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Status asthmaticus is a life-threatening condition of progressively-worsening bronchospasm and respiratory dysfunction due to asthma that is unresponsive to conventional therapy. It typically progresses into respiratory failure or arrest and requires aggressive ventilatory and pharmacological interventions.
Once the EMS professional concludes that the most likely diagnosis is an asthma exacerbation, treatment centers around reversing bronchoconstriction and airway inflammation, correcting hypoxemia, rehydration and monitoring for complications – such as pneumothorax. The child with status asthmaticus presents with air hunger. Because of the profound bronchoconstriction and minimal airflow through the bronchioles, wheezing is either faint or completely absent. Oxygen saturation levels often reflect severe hypoxia, with readings well below 90%. As hypoxemia worsens, the workload on the ventricles of the heart increases, and the child becomes profoundly acidotic from associated hypercarbia. Pediatric asthma interventions and management Prior ED visits or hospitalizations for asthma (including intensive care unit admissions and/or intubations)For critically ill children, several other adjunctive therapies may be considered. Early administration of corticosteroids in addition to inhaled beta 2 agonists is recommended, typically at a dose of 2 mg/kg. Intravenous epinephrine rapidly relaxes bronchial smooth muscles and is dosed at 1.0 mL of 1:10,000 concentration, administered over one minute.
EMS professionals need to keep in mind that a child’s lower airway anatomy is proportionally smaller than an adult’s, and is easily compromised from a lesser degree of swelling and constriction. In response to one of the events mentioned earlier, a series of reactions occur in the lower airway. Dr Michael Marcus: So asthma is a condition where the body has an abnormal reaction to some substance. The reaction in asthma is focused in the lungs where three things occur. First, there’s an inflammatory response within the lungs, which leads to spasm of the airways, swelling of the airways and a buildup of mucus. The combination of those three things leads to narrowing of the airway, making it much more difficult to breathe. Secondly, mucous glands and cells that line the lower airway are stimulated to secrete excessive mucous, which plugs the bronchioles.
First-line treatment of an asthma patient with any degree of respiratory distress should be albuterol. It relaxes bronchial smooth muscle and enhances mucous clearance. Ideally, albuterol is administered as a nebulized solution (2.5 mg per dose for patients less than 10 kg, and 5 mg per dose for patients greater than 10 kg). Common side effects include tachycardia and tremors. Rarely, children may experience arrhythmias, such as supraventricular tachycardia. Dylla L, Acquisto NM, Manzo F, Cushman JT. Dexamethasone-Related Perineal Burning in the Prehospital Setting: A Case Series. Prehosp Emerg Care. 2018 Sep-Oct;22(5):655-658. Breathing isn’t something most people think about but, for some, it doesn’t come naturally. Knowing your child has asthma is the first step to dealing with it. Dr. Michael Marcus discusses what to look out for and what to do about it. EMS responds to a residence for a seven-year-old male with a cough and trouble breathing. This episode began two hours ago and has been accompanied by a runny nose without any other symptoms. His mother has been treating him with albuterol by a nebulizer, but he has progressively become more short of breath. Past medical history is notable for asthma since infancy, with multiple prior hospitalizations. First, the smooth muscle surrounding the bronchioles is stimulated by histamine and leukotriene, causing bronchoconstriction.
Dr Michael Marcus: It’s a common question that I get and weather conditions by themselves really don’t affect asthma other than cold, dry air being a significant trigger for wheezing in patients with asthma. The thing about weather conditions and the thing about moving to different climates is much more related to the things that grow. And so, if you’re in the northeast, you have a certain type of pollen from the grass and the trees and the weeds that are common. If you move to someplace like Arizona, which is more hot and dry, the foliage and pollen in that area is very different. And so, if you hadn’t been exposed to that yet, you won’t have allergies to those things yet. But if you continue in those environments for a long period of time, eventually you develop allergies to those things and eventually the asthma symptoms return. Finally, fluid shifts into the walls of the lower airway, resulting in inflammation and a decrease in airway diameter. The net result is a narrowing of the small airways with increased resistance to airflow. The key here is that if we use daily prevention therapy properly, then we decrease the risk that the asthma will become more severe with age and give children the best opportunity to have the healthiest life. If we delay using the prevention therapy and continue to treat asthma on an as needed basis, treating only the symptoms, then we miss the opportunity of preventing progressive damage and limiting the severity of asthma over time. Dr Michael Marcus: Only that children are a bit less cooperative sometimes. They’re not always able to take the inhaled medications with the right technique and they need that supervision and guidance. The flip side though is that since parents really do control children’s lives and we tend to care for our children better than we care for ourselves, children are more likely to use their medication properly once the parent understands the need for the medication. Nassif A, Ostermayer DG, Hoang KB, Claiborne MK, Camp EA, Shah MI. Implementation of a Prehospital Protocol Change For Asthmatic Children. Prehosp Emerg Care. 2018 Jul-Aug;22(4):457-465.
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Dr Michael Marcus: It’s interesting, but roaches and mice both produce a potent protein that can trigger the same type of inflammatory reaction that leads to the symptoms of asthma. And so early and high concentration of exposure to those things will give a child greater symptoms of their asthma conditions.
Joey Wahler (Host): Asthma is a condition that adversely affects breathing, so we’re discussing pediatric asthma and how it’s treated. This is Maimo Med Talk. Thanks for listening. I’m Joey Wahler. Joey Wahler (Host): Interesting. How about weather conditions, doctor? What impact might living in a warmer climate have on an asthmatic patient?
With inhaled medications, we have different types of devices that can assist the child to use the medication in the best fashion, which will allow the medicine to reach the lungs to the best effect. And so using these assistant devices is an important piece that we add to a child’s therapy where it’s not always necessary in an adult’s therapy. These pathophysiologic changes cause distal alveoli to trap air and become hyperinflated. As the amount of hyperinflated lung tissue expands, the child’s diaphragm is progressively flattened, causing a mechanical disruption of ventilation. Increased workload for ventilation is transferred onto smaller and weaker intercostal and suprasternal muscles, leading to rapid fatigue and onset of respiratory failure. Learn how to assess, monitor and manage pediatric asthma emergencies, as well as underlying pathophysiologic changes
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