It's the time of year when our clinics and the ED are starting to see more kids with acute asthma exacerbations, so it's an opportune time to review the guidelines and resources to address these. The REACH pathway residents provided super helpful updates to this topic this week for morning report, which I have included below. Locally we also have the wisdom of the great Dr. Jim Stout, faculty at Odessa Brown, who has been a national leader in asthma quality of care research. This week's teaching materials:
- Case and discussion
- Asthma guidelines for our outpatient clinics – (Note – there are multiple additional outpatient guidelines here that complement the inpatient pathways so check them out!)
- Acute asthma flow chart
- American Lung Association: 1-800-lungUSA – provide Seattle home assessments
- Clear Air for Kids: (253) 798-4826 | (253) 798-4700 (to fax referrals) – Home assessments in Tacoma/Pierce County
- King County Housing Authority: (206) 214-1240 | Weatherization/ventilation
- King County Asthma Program: Education/green cleaning recipe
Take-home points for acute asthma management:
- Epidemiology: the CDC estimates that 8.3% of children have asthma, making it one of the most prevalent diseases of childhood. Rates are higher among blacks, certain Hispanic groups, and those in poverty. Among those with asthma below age 18, 57.9% report having one or more asthma attacks, so the majority of kids with asthma will be treated for exacerbations.
- Severity guides treatment: Determining severity is based on many components including level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating respiratory scores used at Seattle Children’s Hospital (SCH), such as in the SCH asthma pathway.
- Initial treatment: For moderately severe symptoms, give albuterol MDI 8 puffs (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), start dexamethasone (0.6mg/kg, max of 16mg), and repeat in 24 hours. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity and history.
- Education is critical: as we know, education about asthma is so important to families' understanding and implementation of treatment. It's important to review and update asthma action plans during exacerbations. Families should receive coaching and should be able to demonstrate use of MDIs with a valved holding chamber (VHCs or “aerochamber”). There are great written resources and videos out there on avoiding triggers through the NW Clear Air Agency.
- Provide follow-up: it's important to have follow-up within a few days (in person for more moderate cases, or maybe by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also critical. Refer to these great resources for home health assessments through the American Lung Association.