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This is a 5 year-old boy who came to the ED for an asthma exacerbation in the setting of 3 days of rhinorrhea and sore throat. He has been taking his albuterol with minimal improvement. He has had at least 2 exacerbations in the past month and is only on albuterol. His exam is notable for boggy nasal turbinates and erythematous oropharynx.
How would you classify this child’s asthma?
Asthma treatment in the ED is focused on the acute exacerbation and chronic control. Our patient is having 2 exacerbations per month. This places him in the mild, intermittent category. These patients benefit most from lifestyle modification and rescue inhaler as needed. Click here to see the latest guidelines on classifying asthma and initiating therapy.
There are a few pediatric clinical assessment scores for asthma.
- The Pediatric Respiratory Assessment Measure (PRAM). The PRAM uses 5 variables, (wheezing, air entry, contraction of scalenes, suprasternal retraction, and oxygen saturation) to help determine whether or not a person should be admitted.
- The Pulmonary Index Score (PIS) is an asthma score that is also based on 5 clinical variables (respiratory rate, degree of wheezing, inspiratory to expiratory ratio, accessory muscle use, and oxygen saturation).
- The Pediatric Asthma Severity Score (PASS) consists of three variables (wheezing, prolonged expiration, and work of breathing).
|Air Entry||Degree of wheezing||Prolonged Expiration|
|Contraction of scalene||I:E ratio||Work of breathing|
|Suprasternal retraction||Accessory Muscle Use|
|Oxygen Saturation||Oxygen Saturation|
It is important to note that all risk assessment scores need to have construct validity and reliability. That is, one must check if they measure what they intend to measure and if they are reproducible. Many suggest that asthma severity scores lack validity because there is no gold standard for severe asthma. Additionally, these scores have been criticized for their reliability, as asthma affects many age groups and can manifest differently for each age. Therefore, you should know they exist, but use them cautiously.
Asthma exacerbations have classically been treated acutely with short-acting beta agonist and PO steroids. But these steroid treatments provided short-lived results. Within a short time, the child often has another exacerbation.
The role of systemic steroids has often been challenged because of its potential side effects of immunosuppression, weight gain, and adrenal suppression. Because inhaled corticosteroids (ICS) lack systemic absorption, attempts have been made to replace systemic steroids for acute exacerbation but have failed to show benefits. What these studies neglected was that those with asthma have a chronic underlying process and many require maintenance medications or controllers. In a recent randomized, controlled trial, Sampayo et al. investigated whether or not prescribing a one-month supply of an inhaled corticosteroid would affect symptoms after discharge and follow-up rates with a primary care physician. They found that at 2 weeks, those with ICS had fewer daytime shortness of breath, night-time cough, and required less albuterol but found no significant difference in these outcomes at 8 weeks follow-up. They also found that there was no difference in follow-up with PMD. Now, this study had many limitations. Only 50% of patients actually filled their ICS after discharge or after follow-up with a PMD. There was also no difference in the number of patients in the control group who were either started on ICS by their PMD or maintained on ICS by their PMD after follow-up. Because it was only recommended that patients follow up with their PMD and we don’t know when this “follow-up” actually occurred – presumably at some point both groups received the same rates of ICS making the data hard to interpret. If the point when rates of prescribed ICS became similar was after 2 weeks, that could explain why there was an early benefit (in the first 2 weeks) but not at 8 weeks. Regardless of its limitations, this study attempts to address an interesting future for asthma care in the ED but is clearly not the answer. More research is needed on this topic.
Other interventions should be targeted around asthma triggers. These include reduction in tobacco smoke, dust mites, air pollution, and cockroach allergens. However, in addition to allergic triggers, other overlapping medical conditions should be considered as well.
It is estimated that up to 40% of people with allergic rhinitis have asthma. The exact mechanism is unclear but common hypothesis include include nasal-bronchial reflex, mouth breathing caused by nasal obstruction, and pulmonary aspiration of nasal contents. Some have proposed that given their IgE similarity, that they are really the same disease with different clinical manifestations. Few studies clearly define a benefit with asthma when treating allergic rhinitis; however, though not always significant, most studies have shown some type benefit. Because only 2% of topical nasal corticosteroids are deposited in the lower airways, they have a limited role in acute asthma exacerbation. The Allergic Rhinitis and its Impact on Asthma guidelines (ARIA) recommend treating asthma exacerbations with topical inhaled glucocorticoids and oral non-sedating antihistamines if they were triggered by allergic rhinitis. Some recommend oral decongestants as well although the evidence is limited. Though the data as a while are limited on this subject, the risks from the topical corticosteroids and antihistamines are minimal. Early intervention with these relatively safe medications might be warranted from the ED to help prevent the recurrent acute asthma exacerbation waiting around the corner.
 Sawicki, G. Haver, K. Acute asthma exacerbations in children: Home/office management and severity assessment. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2017.
 Eggink H, Brand P, Reimink R, Bekhof J (2016) Clinical Scores for Dyspnoea Severity in Children: A Prospective Validation Study. PLoS ONE 11(7): e0157724. doi:10.1371/journal.pone.0157724
 Edmonds ML, Milan SJ, Brenner BE, Camargo Jr CA, Rowe BH. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD002316. DOI: 10.1002/14651858.CD002316.pub2.
 Esther M. Sampayo, Maryann Mazer-Amirshahi, Elizabeth A. Camp, Joseph J. Zorc, Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial, Annals of Emergency Medicine, Available online 2 March 2017, ISSN 0196-0644, http://dx.doi.org/10.1016/j.annemergmed.2017.01.005.
 Taramarcaz P, Gibson PG. Intranasal corticosteroids for asthma control in people with coexisting asthma and rhinitis. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003570. DOI: 10.1002/14651858.CD003570.
 Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, van Wijk RG, Ohta K, Zuberbier T, Schünemann HJ, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010 Sep;126(3):466-76.
 Wheatley LM, Togias A. Allergic Rhinitis. The New England Journal of Medicine 2015;372:456–63.