Management of acute Asthma

in children

Dr Mohd Nizam Mat Bah

Case 1
 5 yrs old boy
 1st admission to the hospital
 Acute onset of wheezing
 Severe asthma
 Requiring ICU care
 Continous salbutamol nebuliser and infusion
 High flow oxygen; maintained Sat >95%
 Steroids
Case 1
 CXR: small pneumothorax
 Slowly recovered
 Transferred to general ward after 3
days in ICU
 Asthma Education before discharge
Case 2
 7 years of age
 Known asthmatic, on prophylaxis
 Tachypnea and wheeze
 Admitted after 3 doses of nebuliser
 Well, mildly tachypnea only, speaks in full
sentences
 Discharge with oral steroids
Acute management
 Confirmed the diagnosis
 Assess severity of asthma
 Managed according the severity
Severity asthma (1)

 Apprehensiveness

 Unable to complete sentences in one breath

 SaO2<92% in room air after three

appropriate doses of inhaled salbutamol
within 60 mins.
Severity of asthma (2)
 Tachycardia
 >130 in children aged 2-5 yr
 >120 in children aged >5 yr

Increasing tachycardia denotes worsening

asthma or increasing doses of salbutamol
Severity of asthma (3)
 Tachypnoea:
 >50 in children aged 2-5 yr

 >30 in children aged >5 yr

 Palpable pulsus paradoxus (equates to ≥15 mm Hg)

NB all asthmatics have some degree of pulsus

paradoxus at rest.
 Pulmonary Index Score:
score 0 1 2 3

dyspnoea absent mild dyspnoea: moderate severe dyspnoea:

normal dyspnoea: concentrates
activity decreased on breathing;
and activity; 0-5 word sentences
speech 5-8 word
sentences
accessory muscle no intercostal intercostal and nasal flaring
use retracti retractions suprasternal
on retractions

wheeze none terminal panexpiratory insp. & expiratory or

expiratory audible
without
stethoscope or
silent
inspiratory:expirator I = 2.5 × E I = 1.5 × E I=E I<E
y ratio
Pulmonary index score
 Calculate pulmonary index by adding
up score (0-3) for each category.
 Maximum score 12, minimum score 0.
 A PIS of ≥ 7 is consistent with severe
asthma
Respiratory failure score
0 1 2

Oxygenation In air In air In 40 % oxygen

PaO2 65-100 mm Hg <70 mm Hg <70 mm Hg
or or or or
SaO2 90-97% <90% <90%

Inspiratory breath sounds Normal Unequal Decreased or absent

Use of accessory muscles None Moderate Maximal

Expiratory wheeze None Moderate Marked

Cerebral function Normal Reduced or agitated Poorly responsive or coma

Respiratory failure score

 Calculate respiratory failure score by adding up

score (0-2) for each category.

 Maximum score 10, minimum score 0.

 Acute Respiratory failure is consistent with a score

of > 5, together with a PaCO2 >45 mm Hg.
Modified dyspnea scale

Dyspnoea score
Severity

0 Absent dyspnoea

1 Normal activity and speech; minimal dyspnoea

2 Decreased activity; 5-8 word sentences; moderate dyspnoea

3 Concentrates on breathing; <5 word sentences; severe dyspnoea

Progressive worsening:
1. Agitation and Confusion
2. Exhaustion
3. Cyanosis
4. Increasing tachycardia.
 NB Decreasing heart rate is pre-terminal
5. Poor respiratory effort
Note:

• Wheezing may be less apparent with increasing airway obstruction, with

a silent chest occurring in life threatening asthma.

• Clinical signs correlate poorly with severity of airway obstruction. Thus

objective measurements with SaO2 are essential.

• PEF measurement rarely provides additional useful information.

• CXR may be abnormal but does not usually guide management. A

pneumothorax may be revealed in severe respiratory failure.

• Blood gases rarely guide therapy. A rising pCO2 may be indicative of

worsening respiratory failure, but the decision to intubate is still a clinical
one
 How to access the severity of acute asthma

Mild Moderate Severe

Altered consciousness No
Physical Exhaustion No
Talks In Sentence
Pulsus Paradoxus Not
palpable
Central Cyanosis Absent
Wheeze on auscultation Present
Use of accessory muscles Absent
Sternal retraction Absent
Initial PEF (%predicted or % >60%
Child’s best)
Oximetry (prior nebuliser) >93%
10/23/08 Henry et al, J Paediatr Child Hlth 1993; 29:101-103
 How to access the severity of acute asthma

Mild Moderate Severe

Altered consciousness No No
Physical Exhaustion No No
Talks In Sentence Phrases
Pulsus Paradoxus Not palpable May be
Central Cyanosis Absent Absent
Wheeze on auscultation Present Present
Use of accessory muscles Absent Moderate
Sternal retraction Absent Moderate
Initial PEF (%predicted or % >60% 40-60%
Child’s best)
Oximetry (prior nebuliser) >93% 91-93%

