A five year old male comes to the office with the chief complaint of cough and difficulty breathing. There is no fever or URI symptoms. There is no previous history of asthma. On physical exam he seems uncomfortable and the RR is 35. There are intercostal and subscostal retractions. There are diffuse wheezes in all lung fields and occasional rales. What is your initial approach to this patient?
The above scenario is not an uncommon one, and given the increased prevalence of asthma in large cities, it is important for the general pediatrician to know how to diagnose and treat it when it is encountered.
Asthma is characterized by inflammation of the airways. There is increased production of mucus, edema in the walls of the airways, increased debris in the airway lumen, and bronchospasm.
- Birth history- prematurity, respiratory difficulties, BPD.
- Family history of atopy-asthma, hayfever, and eczema
- Exercise intolerance? Usually related to anaerobic exercise
- Growth and weight gain
- Exposure to smoker and other pollutants. Any new pets?
- Any history of breathing difficulties or pneumonias?
- shortness of breath
- respiratory distress
- exercise intolerance
Common triggers for asthma
- viral infections
- inhalants and pollen
- smoke and other odors
- cold air
- weather changes
Initial therapy in the office
- Nebulized albuterol - bronchodilator with onset in 30 minutes that reverses bronchospasm and effect lasts about 4 hours. If the patients symptoms improve would continue albuterol at home by nebulizer or metered dose inhaler if child able to use.(may need spacer)
- Steroids - For asthma flares not responding to albuterol, a 3-5 day course of oral steroids 1-2mg/kg per day should be started and may be given in one or two doses. There are two liquid preparations, Pediapred 5mg/5ml (tastes OK) and Prelone 15mg./ml(tastes bad). No need to taper the steroids if give for 5 total days.
- Recheck the patient in 1-2 days and talk to the family the following day. Give instructions to call if the patient has developed respiratory difficulties again.
- For first time presentation of asthma, consider obtaining a chest x-ray (2 views) to rule out another etiology for the symptom presentation (i.e., mediastinal mass, etc)
Patient education is key in order to identify triggers, ensure medication compliance and correct inhaler technique. Things that should be discussed includes:
- Environmental issues - can consider obtaining allergy testing
- avoid smoke products, perfumes, scented hair spray, and fresh paint
- keep dust exposure to a minimum- remove carpeting from the bedrooms and vacuum other rooms frequently.
- pillow should be synthetic and have a good dust proof mattress cover
- to decrease mold and mites, keep house humidity under 50%
- Make sure that the patient is using drugs properly and knows how to use spacer device. You tube has great videos on this.
- Emphasize the importance of compliance
- Beta 2 agonists should not be used prophylactically. They are useful for acute exacerbation of asthma and prior to exercise in exercise induced asthma. If they are being used regularly more than twice a week, that indicates poor control and the patient should come to be seen.
- Discuss use of a peak flow meter when developmentally appropriate.
- Stress that point that the medications used to treat asthma are potent and if used improperly can cause serious side effects.
Asthma Action Plan
An individualized, written action plan has been proven beneficial in the management of asthma patients. The asthma action plan serves as a guide for patients to determine when to increase treatment, how to increase treatment, for how long and when to seek medical attention. The plan can be based on symptoms or peak expiratory flows, and can range from 2-4 action points.
It is important to spend time with the family during the initial visits and discuss and explain the natural course of asthma and dismiss any "myths". Express to the parents that most children live a normal live and may participate in normal childhood activities and sports and that most children do outgrow asthma.
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