{
 "topic": "Asthma Exacerbation",
 "slug": "asthma-exacerbation",
 "category_id": 15151,
 "passage_count": 14,
 "source_chars": 12684,
 "enough_material": true,
 "references": [
  {
   "title": "Caring for the Hospitalized Child",
   "author": "Section on Hospital Medicine, American Academy of Pediatrics;Jeffrey C. Gershel;Daniel A. Rauch;",
   "pages": [
    766
   ]
  },
  {
   "title": "Algorithms in Pediatrics",
   "author": null,
   "pages": [
    342
   ]
  },
  {
   "title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024",
   "author": null,
   "pages": [
    1421,
    1423,
    1424
   ]
  },
  {
   "title": "Ghai Essential Pediatrics, 9e (Vinod K Paul, Arvind Bagga)",
   "author": "CamScanner",
   "pages": [
    391
   ]
  },
  {
   "title": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online",
   "author": null,
   "pages": [
    143,
    145
   ]
  },
  {
   "title": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition",
   "author": "Hay, William W., Levin, Myron J., Deterding, Robin R., Abzug, Mark J.",
   "pages": [
    406,
    1157,
    1174
   ]
  },
  {
   "title": "Cover",
   "author": "Vitalsource Download",
   "pages": [
    7720
   ]
  },
  {
   "title": "MedStudy Pediatrics Core 11th Edition 2024-2025",
   "author": null,
   "pages": [
    402
   ]
  }
 ],
 "passages": [
  {
   "source": "Caring for the Hospitalized Child, p. 766",
   "text": "![](/tmp/pdf-images/pdf-0765-00.png) **739** ~~**CHAPTER 95**~~ ## **Acute Asthma Exacerbation** ## **Introduction** Asthma is a chronic respiratory disease characterized by airway inflammation and obstruction with a recurrent, reversible pattern of symptoms. The prevalence of asthma among American children is 7%, with significant racial, ethnic, and socioeconomic disparities. Acute asthma exacerbations (AAEs) and status asthmaticus, defined as a life-threatening asthma exacerbation with risk for respiratory failure, are among the leading causes of pediatric hospitalizations. ## **Clinical Presentation** ## _**History**_"
  },
  {
   "source": "Algorithms in Pediatrics, p. 342",
   "text": "_Ankit Parakh, Shalu Gupta, Varinder Singh_ ## **INTRODUCTION** Acute severe asthma or acute exacerbations are acute episodes of progressive deteriorating shortness of breath, cough, wheezing, chest tightness, or a combination of these symptoms. These acute episodes of asthma are an important cause of morbidity, school absenteeism, and frequent hospital admissions in children. The severity of these episodes varies from mild to severe and each episode has the potential to progress to respiratory failure. The term \u201ccritical asthma syndrome\u201d is now used to describe any child who is at high risk of fatal asthma and includes acute severe asthma, refractory asthma, status asthmaticus, and near fatal asthma. Status asthmaticus refers to an acute asthma exacerbation in which bronchial obstruction is severe and continues to worsen or not improve despite the institution of adequate standard therapy, leading to respiratory fatigue and finally to respiratory failure."
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 1421",
   "text": "A severe exacerbation of asthma that does not improve with standard therapy is termed **status asthmaticus** . Immediate management of an asthma exacerbation involves a rapid evaluation of the severity of obstruction and assessment of risk for further clinical deterioration (Fig. 185.6; see Tables 185.4 and 185.17). For most patients, exacerbations improve with frequent bronchodilator treatments and a course of systemic (oral or intravenous) corticosteroid. However, the optimal management of a child with an asthma exacerbation should include a more comprehensive assessment of the events leading up to the exacerbation and the underlying disease severity. Indeed, the frequency and severity of asthma exacerbations help define the severity of a patient\u2019s asthma. Whereas most children who experience life- threatening asthma episodes have moderate to severe asthma by other criteria, some children with asthma appear to have mild disease except when they have severe, even near- fatal exacerbations. The biologic,"
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 1423",
   "text": "Asthma exacerbations characteristically vary among individuals but tend to be similar in the same patient. Severe asthma exacerbations, resulting in respiratory distress, hypoxia, hospitalization, and respiratory failure, are the best predictors of future life- threatening exacerbations or a fatal asthma episode. In addition to distinguishing such high- risk children, some experience exacerbations that develop over days, with airflow obstruction resulting from progressive inflammation, epithelial sloughing, and cast impaction of small airways. When such a process is extreme, respiratory failure because of fatigue can ensue, necessitating mechanical ventilation for numerous days. In contrast, some children experience abrupt- onset exacerbations that may result from extreme AHR and physiologic susceptibility to airways closure. Such exacerbations, when extreme, are asphyxial in nature, often occur outside medical settings, are initially associated with very high arterial partial pressure of carbon dioxide"
