Physically, the patient appears to be in moderate respiratory distress, with suprasternal and intercostal retractions. His vital signs include a respiratory rate of 40/minute, heart rate of 120/minute, and pulse oximetry of 93% on room air. Lung exam is notable for diffuse inspiratory and expiratory bilateral wheezing, poor air movement and a prolonged expiratory phase. The remainder of the examination is unremarkable. Case discussion – Asthma pathophysiology Joey Wahler (Host): Asthma is a condition that adversely affects breathing, so we’re discussing pediatric asthma and how it’s treated. This is Maimo Med Talk. Thanks for listening. I’m Joey Wahler. It is difficult to match an asthma patient’s hyperventilation, and lower tidal volumes should be used to avoid barotrauma in the setting of hyperinflation. Finally, intravenous ketamine at doses starting at 2 mg/kg, is gaining favor as an adjunctive bronchodilator, especially for agitated patients in respiratory distress [8]. References Dr Michael Marcus: Only that children are a bit less cooperative sometimes. They’re not always able to take the inhaled medications with the right technique and they need that supervision and guidance. The flip side though is that since parents really do control children’s lives and we tend to care for our children better than we care for ourselves, children are more likely to use their medication properly once the parent understands the need for the medication. Dr Michael Marcus: It’s what it’s all about. It’s why I became a physician. It’s what makes the work, the tediousness of writing notes, the headaches of management, it makes it all go away because ultimately that’s what we’re in this for, to help save lives.

Joey Wahler (Host): So how common is pediatric asthma? And is it any more or less prevalent than in years past?Status asthmaticus is a life-threatening condition of progressively-worsening bronchospasm and respiratory dysfunction due to asthma that is unresponsive to conventional therapy. It typically progresses into respiratory failure or arrest and requires aggressive ventilatory and pharmacological interventions. Joey Wahler (Host): Absolutely. Great to hear. Thanks again for the story. And of course, for all the other information. Folks, we trust your now more familiar with asthma in children. Dr. Michael Marcus, thanks so much again. Dr Michael Marcus: It depends on the definition you use. The numbers say that probably about 10% of children will have some form of repeated episodes of wheezing and could be diagnosed as asthma. If you have a family history of asthma, there’s about a 30% chance that you’re going to develop asthma, as opposed to just the general population where that number’s about 10%. Prior ED visits or hospitalizations for asthma (including intensive care unit admissions and/or intubations) Dr Michael Marcus: There are two approaches that are important to take. One is to identify the triggers as best as possible. I do allergy testing, monitor the patient’s response in different environments and to different foods, so that if we can identify the triggers for their asthma and are able to avoid those triggers, we can decrease the risk of symptoms being set off. If a child is allergic to cats, for example, you certainly would rather not have a cat in the house and you definitely do want the cat in the child’s room ever. That’s just one example.

Our guest from Maimonides is Dr. Michael Marcus, Director of Pediatric Pulmonary Medicine and Allergy Immunology and Vice Chair of the Pediatric Ambulatory Network. Dr. Marcus, thanks for joining us. Dr Michael Marcus: It’s interesting, but roaches and mice both produce a potent protein that can trigger the same type of inflammatory reaction that leads to the symptoms of asthma. And so early and high concentration of exposure to those things will give a child greater symptoms of their asthma conditions.The child with status asthmaticus presents with air hunger. Because of the profound bronchoconstriction and minimal airflow through the bronchioles, wheezing is either faint or completely absent. Oxygen saturation levels often reflect severe hypoxia, with readings well below 90%. As hypoxemia worsens, the workload on the ventricles of the heart increases, and the child becomes profoundly acidotic from associated hypercarbia. Pediatric asthma interventions and management

Joey Wahler (Host): Interesting. How about weather conditions, doctor? What impact might living in a warmer climate have on an asthmatic patient? Learn how to assess, monitor and manage pediatric asthma emergencies, as well as underlying pathophysiologic changes Breathing isn’t something most people think about but, for some, it doesn’t come naturally. Knowing your child has asthma is the first step to dealing with it. Dr. Michael Marcus discusses what to look out for and what to do about it. Joey Wahler (Host): Aha. So actually it’s not necessarily warmer climate as much as colder, dryer climate, which most people probably would not think is the case. Okay. So how about treating pediatric asthma. What are the common treatments? Intravenous magnesium has been noted to produce good bronchodilation effects with pediatric patients in status asthmaticus. It is dosed at 50 mg/kg. Common side effects include skin flushing and hypotension, which is rarely clinically significant and responds well to fluid administration.Secondly, if a child has asthma, identify how severe the problem is with the help of a physician, and then decide whether the child can use medicine on an as needed basis, triggering only the symptoms of the disease or whether they’ve crossed that threshold of severity and they need daily prevention therapy. EMS responds to a residence for a seven-year-old male with a cough and trouble breathing. This episode began two hours ago and has been accompanied by a runny nose without any other symptoms. His mother has been treating him with albuterol by a nebulizer, but he has progressively become more short of breath. Past medical history is notable for asthma since infancy, with multiple prior hospitalizations.

Joey Wahler (Host): Wow, what a great story and makes me wonder in closing here, when you’re able to impact lives like that, and I’m sure you’ve done so many times over since, how rewarding is that for you? Once the EMS professional concludes that the most likely diagnosis is an asthma exacerbation, treatment centers around reversing bronchoconstriction and airway inflammation, correcting hypoxemia, rehydration and monitoring for complications – such as pneumothorax. First-line treatment of an asthma patient with any degree of respiratory distress should be albuterol. It relaxes bronchial smooth muscle and enhances mucous clearance. Ideally, albuterol is administered as a nebulized solution (2.5 mg per dose for patients less than 10 kg, and 5 mg per dose for patients greater than 10 kg). Common side effects include tachycardia and tremors. Rarely, children may experience arrhythmias, such as supraventricular tachycardia. Dr Michael Marcus: So asthma is a condition where the body has an abnormal reaction to some substance. The reaction in asthma is focused in the lungs where three things occur. First, there’s an inflammatory response within the lungs, which leads to spasm of the airways, swelling of the airways and a buildup of mucus. The combination of those three things leads to narrowing of the airway, making it much more difficult to breathe.The EMS1 Academy features “Capnography for BLS: Getting Started with Capnography,” a one-hour accredited course designed to introduce the benefits of capnography, present a basic understanding of the capnogram, and how to use it to explore the physiology of the respiratory cycle. Visit the EMS1 Academy to learn more and schedule a demo. With inhaled medications, we have different types of devices that can assist the child to use the medication in the best fashion, which will allow the medicine to reach the lungs to the best effect. And so using these assistant devices is an important piece that we add to a child’s therapy where it’s not always necessary in an adult’s therapy. The key here is that if we use daily prevention therapy properly, then we decrease the risk that the asthma will become more severe with age and give children the best opportunity to have the healthiest life. If we delay using the prevention therapy and continue to treat asthma on an as needed basis, treating only the symptoms, then we miss the opportunity of preventing progressive damage and limiting the severity of asthma over time. EMS professionals need to keep in mind that a child’s lower airway anatomy is proportionally smaller than an adult’s, and is easily compromised from a lesser degree of swelling and constriction. In response to one of the events mentioned earlier, a series of reactions occur in the lower airway.