10/23/08 Henry et al, J Paediatr Child Hlth 1993; 29:101-103

 How to access the severity of acute asthma

Mild Moderate Severe

Altered consciousness No No Yes
Physical Exhaustion No No Yes
Talks In Sentence Phrases Words
Pulsus Paradoxus Not palpable May be palpable
Central Cyanosis Absent Absent Present
Wheeze on auscultation Present Present Silent
Use of accessory muscles Absent Moderate Marked
Sternal retraction Absent Moderate Marked
Initial PEF (%predicted or % >60% 40-60% <40%
Child’s best)
Oximetry (prior nebuliser) >93% 91-93% 90% and
below
10/23/08 Henry et al, J Paediatr Child Hlth 1993; 29:101-103
Management of severe asthma:

Aims:
 Maintenance of adequate oxygenation
(SaO2 ≥ 93%).
 Rapid bronchodilation
 Treatment of haemodynamic compromise
 Maintained adequate oxygenation

Oxygen delivery is best by high flow

oxygen via reservoir fitted facial mask
(thereby increasing FiO2), with the aim
of maintaining SaO2 ≥ 93%.
What are the consequences of hypoxaemia?

 Resp:
 Bronchoconstriction.
 CVS:
 Hypertension
 Decreased systemic oxygen transport
 Increased myocardial oxygen consumption.
 Neuro:
 Reduced level of consciousness, agitation, confusion
Maintained hemodynamic stability

 With acute asthma there is an increased metabolic rate and

insensible respiratory fluid losses as well as decreased oral fluid
intake.

 This may lead to dehydration in addition to increasingly viscous

airway secretions (with intraluminal airway plugging).


Humidification of inspired gas and adequate hydration is indicated.
Maintained hemodynamic stability

 If adequately hydrated, 2/3rds of the child’s maintenance requirement

should be given because of the possibility of inappropriate antidiuretic
hormone secretion.

 Serum electrolytes should be measured and hypokalaemia corrected

if detected.

 Supplemental potassium (to a total of 2-3 mmol/kg/day) in IV fluid

therapy is recommended during regular beta-2 agonist use.
Bronchodilation
 Receiving beta-2 agonists continuously via a nebuliser is the
preferred option in severe asthma. Use 2.5 mg for infants, 5 mg for
older children, diluted to 4 ml with 0.9% saline.

 In between nebulisations change to a Hudson mask with rebreather

bag.
Bronchodilation

1. Frequent beta-2 agonist use can lead

to the side effects that include
tachycardia, tremors, agitation,
paradoxical bronchospasm,
hyperglycaemia and hypokalaemia.
Salbutamol infusion:
 Use undiluted salbutamol 1mg/ml.

 Starting dose is 5 mcg/kg/hr for at least one hour. This is likely to

achieve adequate blood levels for maximal bronchodilation.

 Increments should be 2.5 mcg/kg/hr, up to a maximum of

10 mcg/kg/hr (consult intensivist if a higher dose is considered).
Salbutamol infusion
 After adequate response and stability decrement
should be to 3 mcg/kg/hr, then 1 mcg/kg/hr.

 The adverse effects include hypokalaemia,

hyperglycaemia and lactic acidosis, which are mild
Salbutamol infusion
There is probably no added benefit in continuing
nebulised salbutamol concomitantly (so inhalations
may be ceased, especially at night), but during the
weaning phase reintroducing nebulised salbutamol
at 1 hourly intervals is a sensible transition process
 IV adrenaline should be used in prepubertal children only in
life threatening acute attacks or in the presence of
anaphylactic shock.

 The theoretical advantage of adrenaline over other

sympathomimetic agents lies in its added “alpha effects”,
from which mucosal vasoconstriction may reduce oedema.

 In older children IV adrenaline is a (cheaper) alternative to IV

salbutamol
Steroids
 Oral and intravenous steroids are of similar efficacy.

 The intravenous route does not offer any advantage over the
oral route unless the child has nausea &/or vomiting.

 Benefits of systemic steroids can be apparent within three to

four hours, with maximal effect obtained 6 to 12 hours after
administration.

 Dose is prednisolone or methylprednisolone 2 mg/kg/day.

 Switch to oral once on hourly nebulised salbutamol, if
tolerated
Ipratropium Bromide
 There is evidence for the efficacy of
frequent doses of ipratropium bromide
(an anticholinergic) in addition to
inhaled beta-2 agonist
 Algorithm for management of acute asthma in children
Mild
Nebulised B2 Agonist
No improvement
moderate
Nebulised B2 agonist 3 doses
At 20 min intervals
+O2 (8L via face mask)
+/- oral steroids
+/- Ipratropium bromide
Admit if no improvement
improved
Observe for 60 min
-discharge with
Long term plan
Asthma action plan
Observe for futher
60 min; discharge
improved
With B2 agonist +/-
Oral steroids
Long term plan
Asthma action plan
 Algorithm for management of acute asthma in children

SEVERE Nebulised B2 Agonist Improved:

Every 20 min or continously Continuous
+ steroids (oral/IV) observation

Continuous observation

Consider:
Parenteral B2 agonist
IV aminophylline
Intensive care Unit
Summary of management of acute asthma

 Confirm the diagnosis

 History, examination
 Assess the severity:
 Mild ?
 Moderate?
 Severe?
When to refer:

Severe asthma- needs ICU care

Stabilize patient
THANK
YOU