A CU TE S EV ER E

A STHMA

P R E S E N T E R - D R P R AV E E N K U M A R
M O D E R AT O R - D R N U C K S H E E B A A Z I Z B H AT T
ASTHMA:-
• Asthma is a chronic inflammatory condition of lung airways resulting in episodic
airflow obstruction.
• This chronic inflammation heightens the twitchiness of the airways—airways
hyperresponsiveness (AHR)— to common provocative exposures.
• Asthma management is aimed at reducing airways inflammation by minimizing
proinflammatory environmental exposures, using daily controller anti
inflammatory medications, and controlling comorbid conditions that can worsen
asthma.
• Less inflammation typically leads to better asthma control, with fewer
exacerbations and decreased need for quick-reliever asthma medications.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

 ETIOLOGY AND
PATHOGENESIS:-
• Although the cause of childhood asthma has not been determined, a combination
of environmental exposures and inherent biologic and genetic susceptibilities has
been implicated.
• In the susceptible host, immune responses to common airways exposures (e.g.,
respiratory viruses, allergens, tobacco smoke, air pollutants) can stimulate
prolonged, pathogenic inflammation and aberrant repair of injured airways
tissues.
• Lung dysfunction (AHR, reduced airflow) and airway remodeling develop.
• These pathogenic processes in the growing lung during early life adversely affect
airways growth and differentiation, leading to altered airways at mature ages.
NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
• Once asthma has developed, ongoing inflammatory exposures appear to worsen
it, driving disease persistence and increasing the risk of severe exacerbations.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

 EARLY CHILDHOOD RISK FACTOR
FOR PERSISTENT ASTHMA:-

• Parental asthma
Allergy:
• Atopic dermatitis (eczema)
• Allergic rhinitis
• Food allergy
• Inhalant allergen sensitization
• Food allergen sensitization
Severe lower respiratory tract infection:
• Pneumonia
• Bronchiolitis requiring hospitalization
NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
• Wheezing apart from colds
• Male gender
• Low birthweight
• Environmental tobacco smoke exposure
• Reduced lung function at birth
• Formula feeding rather than breastfeeding

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

 ASTHMA TRIGGERS:-
• COMMON VIRAL INFECTIONS OF RESPIRATORY TRACT
• AEROALLERGENS IN SENSITIZED ASTHMATIC PATIENTS
Indoor Allergens
• Animal dander
• Dust mites
• Cockroaches
• Molds
Seasonal Aeroallergens
• Pollens (trees, grasses, weeds)
• Seasonal molds
AIR POLLUTANTS
• Environmental tobacco smoke
• Nitrogen dioxide
• Sulphur dioxide
STRONG OR NOXIOUS ODORS OR FUMES
• Perfumes, hairsprays
OCCUPATIONAL EXPOSURES
• Farm and barn exposure
COLD DRY AIR EXERCISECRYING, LAUGHTER, HYPERVENTILATION COMORBID
CONDITIONS
• Rhinitis
• Sinusitis
DRUGS
• Aspirin and other nonsteroidal anti inflammatory drugs

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

 CLINICAL MANIFESTATION &
DIAGNOSIS:-
• Intermittent dry coughing and expiratory wheezing.
• Older children and adults report associated shortness of breath and chest
congestion and tightness.
• Younger children are more likely to report intermittent, non focal chest pain.
• Respiratory symptoms can be worse at night, associated with sleep, especially
during prolonged exacerbations triggered by respiratory infections or inhalant
allergens.
• Daytime symptoms, often linked with physical activities (exercise-induced) or
play, are reported with greatest frequency in children.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

• Expiratory wheezing and a prolonged exhalation phase can usually be
appreciated by auscultation.
• Rhonchi and crackles (or rales ) can sometimes be heard, resulting from excess
mucus production and inflammatory exudate in the airways.
• In severe exacerbations the greater extent of airways obstruction causes labored
breathing and respiratory distress, which manifests as inspiratory and expiratory
wheezing, increased prolongation of exhalation, poor air entry, suprasternal and
intercostal retractions, nasal flaring, and accessory respiratory muscle use.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

