Critical Alerts

• Silent chest is ominous: No wheezing may mean severe obstruction
• Hypoxia is a late sign: Respiratory fatigue and hypercapnia precede
• Magnesium for severe asthma: 40-75 mg/kg IV (max 2g)
• Continuous albuterol for severe cases: Not just PRN
• Early steroids reduce admissions: Give within 1 hour
• Don't delay intubation if indicated: But try to avoid

Key Diagnostics

Emergency Treatments (Pediatric Dosing)

Overview

Acute asthma exacerbation in children is an episode of progressive worsening of asthma symptoms including cough, wheeze, chest tightness, and dyspnea, accompanied by decreased expiratory airflow. It ranges from mild exacerbations manageable at home to severe, life-threatening attacks requiring intensive care.

Classification by Severity

GINA/EPR-3 Severity Assessment:

Age-Appropriate Respiratory Rate:

Epidemiology

• Prevalence: 8-10% of children in US have asthma
• ED visits: 1.8 million/year (age <18)
• Hospitalizations: 130,000/year
• Deaths: ~170 deaths/year in children
• Risk factors for death: Prior intubation, recent hospitalization, low socioeconomic status, poor adherence

Etiology/Triggers

Common Triggers:

Signs of Impending Respiratory Failure

Other Causes of Wheezing in Children

Clinical Assessment

Primary Assessment:

• Work of breathing
• Mental status
• Ability to speak
• SpO2 on room air
• Response to initial treatment

Peak Expiratory Flow (If child can perform, usually ≥6 years):

• Compare to baseline or predicted
• <50% predicted = severe
• May not be feasible in severe exacerbation

Scoring Systems

Pediatric Asthma Severity Score (PASS) or Pediatric Respiratory Assessment Measure (PRAM):

• Standardized assessment of severity
• Guides therapy escalation

Laboratory Studies

Not routinely required. Consider:

VBG/ABG Interpretation in Asthma:

When to Image

CXR Indications:

• Fever + localized findings (pneumonia)
• First-ever wheeze (consider foreign body, anatomy)
• Subcutaneous emphysema (pneumothorax/pneumomediastinum)
• Refractory to treatment
• Clinical concern for complication

Discharge Criteria

• Good response to treatment (sustained ≥1 hour after last treatment)
• SpO2 ≥94% on room air
• Minimal to no wheeze
• No retractions
• Tolerating oral steroids
• Able to use inhaler properly
• Family education completed
• Follow-up arranged (24-72 hours)

Admission Criteria

• Persistent hypoxia (SpO2 <92% on room air)
• Persistent respiratory distress after initial treatment
• Inadequate response to ED treatment
• Prior ICU admission or intubation (high-risk)
• Unable to tolerate oral steroids
• Social concerns, unable to follow up
• Need for q1-2h bronchodilators

ICU Admission Criteria

• Severe exacerbation not responding to treatment
• Need for continuous albuterol
• Hypercapnia or rising PaCO2
• Altered mental status
• Impending respiratory failure
• Need for intubation

Follow-Up

Condition Explanation (For Parents)

• "Your child is having an asthma attack, which means their airways are narrowed and inflamed."
• "We are giving medicine to open up the airways and reduce the swelling."
• "It's important to complete the steroid course to prevent the attack from coming back."

Discharge Instructions

• Complete steroid course (prednisolone for 3-5 days or dexamethasone as prescribed)
• Continue rescue inhaler as needed (with spacer)
• Resume controller medications
• Avoid known triggers
• Follow up as scheduled

Warning Signs (Return immediately)

• Worsening breathing difficulty
• Rescue inhaler not helping
• Unable to speak or drink
• Lips or nails turning blue
• Child becoming very sleepy or confused

Prevent Future Attacks

• Controller medication adherence (ICS)
• Avoid triggers
• Written asthma action plan
• Influenza vaccination yearly
• Follow up with primary care/specialist

Infants (<12 months)

• Diagnosis of asthma uncertain (may be bronchiolitis, viral wheeze)
• Response to bronchodilators may be less predictable
• Higher risk for complications
• Low threshold for admission

Adolescents

• Adherence issues common
• Assess for tobacco/vaping/marijuana use
• Mental health comorbidities
• Transition planning to adult care

Known High-Risk Patients

• Prior ICU admission or intubation
• ≥3 ED visits or ≥2 hospitalizations in past year
• Recent oral steroid use
• Poor adherence to controller therapy
• Significant allergies
• Low threshold for escalation and admission

Performance Indicators

Documentation Requirements

• Baseline asthma severity and control
• Current medications
• Trigger for exacerbation
• Physical exam including severity assessment
• Response to treatment
• Discharge medications and instructions
• Follow-up plan

Diagnostic Pearls

• Silent chest = severe obstruction: Not improving, just worse
• Normal or rising PaCO2 is a red flag: Patient tiring
• Paradoxical breathing in infants: Sign of fatigue
• Not all wheeze is asthma: Consider foreign body, cardiac, etc.
• First wheeze in <12 months: May not be asthma
• Pulsus paradoxus >20 mmHg: Severe obstruction

Treatment Pearls

• Steroids within 1 hour: Reduces admissions
• Continuous nebs for severe: Not PRN
• Ipratropium only in first hour: No benefit later
• Dexamethasone 1-2 doses: May equal 5-day prednisolone
• Magnesium for severe: Give before intubation
• Ketamine for intubation: Bronchodilator properties

Disposition Pearls

• Discharge only if sustained improvement: 1+ hour after last treatment
• Low threshold to admit high-risk patients: Prior intubation, frequent visits
• Written asthma action plan: Prevents future attacks
• Follow-up is critical: 24-72 hours