2018-19 TOW #19: Acute Asthma

It’s the time of year when our clinics and the ED are starting to see more kids with viral-induced asthma exacerbations, so it’s an opportune time to review the guidelines and resources to address these. The REACH pathway residents have provided some helpful materials, 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:

Take-home points for acute asthma management:

  1. 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.
  2. 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.
  3. 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.
  4. 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. Families in Seattle/King Co are eligible to receive a free home health assessments through the American Lung Association. Most families do not know about this great program, so referral is key.
  5. 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 important. The Washington Medical-Legal Partnership (MLP) has great sample letter templates we can use to help families notify landlords of needed repairs, such as improving ventilation, removing mold or insects. If you need additional assistance, remember to refer patients via the Washington MLP at Seattle Children’s Hospital (patients are eligible if they are patients at SCH).

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