Episode 79 – Management of Acute Pediatric Asthma Exacerbations

In this EM Cases episode on Pediatric Asthma we discuss risk stratification (including the PASS and PRAM scores), indications for CXR, the value of blood gases, MDIs with spacer vs nebulizers for salbutamol and ipatropium bromide, the best way to give corticosteroids, the value of inhaled steroids, the importance of early administration of magnesium sulphate in the sickest kids, and the controversies around the use of ketamine, heliox, high flow nasal cannuala oxygen, NIPPV, epinephrine and IV salbutamol in severe asthma exacerbations. So, with the multinational and extensive experience of Dr. Dennis Scolnik, the clinical fellowship Program Director at The Hospital for Sick Children in Toronto and Dr. Sanjay Mehta, multiple award winning educator who you might remember from his fantastic work on our Pediatric Orthopedics episode, we'll help you become more comfortable the next time you are faced with a child with asthma who is crashing in your ED...



Written Summary and blog post written by Anton Helman, April 2016

Cite this podcast as: Scolnik, D, Mehta, S, Helman, A. Management of Acute Pediatric Asthma Exacerbations. Emergency Medicine Cases. April, 2016. https://emergencymedicinecases.com/pediatric-asthma/. Accessed [date].

Pediatric Asthma Severity Indicators on History



* life-threatening exacerbations

* admissions to ICU

* intubation

* deterioration while already on systemic steroids

* using more than 2 canisters of short acting B-agonist per month

* cardiopulmonary and psychiatric comorbidities



Its important to realize that a lack of risk factors does not necessarily confer a lack of risk, so even if a patient has none of these risk factors, they can still be at risk for deterioration from their asthma.



Reliable Validated Measures of Pediatric Asthma Severity



PASS Score for Pediatric Asthma Severity





VBG in Pediatric Asthma

A PaCO2 >42 is indicative but not diagnostic of a severe exacerbation

A PaCO2 >50 is a risk factor for impending respiratory failure

Metabolic Acidosis is an indicator of impending arrest!

A VBG is seldom indicated unless the child has no clinical improvement with maximal  therapy. The timing of the VBG is important: It may be most useful as a baseline after ED treatment in a patient going to the ICU.

Don't forget the classic teaching: A 'normal' Hg partial pressure of CO2 in a patient with extreme tachypnea and retractions could indicate impaired ventilation and impending respiratory failure.

Indications for CXR in presumed Pediatric Asthma

The rate of CXR use in kids with asthma increased significantly from the mid 90’s to around 2010. Although it’s not unreasonable for first time wheezers to get a baseline CXR, it’s important to realize that an unsuspected diagnosis made on the basis of a CXR in an acutely wheezing child is rare, even if the child has never wheezed before.

In fact there are no set of predictors in the literature that can accurately identify children likely to have abnormalities on CXR.

Nonetheless, some situations that might warrant a CXR in a child with a wheeze, are focal chest findings, fever, subcutaneous emphysema or a history of choking.

MDI vs Nebs vs IV B-agonists in Pediatric Asthma



Compared with nebulized treatments, metered-dose inhaler (MDI) with a spacer use has been shown to be equally effective for children of all ages with a wide range of ill...