ACUTE ASTHMA ATTACK IN CHILDREN
Emergency Medical Service Jagodina
INTRODUCTION. Asthma is a chronic inflammatory disease of the respiratory tract. In young children and infants the symptoms are caused by mechanical obstruction of the bronchial lumen with secretions and/or mucosal edema. Infant asthma can be defined as the presence of typical symptoms (wheezing, difficulty breathing, tachypnea) in the absence of other conditions that can lead to obstruction. Asthma in children is more related to heredity and the presence of allergies. An acute asthma attack is an episode of progressive worsening of choking, coughing, and/or wheezing.
AIM of this paper is to gain insight into the basic principles of asthma attack therapy in children. The target group is all the profiles of medical workers who come into direct contact with children with asthma.
METHODOLOGY. Guidelines from the GINA (Global Initiative for Asthma), the Guide to Good Clinical Practice, as well as guidelines from the available literature.
RESULTS show that it is best to use a step-
CONCLUSION. In the approach of a child with an acute attack, we rely on a precise anamnesis, clinical status and objective measurement of lung function (SatO2 and PEF) to assess the severity of the attack. The most useful parameters in monitoring are the clinical appearance of the child and gas analysis. The goal of therapy is to stop the attack and finally educate the child and parents about the adequate response in case of further deterioration.
Key words: acute asthma attack, children, neonates
Asthma is a chronic inflammatory disease of the respiratory tract. In atopics, this inflammation is the cause of repeated episodes of wheezing, choking and coughing, during the day and at night and after physical fatigue. All these symptoms are a consequence of the increased response of the airways to various stimuli. As a result, diffuse airway obstruction occurs, which is of varying degrees and is lost either spontaneously or under the influence of bronchodilators and/or steroids. [1,2]
This definition is acceptable in adults and older children but is not appropriate for infants and young children. Among them, the inflammatory process is sometimes minimal or completely absent, and the symptoms are caused by mechanical obstruction of the bronchial lumen with secretions and/or mucosal edema. The response to bronchodilators (reversibility of obstruction) may be only partial or completely absent. Therefore, infant asthma (so-
Figure 1. Pathology of asthma (Adapted and taken from Asthma NCLEX review. Photo credit: Alila Medical media).
A child's lungs and their immune system are developing and this is the main reason that separates adult asthma from children's asthma. Asthma in children is more related to heredity and the presence of allergies. The higher the allergic predisposition, the earlier the disease will manifest itself and the more severe the course. Thus, 80% of children with asthma have the onset of symptoms in the first five years of life. Asthma in children comes in several forms. The most difficult is the so-
The second group of asthmatics in childhood are those in whom the disease occurs after the third year of life, who have allergies (but not as pronounced as the first group) and whose disease has a variable course. Most of them belong to relatively mild forms, which gradually subside, and in about half, the disease completely disappears at puberty. This group has significantly less pronounced inflammation in the bronchial wall, and the degree of activation of Th2 cells is significantly lower. [1,2]
The third group are children who have repeated episodes of wheezing, without allergic sensitization. This type of asthma is often called infectious asthma, due to the importance of viral infections in the development of obstructions. Since virus infections are occasional, and susceptibility to them decreases with age, these children markedly improve towards puberty (especially obstructions become thinner after the age of six). Most people completely lose their asthma symptoms after puberty. [1-
The fourth group are children with true non-
PATHOPHYSIOLOGY OF ACUTE ATTACK
An acute asthma attack is an episode of progressive worsening of choking, coughing, and/or wheezing. Depending on the mechanism of occurrence and severity of asthma (mucus secretion, mucosal edema at one end of the spectrum -
Several factors contribute to the obstruction of breathing that is characteristic of asthma. A mild asthma attack is characterized by mild bronchoconstriction and a less inflammatory reaction. With increasing severity of the attack, mucosal edema occurs, followed by submucosal edema with enlarged capillaries and hypertrophic glands. The inflammatory process is accompanied by the presence of eosinophils and later neutrophils in the walls of the airways with hypersecretion of mucus. This process leads to obstruction of the distal parts of the airways, primarily the bronchioles. Such lungs are in hyperinflation with air and cannot collapse. With increasing obstruction, bronchoconstriction also increases and leads to danger to the patient's life due to complete obstruction of breathing. [1,2] Physiologically, as a consequence of significant obstruction, ventilation increases, as well as a significant difference between ventilation and perfusion, which leads to hypoxemia followed eventually by both respiratory and metabolic acidosis. Hypoxemia seen in asthmatics is a consequence of obstruction of the small airways. As this process progresses, the patient becomes tired, and pCO2, which was initially reduced due to hyperventilation, now begins to grow. Hypocapnia and mild respiratory alkalosis can even be expected at the beginning. Normal levels of pCO2 in asthmatics are a sign of initial respiratory insufficiency and a clear indication for hospitalization and more aggressive therapy. [1-
The aim of this paper is to gain insight into the basic principles of asthma attack therapy in children, as well as to acquaint the general medical public with it. The target group is all the profiles of medical workers who come into direct contact with children with asthma, who should be educated for the right help for such children.
