Management of Acute

Exacerbation in Children

DR. RAGHVENDRA SINGH

SENIOR RESIDENT
K.S.C.H.
 INTRODUCTION
 Exacerbations of asthma are episodes of
progressive increase in shortness of breath,
cough, wheezing, or chest tightness, or some
combination of above symptoms.

 Respiratory Distress is a common sign.

 Very frequent cause of emergency visit and

often the first presentation of the disease
 INTRODUCTION

 Exacerbations characterized by decrease in

expiratory airflow, quantified by measurement of
lung function (PEF or FEV1)

 Degree of symptoms may be a more sensitive

measure of the onset of exacerbation, as the
increase in symptoms usually precedes the
deterioration in peak flow rate

 Severe exacerbations are potentially life

threatening, their treatment requires close
supervision.
 INTRODUCTION

AIM OF THE TREATMENT

 Relieve airflow obstruction

 Hypoxemia as quickly as possible

 Plan the prevention of future relapses

PRIMARY THERAPY FOR EXACERBATIONS

 Repetitive administration of rapid-acting
inhaled bronchodilator
 Early introduction of systemic glucocorticoids

 Oxygen supplementation.
 HIGH RISK ASTHMA

 History of near-fatal asthma

 Frequent emergency visit
 Recently stopped oral steroids
 Overdependence β2 agonists
 Psychosocial problems
 A history of noncompliance with an
asthma medication plan.
 Brittle asthma
 ASSESSMENT

History
 Severity and duration of symptoms, exercise
limitation and sleep disturbance
 Current medications, including dose
prescribed, doses taken and in response to
the deterioration, and the response (or lack
thereof) to this therapy.
 Time of onset and cause of the present
exacerbation.
 Risk factors for asthma-related death.
 ASSESSMENT

Physical examination
 Assess exacerbation severity- Ability to complete a sentence,
pulse rate, respiratory rate, use of accessory
muscles,Wheeze
 Functional assessments such as PEF or FEV1 and arterial
oxygen saturation measurements are recommended as
physical examination alone may not fully indicate the
severity of the exacerbation, particularly the degree of
hypoxemia
 Oxygen saturation <92% is a good predictor of the need for
hospitalization.
ASSESSMENT OF EPISODE
SEVERITY
RED FLAG SIGNS

 Altered sensorium (drowsy or very agitated)

 Bradycardia
 Poor pulse volume
 Cyanosis (with 60 % oxygen)
 Excessive use of accessory muscles or state of exhaustion
(vocalization limited to 1-2 words)
 Excessive diaphoresis
 Silent chest on auscultation
 ABG: rate of rise of pCO2>5mm Hg/hr, pCO2>40 mm Hg,
pO2<60 mm Hg, metabolic acidosis (-BE>7-10)
 SaO2 on room air < 92%
GRADING OF SEVERITY

PULMONARY RISK SCORE(IAP)

MILD EXACERBATION
HOME PLAN(PS 0-3)

β 2 agonist 2-4 puffs via spacer ± facemask q 20

min.

GOOD RESPONSE OR SUSTAINED RESPONSE

 Continue puffs of nebulised β2 agonist as needed, not
exceeding 4 hourly

SYMPTOMS ARE NOT CONTROLLED OR POOR RESPONSE

 Repeat β 2 agonist and refer to hospital

 Consider soluble prednisolone 1-2mg/kg

 Arrange follow-up clinic or emergency visit

MODERATE
EXACERBATION
EMERGENCY ROOM PLAN (PS 4-6)
 Continue O2 via face mask/nasal prongs

 Give nebulised β2 agonist salbutamol or

terbutaline with oxygen q 20min*3

 Give or continue steroids (iv hydrocortisone

if unable to except orally)

 Observe hourly for 3-4 hours

 β2 agonist nebulization hourly

 SEVERE EXACERBATION
INTENSIFIED PLAN(PS >6)
 Monitor vital signs, SaO , pulmonary score q 15-30
2
minutes.
 Start oxygen, IV fluids. May switch to IV steroid.

 CBC, X-Ray chest to identify complications.

 Consider blood gas studies if SaO < 92%. Observe over

2
1-2 hours
 Continue SA β agonist neb q1hour / continuous.
2
 Start iptratropium neb q 30 minutes x 3 (may mix or

alternate with SA β2 agonist neb ) and then q 6 hours.

SEVERE
EXACERBATION(cont.)

 Continuous monitoring
 Monitor serum potassium.
 SA β2 agonist neb q1 hour / continuous.
 Ipratropium neb q 2-4 hours.
 Bolus IV salbutamol 15 mcg/kg of 200 mcg/ml
solution over 10 minutes or subcutaneous
terbutaline 10mcg/kg(can be repeated thrice)
 Magnesium sulfate iv infusion over 30 mins.
 INTENSIVE CARE
MANAGEMENT
 Blood gas studies.
 Aminophylline continuous iv infusion.
 Terbutaline continuous iv
infusion.Discontinue nebulizations at higher
infusion rate of if signs of toxicity develop
 Ventillator on standby mode.
 Possible intubation and mechanical
ventilation with ketamine and midazolam /
fentanyl iv infusion
 Paralysis with vecuronium, if required.
 MECHANICAL
VENTILLATION
 Early stages FEV1 reduced > FVC
 Progression of process leads to dynamic
hyperinflation i.e. ↑ airway resistance leads to
↑air trapping and residual volume
Phenomenon of AutoPEEP .
 Benefit from strategies which ↑ expiratory
time, reducing end expiratory lung volume,
intrinsic PEEP and cardioresp. compromise
 MECHANICAL
VENTILLATION(cont…)
 Turbulence, noncompliant airways and
constriction-flow dependent increase in
inspiratory resistance
 Lowest minute ventillation that produces gas

exchange to minimise hyperinflation

Physiological tidal volume at low Freq.
 Permissive Hypercapnia - Gold Standard
DISCHARGE PLAN
 Continue inhaled Beta2 therapy
 Rescue steroids
 Initiation of maintanence therapy
 Removal of trigger,Precipitants
 Follow up visit 1-2 weeks
 Counselling for treatment compliance
&rechecking of technique
THANK YOU