This post contain Dr. Sarah Reid’s great talk, EMU 365: Pediatric Asthma Pearls and Pitfalls, [Link is to the vidcast and show notes] from Emergency Medicine Cases, posted by Dr. Hellman on Dec. 2, 2019
I’ve included the show notes [with additional resources throughout the notes] in the post for ease of my review:
EMU 365: Pediatric Asthma Pearls and Pitfalls
This EMU365 video features Dr. Sarah Reid, presenting common pitfalls made in pediatric asthma diagnosis and management in the ED. She explains the importance of risk stratification using the PRAM score, early diagnosis of preschool asthma and initiating maintenance inhaled corticosteroid therapy upon discharge.
Pediatric Asthma Pitfalls
Pitfall #1: Making the diagnosis of bronchiolitis instead of asthma
- If age of child less than or ~12mo: likely bronchiolitis
- If diagnosis is unclear in children ~12mo, or unsure if presenting as early asthma or late bronchiolitis, check for response to salbutamol. Bronchiolitis will not respond to salbutamol
I recommended quickly reviewing the outstanding EMC Resources on Bronchiolitis:
- Episode 59: Bronchiolitis, January, 2015 by Dr. Anton Helman. The podcast runs about an hour and is well worth listening to. But you can quickly review Dr. Helman’s outstanding show notes very quickly. I recommend do that review if you are reviewing this post [note to myself].
- BCE 66 CHD with Bronchiolitis: A Delicate Balance, February, 2015, by Dr. Anton Helman.
Now returning to notes from EMU 365: Pediatric Asthma Pearls and Pitfalls:
Pitfall #2: Not diagnosing asthma in preschoolers (1-5 years of age)
- PFTs are difficult to perform in children <6 years old, there’s a huge burden of ED visit and admissions in this age group for asthma like symptoms
- Wheezing in early life is associated with a 10% reduction in FEV1 by 6 years of age and irreversible airway remodelling
- CPS 2015: Diagnosis of asthma in preschoolers = >2 episodes of wheezing/airflow obstruction + demonstrating reversibility with bronchodilators +/- corticosteroids
Pitfall #3: Not using the PRAM score
- Score stratifies severity and guides management
- Mild 0-4: salbutamol
- Moderate 5-8: plus steroids and ipratropium bromide
- Severe 8-12: consider Mg
- 5 clinical criteria: Tracheal tug, scalene muscle use, air entry, wheeze and O2 sat
Note to Myself: Please see BCCH PRAM (Pediatric Respiratory Assessment Measure) Score Assessment for Asthma [Link is to PDF] for important information on the use of the PRAM score.
PRAM is a 12-point clinical scoring rubric that captures a patient’s asthma severity using a combination of scalene muscle
contraction, suprasternal retractions, wheezing, air entry and oxygen saturation.1 PRAM was originally developed for
patients aged 3 – 6 years and subsequently validated in children aged 1 to 17 years old, in whom it preformed equally well.1
An example:
Scalene Retractions from the above link
Scalene muscle Contraction: The scalenes are deep cervical muscles located in the floor of the lateral aspect of the neck.
Scalene contraction cannot be seen.
This is a palpable assessment.Land mark for locating scalene muscles in the triangle bordered by the clavicle (in the front), the trapezius (in the back) and neck
(medially) in line with the ear lobe.Occurs in about 10% of all patients – only those with severe asthma exacerbations.
Now returning to notes from EMU 365: Pediatric Asthma Pearls and Pitfalls:
Pitfall #4: Waiting to give corticosteroids
- PRAM scores of moderate to severe – give systemic corticosteroids steroids as soon as possible
- Systemic corticosteroids given in the first hr decreases length of stay and admission
- Dexamethasone 0.6mg/kg (Max 12mg) for 2 days
Pitfall #5: Not giving controller medications when child goes home
- Need inhaled corticosteroids (ICS) for a therapeutic trial at the time of discharge to prevent chronic symptoms in moderate to severe PRAM scores
- Prescribe ICS for 3mo at the time of discharge, it takes 1-4 weeks to start working, reinforce daily use, cannot be on a PRN basis