  },
  {
   "source": "Ghai Essential Pediatrics, 9e (Vinod K Paul, Arvind Bagga), p. 391",
   "text": "previous year Ever intubated or PICU admissions Start of the usual \u2018flare-up\u2019 season Exposure: Tobacco smoke; Indoor or outdoor alr pollution; Indoor allergens Major psychological or socioeconomic problems for child or family Poor adherence with controller medication, or incorract Inhaler technique Co-morbidities: Obesity, rhino-sinusitis, confirmed food allorgy Assessment of risk of exacerbations: Based on history, children are assessed for risk of exacerbations (Table 15.7), Appropriate treatment to children who are at risk of exacerbation may help in prevention of exacerbation. Selection of medication: After assessment of control of asthma and risk for exacerbation, antiasthma drugs are selected. Treatment of asthma according to the assessment is shown in Table 15.8. Infrequent episodes with no risk for exacerbation are treated with salbutamol or terbutaline as and when required. The oral route is used, if inhalation is not possible for any reason. Children with infrequent episodes but"
  },
  {
   "source": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online, p. 145",
   "text": "The early stages of an asthma exacerbation in children are characterized by the onset of cough, chest tightness, and chest retractions or audible wheezing. The parents should be educated to critically and accurately observe their child for the warning signs and, in collaboration with the managing Table 4-6 When Is It Asthma?* ## _**History of recurrent:**_ - Coughing - Wheezing \u2022 Shortness of breath or rapid breathing \u2022 Chest tightness - _**Symptoms made worse by:**_ \u2022 Viral infection \u2022 Tobacco smoke, wood smoke, and other irritants (e.g., strong odors or fumes) - \u2022 Exercise \u2022 Allergens (e.g., house dust mites, pollens, cockroaches, molds, animal dander) - \u2022 Changes in weather/humidity \u2022 Crying, laughing - _**Symptoms occur/worsen at night, waking the child and/or parent Reversible airflow limitation by spirometry in children older than 4 yr of age and diurnal variation in peak flow**_ \u2022 Wheezing (high-pitched whistling sounds when exhaling) may or may not be present"
  },
  {
   "source": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition, p. 406",
   "text": "## \u00bb **Pathogenesis** Life-threatening asthma exacerbations are caused by severe bronchospasm, excessive mucus secretion, inflammation, and edema of the airways (see Chapter 36). Infants and children are at particular risk for respiratory failure from asthma due to several structural and mechanical features of their lungs. They have less elastic recoil than the adult lung, thicker airway walls leading to greater peripheral airway resistance for any degree of bronchoconstriction, increased airway reactivity to bronchoconstrictors, fewer collateral channels of ventilation, and a more compliant chest wall which can lead to increased work of breathing with airway obstruction. Additional risk factors for severe asthma **374** **CHAPTER 14** exacerbation include obesity, lower socioeconomic status, non-Caucasian race, and a prior history of previous ICU admissions or intubations. ## \u00bb **Clinical Findings**"
  },
  {
   "source": "Cover, p. 7720",
   "text": "Extrapolating adult severity classifications to children is difficult for a number of reasons. Adults with asthma are more likely to exhibit a persistent pattern, whereas children may have a pattern of rapidly evolving, frequent, and often severe exacerbations. Children have severe exacerbations triggered by viral infections and/or exposure to allergens that can result in healthcare utilization but then often remain asymptomatic between these episodes. Lung-function measurements also show different patterns, are age-dependent, and may be within normal limits despite significant symptom burden and medication use. In children, the distal airways are more affected, and increased distal lung resistance explains the often unimpaired FEV1 values. Other measures of lung function such as FEV1/FVC, forced expiratory flow at 25% to 75% of predicted, or the degree of airway responsiveness to bronchodilators may relate better to asthma severity."
