4-20
Objective: Signs
Using Basic Tools: Vital signs: respiratory rate >18; potentially unstable BP— pulsus paradoxus (systolic
BP varies by more than 10 mmHg during breathing ; can be seen in other intrathoracic diseases, such as
tumor or pneumothorax also)
Inspection: Nasal cavity: Nasal polyps (seen in cystic fibrosis and asthmatics with aspirin sensitivity).
Accessory respiratory muscle use in severe cases. Auscultation: Respiratory system: wheezing, prolonged
expiration are common. Decreased breath sounds may mean worsening!
Using Advanced Tools: Labs: Eosinophils on Gram stain of nasal secretions or blood; Chest x-ray: rule
out other diseases; Pulmonary function tests or peak flow meter (if available) documents airflow obstruction
and serial improvements predicts better response. The response on peak flow or pulmonary function tests
after administration of a bronchodilator can be helpful from a diagnostic, as well as therapeutic, view point.
Remember the pearl: “All that wheezes is not necessarily asthma!”
Assessment:
Differential Diagnosis
Foreign body aspiration (always consider in children), viral respiratory infections (croup, bronchiolitis), epiglot-
titis, chronic obstructive pulmonary disease, rarely vocal cord dyskinesis (paradoxical vocal cord motion as a
post traumatic stress disorder or panic attack).
Plan:
Treatment
Primary: MDI = Metered Dose Inhaler
- Emergency Treatment : Measure initial peak flow if possible, provide a baseline for repeated
measures (doubling of the initial peak flow value, measured hourly is a reliable indicator of
improvement).
Initial therapy:
a. Inhaled beta-agonist (albuterol) to reverse obstruction (1 ml albuterol neb) or MDI (2-4 puffs, .36
mcg, every 1-2 hours until clear)
Children under 2 - nebulizer or MDI with valved spacer and mask; children 2-4 years - MDI and valved
spacer; children over 5 years - MDI or powder inhaler
b. Short course of oral corticosteroids, 2 mg/kg po q am for 5-7 days - Non-emergent treatment based on NIH asthma severity categories.
a. Mild intermittent asthma: Brief wheezing once or twice a week
Give albuterol (short-acting beta-agonist) in Metered Dose Inhaler (MDI), the preferred method, or nebuliz-
ers, or oral syrup.(Inhaler: 2-4 puffs .18 – 36 ug q 6 hr prn ) (Nebulizer: Dilute 1⁄2 ml (1 ml of 5% albuterol
contains 5 mg of albuterol) to 3 ml total volume, with sterile normal saline for nebulizing). (Syrup: Adults and
children over 14 years, 2 mg or 4 mg (1 teaspoonful = 2 mg) tid to qid; children 6 to 14 years: 2 mg po tid to
qid; children 2 to 6 years of age, start at 0.1 mg/kg of body weight tid and do not exceed 2 mg tid. Alternative
for stable patients: Long acting beta-agonists (e.g., salmeterol [Serevent] 2 puffs bid).
b. Mild persistent asthma: Symptoms >2 times a week, but < 1 time a day; affects activity. Add long-term
control medication - choose from:
Inhaled Steroid: Beclomethasone dipropionate or equivalent: 2 inhalations (84 micrograms) given
tid to qid or alternatively, 4 inhalations (168 micrograms) can be given bid. Or zafirlukast: adults and
children 12 years of age and older: 20 mg po bid; children 7-11years of age: 10 mg po bid or
montelukast: adults 15 years of age and older: 10 mg po q evening; children 6-14 years of age: one
5 mg chewable tablet q evening
c. Moderate persistent asthma: Weekly symptoms interfering with sleep or exercise; occasional ER visits;
peak flow is 60-80% of predicted.
Increase inhaled steroids (beclomethasone dipropionate or equivalent) to 12 to 16 inhalations a
day (504 to 672 micrograms) and adjust the dosage downward according to the response of the
patient. Add additional long-term control medications (consider theophylline but blood levels are
required to prevent toxicity). Consider adding inhaled 2-4 puffs qid ipratropium bromide
(anticholinergic drug)
d. Severe persistent asthma: Daily symptoms affecting activity; occasional ER visits; peak flow < 60 %