

Spirometry cut off points for acute asthma (exacerbations) versus chronic asthma

At assessment: agitation, increased respiratory rate, increased pulse, and decreased lung function as measured by FEV1, peak expiratory flow (PEF), PaO2, PaCO2, and arterial oxygen saturation (SaO2).

May have accessory muscle usage or inability to speak in full sentences or even phrases

Present Illness

Presented with Normal temp, pulse 90bpm, BP 125/77mmHg, SpO2 99% ambient air. Venous blood gases - pH 7.34 (7.31-7.41), pCO2 51mmHg (40-52), HCO3 27mEq/L (22-27), lactate 12

Transferred to ICU Relaxed respirations, speech not inhibited by dyspnoea pH 7.32 (7.35-7.45), PaO2 52.5 mmHg (90-99), PaCO2 38.2 mmHg (35-45), HCO3 19.5 mmol/L (22-

26), lac 44 Kept on room air, at 100% saturation; on auscultation - reduced air entry into the lungs, with some

wheezing Lung function: FVC 74%, FEV1 68%, FEV1/FVC 97%

Transferred to paediatric department

What risk factors and conditions should be

addressed in the medical history?

History

Poorly controlled asthma over last 2 years, but has been diagnosed since 3 years old after moving from Atlanta, USA

More shortness of breath in morning and night, with some waking at night; no known triggers

Allergies to cat dander, dust and grass pollen found by previous skin prick testing – has some pruritus on exposure to cats, but fine with his pet dog and rabbit

Hypersensitivity reaction to IvIg – had aseptic meningitis after 6 month regimen, then stopped 1 month ago

Spends a lot of time in hospital; 1 day/week is a good week, and a few days per week on a bad week

Despite missing 100/200 days last year, does well in school (90’s% ave.) Enjoys playing tennis and guitar (and XBOX) as out of school activities Family: unaffected 2 older sisters and younger brother, mother has asthma, father has

moderate/severe seasonal allergies

What does this history suggest?

Reassess and continue management

Repeat assessment after first bronchodilator dose in severe patients and after three (60-90 minutes) in others. Response to treatment in the ED is a better predictor of the need for hospitalization than the severity of an exacerbation at the time of presentation

The signs of impending respiratory failure are inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mmHg.

Intubation should not be delayed once it is deemed necessary. Patients presenting with apnea or coma should be intubated immediately. Persistent or increasing hypercapnia, exhaustion, and depressed mental status strongly suggest the need for ventilatory support.

Because intubation in the severely ill asthmatic patient is difficult and can result in complications, other treatments, such as intravenous magnesium and heliox are sometimes attempted.

Administered IV magnesium sulfate: has no apparent value in patients with exacerbations of lower severity, but may be considered in extreme exacerbations and those whose exacerbations remain severe after 1 hour of intensive conventional treatment

What are the relevant

investigations?

Investigations

Lung function!!! PEF and/or FEV1, FEV1/FVC Blood gases: respiratory failure, theophylline toxicity, or complicating conditions like

cardiovascular disease, pneumonia, or diabetes For example. PaCO2 in patients with suspected hypoventilation, those in severe distress, or

those with FEV1 or PEF results of 25% or less of predicted value after initial treatment Chest X Ray should be taken if suspecting congestive heart failure, pneumothorax,

pneumomediastinum, pneumonia, or lobar atelectasis

Which examinations and what should be ruled out before

discharge?

Examination tailored to asthmatic patient – inpatient assessment

General Well looking adolescent Pulse regular 68/min, respiration rate 24, BP 124/58, T No conjunctival pallor, no cyanosis, capillary refill 2s ENT: mouth, nose and throat clear, no lymphadenopathy

Respiratory: Chest expansion good at 2-3cm, no signs of laboured breathing Equal lung sounds bilaterally, wheeze present throughout

Cardiovascular Regular S1/S2, no added heart sounds

Discharge

FEV1 or PEF 70% or more of predicted value or personal best Symptoms are minimal or absent Extended treatment or observation in a holding or overnight unit might be

appropriate for some patients If given systemic corticosteroids then give prescription to continue therapy for 3

to 10 days after discharge. For high risk of nonadherence, intramuscular depot injections might be as effective as oral corticosteroids in preventing relapse.

If currently using inhaled corticosteroid therapy, then should continue while taking systemic corticosteroids

Consider initiating inhaled corticosteroids at discharge for those without

How should he be monitored after

discharge?

Preventing exacerbation

ED visits are often the result of inadequate long-term management of asthma To help patients recognize and respond to symptoms of asthma, the provider should

prepare a simple asthma discharge plan for asthma symptoms and explain it and be sure to include daily treatment plans, as well as plans for how to manage an exacerbation

it is important to review inhaler technique with the patient and correct technique errors Refer to follow-up asthma care appointment with a primary care physician or an asthma

specialist within 1 week and schedule the appointment before discharge. Encourage the patient's participation in a more formal asthma education program

A discharge plan is useful to ensure that patients are provided with the necessary medications and taught how to use them, instructed in how to monitor symptoms, given a follow-up appointment, and instructed in a written plan for managing recurrence of airflow obstruction

Discharge plan

References

Carlos A. Camargo, Jr., Gary Rachelefsky, and Michael Schatz "Managing Asthma Exacerbations in the Emergency Department", Proceedings of the American Thoracic Society, Vol. 6, No. 4(2009), pp. 357-366. http://www.atsjournals.org/doi/full/10.1513/pats.P09ST2#.VpocUCp96Cg

Guidelines for the Diagnosis and Management of Asthma National Asthma Education and Prevention Program Expert Panel Report 3. http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

BMJ BestPractice. Asthma in Children. http://bestpractice.bmj.com/best-practice/monograph/782/diagnosis/differential.html