Emergency Department Management of Pediatric Acute Asthma: An Evidence-Based Review (Pharmacology CME)

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Delivery Method:	Online
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Publication Date: July 2023 (Volume 20, Number 7)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 07/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credit, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Asthma is the most common chronic disease of childhood. Although home action plans and the use of maintenance medications have improved daily management and control of asthma, many children still require emergency department care at least once per year. Emergency clinicians must be able to manage patients with acute asthma exacerbations and determine their safe disposition. This issue reviews the current evidence-based emergency department management recommendations for moderate to severe acute asthma in pediatric patients. Timely use of bronchodilators and systemic corticosteroids, as well as adjunct modalities, are discussed. Current challenges in asthma management related to vaping and COVID-19 are also addressed.

Case Presentations

A 3-year-old girl presents to the ED with cough, rhinorrhea, and increased work of breathing…

• The child’s parents report she has had mild upper respiratory infection symptoms for the past 3 days that worsened overnight. The girl has a home nebulizer with albuterol for “wheezing” episodes, but she has not been formally diagnosed with asthma. Her breathing initially improved with 2 treatments overnight, but now her parents say she seems worse. They report no vomiting, and the girl is tolerating oral intake. The girl’s past medical history is significant for intermittent eczema and hospitalization for RSV bronchiolitis at 9 months of age. The girl was born at full term without complications. She currently attends day care. Her father smokes but “not in the house.”
• On examination, the child is fussy but consolable and alert. She is febrile to 38°C, tachypneic to the 40s, with subcostal retractions and expiratory wheezes throughout all lung fields, with fair air movement. The girl’s oxygen saturation is 94% on room air.
• Do you believe this girl likely has asthma? If so, what are her risk factors? What is your approach to this child’s management? If she responds to treatment, what criteria would you use for potential discharge?

An 8-year-old girl with a history of obesity and intermittent asthma presents with fever, cough, and difficulty breathing...

• The girl’s father reports she required multiple puffs from her albuterol metered-dose inhaler overnight. Her symptoms improved initially, but this morning she is short of breath and can speak only in shortened sentences. Her history is significant for several prior asthma hospitalizations but no ICU admissions. She currently uses albuterol only as needed. Her primary care physician had prescribed an inhaled corticosteroid for daily use 4 months ago, but her father said the prescription “ran out” and was not refilled. Her older sister was diagnosed with COVID-19 2 days ago.
• On examination, the girl is febrile to 38.5°C and appears tachypneic, with subcostal and intercostal retractions. You hear inspiratory and expiratory wheezing, with fair air entry throughout all lung fields. Her oxygen saturation is 90% on room air.
• What first-line treatments should be initiated immediately? If the girl does not respond to initial therapy, what further treatments should you consider in her management? With potential COVID-19 as a concern, what are the possible considerations for the administration of her medications? Does she require any diagnostic studies?

A 15-year-old boy with a history of persistent asthma presents via EMS in severe respiratory distress …

• EMS reports the teen had several nebulized albuterol treatments at home over the past 12 hours and 2 combined albuterol-ipratropium nebulizers en route to the ED. His mother states he “ran out” of inhaled corticosteroids a month ago. He has been hospitalized for asthma “many times,” including twice to the PICU in the past year, but he has never been intubated. The mother tells you this time he is “really bad.” She says he used to vape, but stopped 6 months ago.
• On examination, the boy is leaning forward on the EMS stretcher as the oxygenated combined nebulization finishes. He has significant tachypnea; nasal flaring; and subcostal, intercostal, and suprasternal retractions. His lips appear bluish, and he has difficulty speaking. You hear faint expiratory wheezing in all lung fields with poor air movement. His oxygen saturation is 85%.
• What is your initial approach to this adolescent’s management? If he fails to improve rapidly, what will your next steps be in attempting to stabilize his acute respiratory distress?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.