Asthma: The silent killer of children

You are called to respond to a child having difficulty breathing. Upon arrival, the 10-year-old patient’s mother tells you he is an asthmatic and has been for most of his young life. Your partner, a relative newcomer to the profession, begins her toe to head assessment. You continue to gather crucial medical history until your partner asks if he/she can borrow your stethoscope because hers isn’t working.

Now, a stethoscope that doesn’t work is a possibilty, but not a probability. It is little more than a tube accessorized with ear pieces and a bell/diaphragm, with little opportunity for failure.

The more likely reality is that the child is in extremis secondary to asthma. His ventilations are exchanging minimal air and therefore breath sounds are significantly reduced or even absent. Silence is deadly!

Pediatric asthma related illness is one of the more common reasons for emergent EMS responses. A primary challenge for responders is adequately recognizing the potential criticality of the child and any comorbid issue(s) that need to be addressed.

There are more than 9 million children in the United States diagnosed with asthma and over the past 20 years the prevalence has increased by more than 75 percent. Even more alarming are the number of young children with asthma under the age of 5 have increased by more than 160 percent during the same time frame.¹

Asthma has a number of biological indicators including bronchiolar obstruction, airway smooth muscle bronchoconstriction, and inflammation in the airways. The major symptoms include cough, wheezing, shortness of breath, chest pain, and significant diurnal variations, variations between morning and evening symptoms.

Internally excessive production of mucus throughout the airways and the infiltration of inflammatory cells is common. The infiltration process is responsible for the classic ventilation defects seen during all stages of the respiratory episode.

One hallmark of asthma is that it causes airway obstruction. It can be classified as reversible or irreversible. Reversible asthma is deemed as such due to its potential to respond to pharmacological therapy; irreversible asthma is less likely to respond to interventions.

The components of reversible asthma include:

• Bronchoconstriction
• Excess mucous secretion
• Tissue edema
• Inflammatory infiltrate process
• Airway lining damage, and
• Bronchial hyper-responsiveness.

If the child’s disease process is less controlled or has repeated cycles of exacerbations and remissions, the resultant changes to the airway structures include smooth muscle hypertrophy, mucus gland hypertrophy, and mucus hyper-production.

Age matters! The younger the child, those who have been afflicted by wheezing since or before they were 3 years old, are more likely to be have persistent asthma and therefore be more likely to progress to worsening stages of the disease.²

Your assessment needs to include questions regarding parental history of asthma. Up to 40 percent of all asthmatics are the offspring of an asthmatic mother and if both parents were or are asthmatics that probability skyrockets to 70 percent.

One interesting and not well understood historical family fact is that children raised in an agricultural environment, primarily on a farm, with livestock appear to be better protected from developing asthma or other allergic diseases than those who do not. It is unclear why or how this happens.

We must perform an adequate assessment, meaning one which provides us with both the global perspective of this child’s medical history while containing enough focused clinical information of his current medical status. This information is key to determining an appropriate therapeutic treatment and transport plan.

The National Association of EMS Physicians (NAEMSP) Model Pediatric Protocols is one example of a model protocol for asthma.³

The Model Pediatric Protocol set defines asthma as bronchospasm that is commonly accompanied by respiratory distress and ultimately respiratory failure presenting signs and symptoms including:

• Wheezing
• Prolonged expiratory phase
• Moderate to severe agitation in early stages
• Increased respiratory effort in the early or earlier stages
  • Decreased respiratory effort is seen in late stages
• Lethargy in late stage
• Retractions including any or all of the following
  • Suprasternal
  • Substernal
  • Intracostal
• Determination to achieve a position of comfort
  • Not wanting to lay supine
  • Tripod position

The following is a summary of the Model Protocols for pediatric asthma: (Note: Please follow the accepted protocols, treatment modalities, and guidelines as provided by your agency and Medical Director.)

• Perform standard initial safety, survey, precautions, and assessments as in all patient encounters..
• Assess breathing. Obtain pulse oximeter reading.
• If breathing is inadequate, assist ventilation with high-flow, 100% concentration oxygen.
• If the airway cannot be maintained by other means, including attempts at assisted ventilation, or if prolonged assisted ventilation is anticipated, perform endotracheal intubation.
  • Consider administration of pharmacological adjuncts, such as sedatives and paralytic agents, to aid with intubation as permitted by medical direction. Confirm placement of endotracheal tube using clinical assessment and end-tidal CO2 monitoring.
• If breathing is adequate, place the child in a position of comfort and administer high-flow, 100% concentration oxygen as necessary.
  • Use a non-rebreather mask or blow-by as tolerated.
• If the patient shows signs of respiratory failure with inadequate ventilation or respiratory arrest together with clinical evidence of bronchospasm or a history of asthma, administer one of the following systemic agents for bronchodilation:
  • Epinephrine 1:1000 at 0.01 mg/kg (maximum individual dose 0.3 mg) SQ
  • Terbutaline at 0.01 mg/kg (maximum individual dose 0.4 mg) SQ
• If the patient shows signs of respiratory distress or respiratory failure together with clinical evidence of bronchospasm or a history of asthma, administer one of the following inhaled beta-2 agonist bronchodilators:
  • Albuterol 2.5 mg via nebulizer over a 10- to 15-minute period or 4 Puffs via metered-dose inhaler (MDI) with spacing device
  • Levalbuterol 0.625-1.25 mg via nebulizer over a 10- to 15-minute period
• Do not delay transport to administer medications.
• If the patient shows signs of respiratory distress or respiratory failure together with clinical evidence of bronchospasm or a history of asthma consider administering 500 mcg ipratropium bromide via nebulizer over a 10- to 15-minute period.
• Do not delay transport to obtain vascular access.
• Consider administration of steroids in one of the following preparations as permitted by medical direction:
  • Prednisone 2.0 mg/kg (maximum individual dose 60 mg) PO
  • Methylprednisolone 2.0 mg/kg (maximum individual dose 125 mg) IV/IM
  • Hydrocortisone 4.0 mg/kg (maximum individual dose 250 mg) IV/IM
• Expose the child only as necessary and maintain the child’s body temperature throughout the examination.
• Initiate transport as soon as feasible.Continue to reassess the patient on a continuous basis.

Proper assessment, therapeutic modality determinations and transport decisions will provide your patient the greatest opportunity to recover from this episode and return to being an active child with a controlled medical condition.