ACUTE ASTHMA

EXACERBATION
PHONG CHIEU DAO, MSIII

CASE STUDY
HPI: 8 y/o M presents to the ED at night with dyspnea. Mother
states he has wheezed in the past, but has been doing well
since started inhaled fluticosone x 1 yr. He requires 2-3 puffs
albuterol per week. Patient develops running nose and cough x
3 days prior. Mother admits using wood-burning stove x 1 week.
Tonight, he develops SOB that is not relieved with multiple puffs
of albuterol. Denies pets and recent traveling.
PMHx: Asthma, Dx 4 yrs ago
PSHx, SHx, Allergy: denies
VITALS: HR 140, RR 48, Sat 90% RA
PHYSICAL EXAM: labored breathing, tachypnea, using
accessory muscle for breathing, inspiratory + expiratory
wheezing

EPIDEMIOLOGY

22 million persons in US
6 million children in US (27%)
200,000 children hospitalization annually
7 millions ambulatory visits

ETIOLOGY

Host vs environmental exposures

Inflammatory process
Involving predominance neutrophil, mast cell, macrophages, and
eosinophil which mediate structural change
Immune system
Imbalance in regulation of Th-1 and Th-2 cytokine response in
early life
Down-regulation of Th-1 cell which fight infection
Up-regulation of Th-2 cell which lead to asthma and allergies

PATHOPHYSIOLOGY

Inflammation process mediated by cytokines causes

airway thickening due to edema and cellular infiltration
Bronchial smooth muscle contraction mediated by
cytokines causes airway constriction.
Epithelial damage lead to mucus plugs that airway
obstruction
Airway remodeling sub-epithelial fibrosis, smooth
muscle hypertrophy and hyperplasia, submucosal gland
hypertrophy which lead to hypersecretion
Ultimately: Impair air exchange

RISK FACTORS FOR

EXACERBATION

Environmental exposures
House dust mite
Airborne allergens
Tobacco smoke
Hydrocarbon in air pollution
Cold air
Exercise
NSAIDs, aspirin, and some beta-blockers
Viral exposures
RSV, rhinovirus, influenza virus, etc

ASTHMA EXACERBATION
SEVERITY
MODERATE

SEVERE

IMPENDING
RESPIRATORY ARREST

FEV1 or PEF

40-69%

<40%

<25%

SYMPTOMS

DOE or SOB w/ talking

SOB @ rest

Severe SOB

EXAM

Expiratory wheezing
+/- accessory muscle

Ins + exp wheezing

+ accessory muscle
Agitation/Confusion

+/- wheezing
+ accessory muscle w/
paradoxical
diaphragmatic movement
Altered or depressed MS

VITALS

RR <28
HR <110
O2 Sat >91% RA

RR >28
HR >110
O2 sat < 91% RA

Same as severe

PaCO2

Normal to hypocapnic
initially

> 42 mm Hg

Hypercapnea is a late
sign

TREATMENT GOALS
1. Inhaled beta 2 agonists: reverse bronchoconstriction
Metered Dose Inhaler (MDI) or continuous nebulizer depends
on severity
SABA albuterol, salbutemol
daily BMP to monitor hypoK, hypoPO4, and hypoMg
2. Systemic glucocorticoids: decrease inflammation
x 5 10 days depends on responds (taper off for >10 days)
Prednisone, Prednisolone or Methylprednisolone
No inhaled glucocorticoids
3. Supplemental Oxygen to maintain O2 Sat > 92%: prevent
hypoxemia
4. Asthma Education
5. Initiation or adjustment of controlled agent

MANAGEMENTS DEPENDS OF
SEVERITY AND RESPONDS OF TRX

MILD TO MODERATE
O2
4-8 puff MDI albuterol or 2.5 mg (<30Kg)/ 5mg (>30Kg) nebulizer
q20min-60min x 4 hrs
Oral CS 1mg/kg q12hr if no immediate improvement or recently taking
OS
D/C or Ward depends of responds
SEVERE
O2
2.5-5.0mg albuterol w/ 0.5mg ipratropium nebulizer q20min-60min or
continuous therapy 0.5 mg/kg*hr albuterol
Oral or IV CS
D/C or Ward depends of responds
IMPENDING RESPIRATORY FAILURE
100% FiO2, high dose SABA + Ipratropium, IV CS
Consider Mechanical ventilation
ICU

ASSESSMENT
RESPONDS
TO
TRX
Cincinnati Childrens Hospital MC Asthma scores
RR

Accessory
muscle

Air Exchange Wheezing

Inspiratory:
Expiratory
Ratio

1 for tachypnea
>50 in infant
>40 in child
>20 adolescent

1 for
suprasternal,
subcostal or
intercostal

1 for localized
decrease BS

1 wheezing
during
expiration

0 for <1:2

2 for
inspiratory +
expiratory
wheezing

1 for >1:3

2 for neck and 2 for multiple

abdominal
area of dec
muscle
BS

Score >2 requires Treatments

CASE STUDY
HPI: 8 y/o M presents to the ED at night with dyspnea. Mother
states he has wheezed in the past, but has been doing well
since started inhaled fluticosone x 1 yr. He requires 2-3 puffs
albuterol per week. Patient develops running nose and cough x
3 days prior. Mother admits using wood-burning stove x 1 week.
Tonight, he develops SOB that is not relieved with multiple puffs
of albuterol. Denies pets and recent traveling.
PMHx: Asthma, Dx 4 yrs ago
PSHx, SHx, Allergy: denies
VITALS: HR 140, RR 48, Sat 90% RA
PHYSICAL EXAM: labored breathing, tachypnea, using
accessory muscle for breathing, inspiratory + expiratory
wheezing

CASE STUDY

What triggered the exacerbation?

Smoke from wood-burning stove

What is classification for the severity of exacerbation of the

pt?
Severe : not responding to MDI SABA, RR 48, HR 140, O2 sat
90%, Inspiratory + Expiratory wheezing, + accessory muscle

How should the pt be manages?

Supplement O2, continuous therapy albuterol + ipratropium
nebulizer, Oral/IV CS, Ward admission

REFERENCES
UpToDate
The Washinton Manual of Medical Therapy. 33rd ed.
http://empracticenews.wordpress.com/category/acuteasthma-in-the-pediatric-emergency-department-case-study/
http://www.alvesco.com/en/About-Asthma/Asthmapathophysiology
http://www.ebmedicine.net/topics.php?
paction=showTopicSeg&topic_id=59&seg_id=1980
http://www.pediatricsconsultantlive.com/display/article/18033
29/1414747