Guidelines from the GINA (Global Initiative for Asthma), the Guide to Good Clinical Practice, as well as guidelines from the available literature dealing with the problem of asthma attacks were used.
The results show that it is best to use a step-
History (occurrence of prodromal symptoms, existence of signs of viral infection of the upper respiratory tract before the attack, applied therapy and response to that therapy, when was the last deterioration, severity of previous attacks and their treatment, previous hospitalizations, current preventive therapy and its dosage). [1,2,6,7]
Clinical examination (dyspnoea, speech, behavior, signs, respiratory rate, use of auxiliary respiratory muscles, whistling, pulse rate). [1,2,8]
The following symptoms should be considered in particular in the clinical examination:
• Prolonged expiration
• Impaired breathing
• Early Inspiration cracks
• Respiratory frequency (Table 1.)
• Heart rate (Table 2.)
Respiratory rate -
Age Normal rate
< 2 months < 60/min
Table 1. Respiratory rate in chilndren
Age Normal rate
Table 2. Heart rate in children
Tests (oxygen saturation with hemoglobin, monitoring of PEFR and / or spirometry, acid-
The following conditions should be considered in the differential diagnosis:
• Acute bronchitis
• Airway obstruction by a foreign body
• Pulmonary edema
Taking into account all the data, the severity of the asthma attack is estimated according to certain parameters listed in the table 3. The patient being admitted due to an acute asthma attack or status is most often dyspnoeic, dysphasic, cyanotic, in acid-
The most useful parameters in monitoring patients with acute severe seizures are the clinical appearance of the child and monitoring of gas analyzes. Unnecessary analyzes are spirometry or PEFR, chest X-
Figure 2. Chest X-
The goal of treating an acute attack is as follows:
• Suppression of obstruction
• Suppression of inflammation
• Correction of hypoxemia
• Correction of lung function
• Relapse prevention
If there is a possibility of starting therapy at home, it should be started with short-
If the child is not for hospitalization, it is necessary to take the initial administration of salbutamol -
They are not helpful in an acute asthma attack and should not be given: [2,7-
• Antibiotics (unless there is verified pneumonia)
• Adrenaline parenterally or by inhalation
(high risk of heart attack or heart rhythm disorders)
• Sedatives (strictly prohibited)
•Antihistamines (although not strictly contraindicated, not particularly useful)
In the approach of a child with an acute attack, we rely on a precise anamnesis, clinical status and objective measurement of lung function (SatO2 and PEF) to assess the severity of the attack. The most useful parameters in monitoring are the clinical appearance of the
child and gas analysis. In hospital conditions, in case of failure of drug therapy, endotracheal intubation, assisted ventilation, and even introduction to general anesthesia are used. The goal of therapy is to stop the attack and finally educate the child and parents about the
adequate response in case of further deterioration.
1. Nacionalni vodič kliničke prakse za dijagnostikovanje, lečenje i praćenje astme u dečjem uzrastu, Septembar 2002
3. Ronit Herzog MD and Susanna Cuningham-
4. Peter K. Franklin, MD, Review of acute severe asthma. West J Med 1989 May; 150:552-
5. David M. Maxwell, Emergency Treatment of Acute Asthma (Can Fam Physician 1986; 32:789-
6. Engelkes M, Janssens HM, de Ridder MAJ, de Jongste JC, Sturkenboom MCJM, Verhamme KMC. Time trends in the incidence, prevalence and age at diagnosis of asthma in children. Pediatr Allergy Immunol. 2015; 26: 367–74. doi: 10.1111/pai.12376.
7. Schifano ED, Hollenbach JP, Cloutier MM. Mismatch between asthma symptoms and
spirometry: implications for managing asthma in children. J Pediatr. 2014; 165: 997–1002. doi: 10.1016/j.jpeds.2014.07.026.
8. Murphy KR, Zeiger RS, Kosinski M, Chipps B, Mellon M, Schatz M, et al. al. Test for respiratory and asthma control in kids (TRACK): a caregiver-
9. Wildfire JJ, Gergen PJ, Sorkness CA, Mitchell HE, Calatroni A, Kattan M, et al. Development and validation of the Composite Asthma Severity Index – an outcome measure for use in children and adolescents. J Allergy Clin Immunol. 2012; 129:694–701. doi: 10.1016/j.jaci.2011.12.962.
10. Van Vliet D, van Horck M, van de Kant K, Vaassen S, Gulikers S, Winkens B, et al. Electronic monitoring of symptoms and lung function to assess asthma control in children. Ann Allergy Asthma Immunol. 2014; 113:257–62. doi: 10.1016/j.anai.2014.05.015.
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