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Pediatric Asthma

Diagnosis/Definition:

Reversible obstructive airways disease manifested by cough, wheezing and shortness of breath which responds to beta-agonists and corticosteroids.

Initial Diagnosis and Management

• History: Recurrent cough, especially at night. Persistent cough after URI’s, shortness of breath, exercise induced cough and chest tightness.
• Physical exam: Wheezing, chest retractions, prolonged expiratory phase, cough.
• Laboratory tests: Air flow obstruction documented by pulmonary function tests/spirometry (PFT’s); hyperinflation on CXR. PFT’s can be ordered with a direct consult to the MAMC Pediatric Pulmonary Function Lab.
• Educate about asthma so that important signs and symptoms can be recorded by the patient and family.
• Medications: PRN beta-agonists (albuterol) 2 puffs via MDI or 0.5cc in 2-3 cc normal saline by nebulizer Q 4 hours. Consider a short course of corticosteroids, prednisone 2mg/kg/day for 3-7days, for exacerbations of asthma or a trial of a controller medication, e.g., inhaled corticosteroids.

Ongoing Management and Objectives

• Decrease hospitalizations and acute care visits, decrease missed school days, decrease symptoms and increace exercise tolerance.
• Educate the patient and family about asthma. Provide the patient/family with a written treatment plan.
• For episodic asthma: PRN beta-agonists, and prescribe short courses of PO corticosteroids for exacerbations.
• For mild-moderate persistent asthma: controller medications include – cromolyn (by nebulizer or MDI), leukotriene receptor antagonist (LTRA; for children > 1 years-old only), or low-moderate dose inhaled steroids.
• Use short-acting beta2-agonists Q 4 hours PRN, and prescribe short courses of PO prednisone for persistent exacerbations. Refer to Allergy for skin testing.
• For moderate-severe persistent asthma: controller medications are moderate-high dose inhaled steroids, and consider combining a LTRA or long-acting beta2-agonist (salmeterol) with inhaled corticosteroids.
• For reliever medications use short courses of prednisone for exacerbations, and PRN short-acting beta2-agonists. Refer to Allergy for skin testing.
• Avoidance of identified asthma triggers.

Indications for Specialty Care Referral

Consider referral for any child with moderate or severe persistent asthma.

Can refer directly to the Pediatric Pulmonary Function Laboratory for PFT’s or asthma education.

Patients with > one ED visits for asthma or who have been hospitalized with asthma within the past year.

Patients not well controlled with cromolyn, nedocromil, or low-doses of inhaled corticosteroids.

Patients missing more that 5 days/year of school due to asthma.

Non-complaint patients who require significant time and education to help them deal with their asthma.

Any children < 2 years-old with asthma requiring daily asthma therapy.

Criteria for Return to Primary Care:

The patient is well controlled on a set regimen of asthma medication.

Emergency department visits decreased to fewer than two per year.

Missed school days to < 5/year.

No hospitalizations.

The parents/patient and primary care physician feel comfortable with the asthma care plan.

The patient’s asthma has decreased in severity so that a less intense asthma treatment regimen is required.