Asthma exacerbations in children IPD Mx

Asthma exacerbations in children IPD Mx

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INTRODUCTION

Asthma เป็นโรคเรื้อรังที่พบบ่อยในเด็ก และเป็นสาเหตุสำคัญของ ED visit และการนอนโรงพยาบาล เด็กส่วนใหญ่มี exacerbation ระดับ mild แต่ผู้ที่ไม่ตอบสนองต่อ outpatient/ED therapy หรือมี severe exacerbation จำเป็นต้อง admit เพื่อ monitoring และ escalation of therapy

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OVERVIEW

• การรักษาใน ward มักเป็น continuation จาก ED
• เด็กส่วนใหญ่ได้รับ:
• ≥3 doses of inhaled SABA ± ipratropium
• systemic glucocorticoids
• supplemental oxygen
• หัวใจสำคัญ:

1.                   Initial assessment + ongoing monitoring

2.                   Management of bronchospasm, inflammation, hypoxemia

3.                   Discharge planning + asthma education + controller optimization

การ handoff ระหว่าง clinic → ED → ward ต้องชัดเจน เพื่อไม่ให้ miss หรือ duplicate therapy

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INITIAL ASSESSMENT & ONGOING MONITORING

Key clinical parameters

• Respiratory rate
• Work of breathing (retractions, accessory muscle use)
• Wheeze / air entry
• Inspiratory:expiratory ratio
• Pulse oximetry
• Dyspnea / ability to speak
• Mental status
• Heart rate & rhythm (beta-agonist adverse effects)

⚠️ Pulse oximetry เพียงอย่างเดียวไม่พอ โดยเฉพาะในผู้ป่วยที่ได้ supplemental O₂ (อาจ mask deterioration)

Signs of impending respiratory failure

• Cyanosis
• Severe tachypnea หรือ fatigue + poor air movement
• Altered mental status
• SpO₂ <90%
• Hypercarbia (PaCO₂ >40 mmHg)

➡️ Indication for PICU transfer

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ROLE OF INVESTIGATIONS

Pulmonary function testing

• ❌ ไม่ใช้ routine
• ✔️ พิจารณาเฉพาะเด็กที่ cooperative หลัง stabilize และ diagnosis/control ยัง unclear

Chest radiograph

❌ ไม่ทำ routine
✔️ ทำเมื่อ:

• Clinical deterioration
• Suspected complication: pneumothorax, pneumomediastinum, pneumonia
• Poor response to therapy → rule out asthma mimic (foreign body, vascular ring, ILO)

Laboratory studies

• ❌ ไม่จำเป็นใน intermittent therapy
• ✔️ Monitor electrolytes (K, Mg, PO₄) ในผู้ที่ได้ continuous albuterol
• Blood gas:
• Venous/capillary: selected cases
• ABG: signs of impending respiratory failure
• Normal or rising CO₂ ใน tachypneic child = red flag

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INITIAL THERAPY

1. Inhaled short-acting beta agonists (SABA)

• Cornerstone therapy
• Frequency:
• Moderate: q1–3 hr
• q2 hr → switch to continuous nebulization
• PRN doses should always be available

2. Systemic glucocorticoids

• Indicated in all hospitalized patients
• Oral preferred (prednisone/prednisolone/dexamethasone)
• IV/IM only if PO not tolerated

3. Supplemental oxygen

• Target SpO₂ ≥92%
• All nebulized meds delivered with oxygen (FiO₂ ~100%)

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THERAPY ADJUSTMENT

• No improvement / worsening → increase frequency or escalate to continuous nebulization
• Stable but not improving → maintain current regimen
• Clear improvement → space treatments

Many hospitalsใช้ clinical pathways / asthma scores (PRAM, PIS)
→ ลด length of stay และ cost

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ESCALATION & FAILURE TO RESPOND

Escalation

• Switch to continuous nebulized SABA when:
• Minimal response to intermittent therapy
• Need SABA more often than q2 hr

Failure to respond

Consider:

• Severe asthma
• Complication (atelectasis, pneumothorax, pneumonia)
• Misdiagnosis (asthma mimic)

➡️ Chest X-ray + specialist consultation recommended

Indications for PICU/anesthesia consult

• Continuous SABA + worsening fatigue/work of breathing
• CO₂ retention
• Worsening hypoxemia

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ELEMENTS OF TREATMENT

Management of bronchospasm

Inhaled SABA

• Nebulized albuterol:
• <30 kg: 2.5 mg
• ≥30 kg: 5 mg
• MDI: 4–8 puffs (usually ≤6)
• Nebulizer flow: 6–8 L/min

Adverse effects

• Tachycardia, diastolic hypotension
• Electrolyte shifts (K, Mg, PO₄)
• Lactic acidosis (continuous therapy)

Other bronchodilators (ipratropium, MgSO₄, terbutaline, epinephrine)
➡️ ใช้ใน ED / ICU ไม่ใช่ routine ward

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Management of inflammation

Systemic glucocorticoids

• Prednisone/prednisolone/methylprednisolone:
• ~2 mg/kg/day (max 60 mg) × 5 days
• Dexamethasone:
• 0.3–0.6 mg/kg/day × 1–2 days

Course นานขึ้น (7–10 วัน) พิจารณาใน severe/slow response หรือ frequent exacerbation

Inhaled corticosteroids

• ❌ ไม่ใช้แทน systemic steroids
• ✔️ Continue/initiate ระหว่าง admit เพื่อ promote adherence post-discharge

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Management of hypoxemia

• Target SpO₂ ≥92%
• Titration:
• ≥94% → decrease flow
• 91–94% → maintain
• ≤90% → increase flow
• Continuous pulse oximetry ระหว่างให้ออกซิเจน

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THERAPIES RESERVED FOR SPECIAL SITUATIONS

• ICU-only:
• IV beta agonists
• Magnesium sulfate
• Methylxanthines
• NIV / HFNC / mechanical ventilation
• ❌ Antibiotics: no role unless bacterial infection suspected
• ❌ Chest physiotherapy (ยกเว้น atelectasis)
• ❌ Ipratropium และ LTRA: ไม่ใช้ routine ใน inpatient

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CONSULTATION

Asthma specialist (pulmonologist/allergist)

Indicated when:

• Diagnosis unclear / poor response
• Life-threatening exacerbation / ICU admission
• Recurrent admission, frequent ED visits
• Significant comorbidities
• Severe or difficult-to-treat asthma

Social services

• Medication access
• Adherence issues
• Environmental triggers (housing, smoke, pests)

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DISCHARGE PLANNING

Discharge criteria

• Symptoms mild
• SpO₂ ≥94% room air
• Treatment regimen manageable at home (q4–6 hr)
• Caregiver demonstrates correct inhaler/nebulizer technique
• Medications + follow-up confirmed
• Asthma education completed

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Discharge medications

• SABA (MDI + spacer หรือ nebulizer)
• Oral glucocorticoids (complete course)
• Controller therapy
• Almost all hospitalized children should receive daily controller
• Step-up therapy often indicated

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Discharge education

• Difference between controller vs rescue meds
• Proper inhaler/nebulizer technique
• Trigger avoidance
• Influenza vaccination
• Written Asthma Action Plan

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Follow-up

• Within 3–5 days
• Reassess severity/control
• Adjust controller therapy
• Taper SABA frequency

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KEY TAKE-HOME POINTS

• Inpatient asthma care = continuation + close monitoring
• Clinical assessment สำคัญกว่า SpO₂ อย่างเดียว
• SABA + systemic steroids = cornerstone
• Early recognition of deterioration → PICU referral