Acute Bronchial Asthma in Children (Over Two Years)

Bronchial asthma is a long-term (chronic) inflammatory disease, which leads to an episodic obstruction of the airways. It is a reversible condition and can be managed and controlled with lifestyle changes and some medications. However, some children with bronchial asthma may get acute exacerbations (attacks). Diagnosis of acute asthma can be done with the help of symptoms, signs, and some tests.

Features of acute bronchial asthma

Acute severe bronchial asthma

Children with acute severe asthma show following features.

They cannot complete a sentence in one breath or cannot talk or feed due to shortness of breath.

Saturation of oxygen in the blood (SpO2) is less than 92 %. (SpO2 is measured by the pulse oximetry.)

Peak expiratory flow (PEF) is about 33-50 % of the predicted or previous best value.

Respiratory rate is more than 40 cycles per minute in children aged two to five years or is greater than 30 cycles per minute in children aged more than five years.

Pulse rate or heart rate is more than 140 beats per minute in children aged two to five years or is greater than 125 beats per minute in children aged more than five years.

Life-threatening bronchial asthma

Children with life-threatening asthma show following features.

Low blood pressure (hypotension)

Confusion

Physical exhaustion

Bluish discolouration of tongue, lips, or fingers (cyanosis)

Poor respiratory effort

Silent chest

Coma

SpO2 is less than 92 %.

PEF is less than 33-55 % of the predicted or previous best value.

A child with acute asthma should be offered an inhaled β2 agonist like Salbutamol as the first-line treatment. Inhaled β2 agonists will help dilate the constricted airways and facilitate the airflow. The dose of the inhaled β2 agonist can be increased by two puffs every two minutes (up to ten puffs) according to the response.

Children with acute bronchial asthma, who have not improved following up to ten puffs of inhaled β2 agonists, should be referred to a hospital from the primary care. Further doses of the medication can be offered as necessary while waiting for the transfer. During the transfer, the child should be provided a nebulised β2 agonist like Salbutamol with oxygen in the ambulance as required. Children with life threatening or acute severe bronchial asthma should be transferred to a hospital immediately.

Health-care professionals may consider intensive care for children with SpO2 of less than 92 % on air following initial treatment with β2 agonists.

Health-care professionals will monitor and record following signs of the child.

Degree of shortness of breath and respiratory rate.

The degree of shortness of breath can be monitored by observing whether the child can complete a sentence in one breath or can feed.

Pulse rate

Increasing pulse rate implies worsening of bronchial asthma. If the child with life-threatening asthma has a fall in pulse rate or heart rate, it denotes a very critical situation.

Use of accessory muscles for breathing.

It can be observed by looking at the intercostal (between ribs) muscles, subcostal (under the rib cage) muscles, and neck muscles. Health-care professionals may palpate the neck muscles during their examination.

Conscious level and the degree of agitation of the child
It helps identify the severity of the bronchial asthma attack.

The amount of wheezing

Health-care professionals will auscultate (hear with a stethoscope). The auscultation will help identify wheezing with biphasic or fewer apparent sounds, which indicates the worsening of airway obstruction.