EVALUATION OF ASTHMA SEVERITY:-

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
 ASTHMA EXACERBATIONS
AND THEIR MANAGEMENT:-
• Asthma exacerbations are acute or subacute episodes of progressively worsening
symptoms and airflow obstruction.
• Airflow obstruction during exacerbations can become extensive, resulting in life-
threatening respiratory insufficiency. Often, asthma exacerbations worsen during
sleep (between midnight and 8 AM ), when airways inflammation and
hyperresponsiveness are at their peak.
• Importantly, SABAs, which are first-line therapy for asthma symptoms and
exacerbations, increase pulmonary blood flow through obstructed, unoxygenated
areas of the lungs with increasing dosage and frequency.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

• When airways obstruction is not resolved with SABA use, ventilation/perfusion
mismatching can cause hypoxemia, which can perpetuate bronchoconstriction
and further worsen the condition.
• Complications that can occur during severe exacerbations include atelectasis
(common) and air leaks in the chest (pneumomediastinum, pneumothorax; rare).

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

 MANAGEMENT OF ASTHMA
EXACERBATION (STATUS
ASTHMATICUS):-
• Focused history:-
1. Onset of current exacerbation
2. Frequency and severity of daytime and night time symptoms and activity
limitation
3. Frequency of rescue bronchodilator use
4. Current medications and allergies
5. Potential triggers
6. History of systemic steroid courses, emergency department visits,
hospitalization, intubation, or life-threatening episodes
NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
• Clinical assessment:-
1. Physical examination findings: vital signs, breathlessness, air movement, use
of accessory muscles, retractions, anxiety level, alteration in mental status
2. Pulse oximetry
3. Lung function (defer in patients with moderate to severe distress or history of
labile )
• Risk factors for asthma morbidity and death:-
Biologic
1. Previous severe asthma exacerbation (intensive care unit admission, intubation
for asthma)
2. Sudden asphyxia episodes (respiratory failure, arrest)

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

Environmental
1. Allergen exposure
2. Environmental tobacco smoke exposure
3. Air pollution exposure
Economic and Psychosocial
1. Poverty
2. Crowding
3. Mother <20 yr old
4. Inaccessible
5. Unaffordable
6. No regular medical care (only emergency)

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

TREATMENT:-

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
 OTHER MEDCATIONS:-
• Magnesium sulfate (25-75 mg/kg, maximum dose 2.5 g, given intravenously over
20 min). Administration of magnesium sulfate requires monitoring of serum levels
and cardiovascular status.
• Inhaled heliox (helium and oxygen mixture).
• Parenteral (SC, IM, or IV) epinephrine or terbutaline sulfate may be effective
in patients with life threatening obstruction that is not responding to high doses of
inhaled β- agonists, because inhaled medication may not reach the lower airway in
such patients.
• Mechanical ventilation in severe asthma exacerbations requires the careful
balance of enough pressure to overcome airways obstruction while reducing
hyperinflation, air trapping, and the likelihood of barotrauma (pneumothorax,
pneumomediastinum).
NELSON TEXTBOOK OF PEDIATRICS 21st EDITION
• Mechanical ventilation aims to achieve adequate oxygenation while tolerating
mild to moderate hypercapnia (PCO 2 50-70 mm Hg) to minimize barotrauma.
• Volume-cycled ventilators, using short inspiratory and long expiratory times, 10-
15 mL/kg tidal volume, 8-15 breaths/min, peak pressures <60 cm H2 O, and
without positive end-expiratory pressure are starting mechanical ventilation
parameters that can achieve these goals.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

 RISK ASSESSMENT FOR
DISCHARGE:-
• Discharge home if there has been sustained improvement in symptoms and
bronchodilator treatments are at least 3 hr apart, physical findings are normal,
PEF >70% of predicted or personal best, and oxygen saturation >92% when
breathing room air.

NELSON TEXTBOOK OF PEDIATRICS 21st EDITION

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