2009/9/3

Chronic disease of the tracheobronchial tree characterized by airway obstruction, inflammation, and hyperresponsiveness Generally reversible with appropriate, aggressive therapy

4.8 million children younger than 18 years of age Prevalence of asthma has increased in all age groups by 40 percent in the last decade Risk factors associated with the development of asthma
low birth weight family history of asthma urban household low-income household race (children of African-American, Asian, and Hispanic descent

Most children presenting with asthma do so before age 8

male predominance in the prepubertal age group ratio equalizes during adolescence

Bronchial hyperreactivity
genetic basis usually initiated by environmental factors

Asthma is a two-stage process

bronchoconstriction due to histamine and leukotriene release (early stage) airway mucosal edema with mucous plugging (late phase)

Children are at higher risk of respiratory failure than an adult

Increased compliance of the infant rib cage and immature diaphragm contributes to increased work of breathing and respiratory muscle fatigue Young lung tissue lacks elastic recoil and is more prone to atelectasis Airway walls are relatively thicker and result in greater narrowing with bronchoconstriction

Avoid delays in treatment Brief physical examination should be performed before a detailed history is obtained Examination of vital signs Supplementary oxygen administration

After initial stabilization, perform a complete examination

assess ventilation, accessory muscle use, and work of breathing nasal flaring, foreign bodies, and concurrent sinusitis "musical" polyphonic inspiratory and expiratory wheezes may not always be present on lung examination and are not prognostic of severity of disease Extremities should be inspected to assess cyanosis and clubbing

Complete history (aspiration, choking, possible ingestion should be included for all ages)

Peak expiratory flow rate (PEFR)

Forced expiratory volume in 1 s (FEV1)

monitor response to acute treatment ongoing assessment and management of asthma values in liters per minute are based on the child's height decreased by 25 percent once wheezing is detected by stethoscope PEFR of less than 50 percent indicates severe obstruction, and less than 25 percent indicates possible hypercarbia In the ED, PEFR is an excellent tool to evaluate mild asthma or for reevaluating patients after treatment Limited by patient cooperation in children younger than age 5 may not be feasible during an acute exacerbation

correlates with the degree of airway obstruction

ABGA should be obtained in children with

impending respiratory failure Hypoventilating if PEFR is less than 30 percent of predicted not responding as expected to treatment

Complete blood count and chemistries Chest x-ray

usually unnecessary unless there is a concurrent febrile illness or coexisting disease not recommended routinely new-onset asthma, for severe episodes requiring admission, or if pneumonia, pneumothorax, foreign body, or pneumomediastinum are in the differential diagnosis

Upper and lower respiratory causes Nonrespiratory causes

cause bronchial smooth muscle relaxation continuous aerosolized therapy with albuterol is safe, fast, and effective

Unresponsive to the preceding therapy or respiratory distress increases Administered while intravenous line placement is attempted 0.01 mL/kg aqueous epinephrine 1:1000 to a maximum of 0.3 mL may be repeated every 20 to 30 min for a total of three doses

Inhibit the secretion of inflammatory leukotrienes and prostaglandins Prevent and reverse the increase in vascular permeability that leads to airway edema Early administration during the course of an acute exacerbation is recommended for all patients unless
the PEF is greater than 50 percent and there is an immediate response to the first treatment when exercise-induced attacks occur in a previously well child

Dose : 2 mg/kg There is no real advantage to the administration of intravenous over oral glucocorticoids in the acute setting

Most children presenting in status asthmaticus will be dehydrated because of increased insensible losses Administer a bolus of fluid 20 mL/kg of NS

Prevent bronchoconstriction induced by cyclic guanosine monophosphate Additive benefit when used with albuterol Ipratropium is a safe drug with few side effects and may be given to patients of all ages The dosage of nebulized ipratroprium bromide is as follows:
Adolescents >14 years of age: 500 mcg in an initial nebulization Children up to 14 years of age: 125 ~ 250 mcg in an initial nebulization Neonates: 25 mcg/kg in an initial nebulization