  },
  {
   "source": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online, p. 143",
   "text": "## **Asthma** Asthma is the most common chronic respiratory condition affecting children. Defining characteristics of asthma, as elucidated by the National Heart, Lung, and Blood Institute (NHLBI) _Guidelines for the Diagnosis and Management of Asthma_ (see Bibliography), include the following: (1) lower airway obstruction that is partially or fully reversible either spontaneously or with bronchodilator or antiinflammatory treatments, (2) the presence of lower airway inflammation, and (3) increased lower airway responsiveness (bronchial **4**[|] Allergy and Immunology **121**"
  },
  {
   "source": "MedStudy Pediatrics Core 11th Edition 2024-2025, p. 402",
   "text": "appropriate use of controller therapy to manage asthma in pediatric patients, see Appendix \u2014 Asthma Treatment Regimens on page 11-34, Common triggers of asthma attacks include: \u00b0 Viral infection * Cigarette smoke (including secondhand smoke) \u00a2 Exercise * Allergen exposure * Breathing cold, dry air Aspirin \u00a2 Aspiration * Acid reflux As many as 85% of exacerbations coincide with viral infec- tion in school-age children and are the biggest risk factors for hospitalization. Physical examination when \u201cwell\u201d can be normal or reveal only a prolonged expiratory phase. Wheezing, respiratory distress, tachypnea, and use of accessory muscles are hallmarks of attacks. Office spi- rometry is used to document variable expiratory airflow obstruction (see Figure 11-3 on page 11-2). \u2018The latest update (2020) to the asthma management guidelines from the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma"
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 1424",
   "text": "In children, management of severe exacerbations in medical centers is usually successful, even when extreme measures are required. Consequently, asthma deaths in children rarely occur in medical centers; most occur at home or in community settings before lifesaving medical care can be administered. This point highlights the importance of home and community management of asthma exacerbations, early intervention measures to keep exacerbations from becoming severe, and steps to reduce asthma severity. A follow- up appointment within 1- 2 weeks of a child\u2019s discharge from the hospital after resolution of an asthma exacerbation should be used to monitor clinical improvement and to reinforce key educational elements, including action plans and controller medications. ## **Special Management Circumstances** ## Management of Infants and Young Children"
  },
  {
   "source": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition, p. 1174",
   "text": "## **B. Acute Asthma** **1. General measures\u2014** The most effective strategy in managing asthma exacerbations involves early recognition of warning signs and early treatment. For patients with moderate or severe persistent asthma or a history of severe exacerbations, this should include a written action plan. The latter usually defines the patient\u2019s green, yellow, and red zones based on symptoms (and PEFR for patients with poor symptom perception) with corresponding measures to take according to the state the patient is in. PEFR cut-off values are conventionally set as > 80% (green), 50%\u201380% (yellow), and < 50% (red) of the child\u2019s personal best. Prompt communication with the clinician is indicated with severe symptoms or a drop in peak flow or with decreased response to SABAs. At such times, intensification of therapy may include a short course of oral corticosteroids. The child should be removed from exposure to any irritants or allergens that could be contributing to the exacerbation."
  },
  {
   "source": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition, p. 1157",
   "text": "- \u00bb Due to the heterogeneity of asthma pathogenesis and still inadequate control found in some children with asthma-causing emergent health care utilization and school absences on regular controller therapy, add-on medications modulating specific immune responses can be helpful. ## **ASTHMA** ## ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES - \u00bb The diagnosis of asthma is based on recurrent episodes of cough, wheezing, dyspnea, or chest tightness, with various triggers, most commonly respiratory infections, exercise, aeroallergens, cold air, and irritants. At least 80% of children with asthma have an allergic predisposition. - \u00bb Chronic airway inflammation, variable expiratory airflow limitation, and bronchial reactivity characterize the disease, but presentation is heterogeneous, and course over time,"
  },
  {
   "source": "Pediatric Board Study Guide, p. 723",
   "text": "- Asthma symptoms are more common in boys before puberty, but more severe in girls after puberty - Viral respiratory infections (such as RSV and rhinovirus) have been associated with future development of asthma and are the most common trigger of exacerbations in young children - All that wheezes is not asthma! Think about the differential if the diagnosis is not clear - If cough is the only symptom or chronic sputum production is reported, broaden your differential - ICS is the most potent and effective medication for long- term control of asthma - ICS-formoterol maintenance and reliever therapy preferred in most adolescents - EIA: In 80% patients, SABA before exercise prevents symptoms for about 2\u20133 h - Acute asthma exacerbation: SpO2 <92% after an hour of therapy is a good predictor for hospitalization needs ## **Pneumonia** - _Streptococcus pneumoniae_ is the most common bacterial cause in children older than 1 week of age - Viruses account for 14\u201335% of cases"
  }
 ]
}