Magnesium Sulfate

Heliox

exact mechanism of action is unknown tocolytic effects of magnesium sulfate on uterine smooth muscle improvement in short-term pulmonary function given as 25 to 50 mg/kg IV over 20 min; this may be repeated once Maximum dose for children is 2 g generally available as 80:20 or 60:40 mixtures of helium and oxygen recommended for the asthmatic who does not improve with conventional treatment but in whom intubation is not imminent

Theophylline
competitive phosphodiesterase inhibitor no longer used routinely reserved for patients who clearly respond to it or for those who remain refractory to other modes of treatment

Children responding well to conventional therapy may be discharged after 2 to 4 h of treatment Short ED observation period is recommended for patients with an incomplete response but acceptable PEFR Detailed discharge instructions should outline medication administration, inhaler use, and follow-up All children should be referred to their pediatrician for follow-up within 24 h

Inflammation of the bronchioles Clinical syndrome of wheezing, chest retractions, and tachypnea in children younger than age 2 years

Peak prevalence is from late October to May. Peak age of incidence in urban populations is 2 months and results in hospitalizations lasting 5 to 7 days Disease in older children is usually milder

Respiratory syncytial virus (RSV) causes 50 to 70 percent of clinically significant bronchiolitis

Non-RSV bronchiolitis is caused by infiuenzavirus, parinfluenzavirus, echovirus, rhinovirus, Mycoplasma pneumoniae and Chlamydia trachomatis

transmitted by direct contact with large droplets of secretions and self-inoculation by contaminated hands via the eyes and nose no significant transmission occurs by small-particle aerosol

Peripheral airway narrowing and variable obstruction

Mucous plugging
necrosis of the respiratory epithelium and destruction of ciliated epithelial cells

Submucosal edema

Symptoms range from minimal rhinorrhea to bronchiolitis or pneumonia and respiratory failure Infection begins with nasal discharge, pharyngitis, and cough Fever accompanies the first few days of illness Symptoms reach a peak at 3 to 5 days, generally resolving in 2 weeks

Physical findings
tachypnea greater than 50 to 60 breaths/min tachycardia mild conjunctivitis chest retractions prolonged expiration with hyperresonant chest wheezing hypoxemia

Suggested by clinical presentation, patient age, and history of RSV exposure or community epidemic. Immunofluorescence assays currently available are extremely sensitive but not necessary for all patients Complete blood counts and chemistries may not be helpful in diagnosis Chest radiography to rule out pneumonia is indicated for children with concurrent cardiopulmonary illness or those who are illappearing and hypoxemic

Treatment is mainly supportive, the most important therapy being supplemental humidified oxygen Increased insensible fluid loss occurs from increased work of breathing and can cause significant dehydration that warrants a NS bolus Fever should be controlled with acetaminophen or ibuprofen Antibiotics should be reserved for identifiable bacterial infections Workup for occult bacteremia is not required unless they appear toxic

Nebulized epinephrine

Albuterol and Ipratropium

effective treatment for wheezing of bronchiolitis found to reduce hospitalizations in children with bronchiolitis compared with albuterol It can be used safely in hospitalized children up to every 2 h as a 0.1% solution (0.5 mL in 3.5 mL of NS) If used in the ED, recommend an observation period of 4 h before a disposition decision is made Generally, infants and children showing minimal response or deterioration after a single treatment will require hospitalization limited role for bronchodilator therapy in the treatment of bronchiolitis

Glucocorticoids
Controlled studies have failed to demonstrate any proven benefit to the use of glucocorticoids

Ribavirin
decrease viral protein synthesis improvement in oxygenation those with immunodeficiency, cystic fibrosis, congenital heart disease, and severe illnesses of infancy

RSV Immune Globulin

Palivizumab

passive immunization monthly intravenous infusions recommended for infants with documented BPD and for those with a gestational age of less than 35 weeks monoclonal antibody can be given by intramuscular injection administered monthly desirable for children in whom vascular access is a challenge

Admission
visible moderate to severe respiratory distress hypoxia apneic spells dehydration sustained tachypnea (RR >60 breaths/min) considered in all infants with a history of BPD, congenital heart disease, and immunocompromise

Discharge
mild disease taking fluids well whose parents are capable

Parents should be instructed on how to perform aggressive nasal suctioning and evaluate respiratory distress Decongestants and antihistamines are of questionable benefit