eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Reactive Airway Disease: Follow-up

Author: Eric S Chin, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Hospital, South San Francisco
Contributor Information and Disclosures

Updated: Jun 30, 2009

Follow-up

Further Inpatient Care

  • Consider admission if the initial peak expiratory flow rate (PEFR) is less than 20-25% of predicted and posttreatment is less than 70% of predicted or if no improvement occurs after 4 hours.
  • If a child fails to improve within the first 2-3 hours of ED management, admission to an ED observation area, inpatient unit, or pediatric critical care unit is warranted.
  • If the patient is able to ambulate and tolerate fluids in the ED without distress, discharge may be considered.
  • Arrange for follow-up with the primary care provider within 24 hours.

Further Outpatient Care

Monitoring

Follow-up of pediatric asthma patients may be conducted by phone or in person; may include physical examination and/or spirometry; and may be performed by a case manager, registered nurse, nurse practitioner, or physician. Follow-up is recommended:

  • Within 1 week of an asthma exacerbation
  • Within 4 weeks after initiation of therapy or any significant change in therapy, and every 2-4 weeks thereafter until control is obtained
  • Every 4-6 months to assess control for patients with persistent asthma

Inpatient & Outpatient Medications

  • The child should be started on an inhaler corticosteroid for mild cases and addition of an oral steroid, prednisone or prednisolone (Prelone) (1-2 mg/kg/d) for 3-7 days, or dexamethasone for one additional day, for more severe cases.
  • Leukotriene receptor antagonists are an option for the preventive treatment of recurrent asthma exacerbations secondary to viral respiratory tract infections in children aged 5 years or younger who do not have evidence of persistent asthma.

Deterrence/Prevention

  • Parents of asthmatic children should have at least 2 sets of inhalers (eg, one for school and one for home).
  • After an asthma exacerbation, the child may return to school when asymptomatic and the PEFR is within 20% of normal.
  • Reduction in allergen exposure results in reduction of asthma and rhinitis symptoms and medications needed.
  • Avoid outdoor exposure and/or physical activity during periods of high smog alerts in community.
  • Change home furnace filters, remove dust, change linen, and vacuum regularly to reduce potential triggers.
  • In humid climates, keep humidity below 50% by using a dehumidifier to keep mold from growing
  • Avoid second-hand tobacco smoke, a well-known trigger of asthma attacks in infants and children.
  • Pediatric Asthma Controller Trial (PACT)11 compared the effectiveness of 3 regimens in achieving asthma control:
    • Fluticasone 100 mg twice daily (fluticasone monotherapy), fluticasone 100 mg/salmeterol 50 mg in the morning and salmeterol 50 mg in the evening (PACT combination), and montelukast 5 mg in the evening
    • The conclusions of the study were in favor of fluticasone monotherapy in treating children (>6 y) with mild-to-moderate persistent asthma.

Complications

  • Respiratory failure/mechanical ventilation
  • Atelectasis
  • Flaccid paralysis (self-limited)
  • Death
  • Pneumothorax
  • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
  • Altered theophylline metabolism

Prognosis

  • The prognosis is excellent with attention to general health and appropriate use of medications.
  • Fewer than 50% of patients "out grow" asthma.
  • Predictors of mortality risk
    • More than 3 ED visits per year
    • More than 2 hospitalizations per year
    • Hospitalization or ED visit in the last month
    • History of ICU admission
    • Mechanical ventilation
    • Use of 2 or more albuterol canisters in a month
    • Current use or recent discontinuation of systemic steroids
    • History of an acute onset of severe asthma exacerbation
    • Nocturnal symptoms
    • History of syncope
    • Comorbid cardiac disease
    • Illicit drug use
    • Serious psychosocial or psychiatric problems
    • Low socioeconomic situation
    • Limited access to health care

Patient Education

  • Monitoring PEFR is an easily performed test that can be mastered for those as young as 3-4 years. PEFR monitoring is an important tool in asthma management that uses a zone system to optimize effectiveness of asthma control.
    • Green zone (80-100% predicted or child's best) - Good control
    • Yellow zone (50-80%) - Necessitates increased awareness and treatment
    • Red zone (<50%) - Poor control, requires immediate intervention
  • Educate children and their families about asthma.
    • Avoidance of potential triggers.
    • Emphasis on the use of anti-inflammatory inhalation
    • Instruct on peak expiratory flow and symptom monitoring
  • Spacer devices should be used in all children with asthma. They improve the deposition of drug into the lower airway, hence improving efficacy of medication.
  • Long-acting bronchodilators do not replace the need for routine preventers. Their slow onset means the short-acting dilators may still be required. 
  • There is little evidence to support or refute the use of alternative medicine such as acupuncture, osteopathic, chiropractic, physiotherapy or respiratory therapeutic maneuvers.
  • There is no evidence that air ionizers improve asthma symptoms.12
  • For excellent patient education resources, see eMedicine's Asthma Center. Also, visit eMedicine's patient education article, Asthma.

Miscellaneous

Medicolegal Pitfalls

  • Failure to initiate steroid therapy
  • Discharging a patient with abnormal vital signs without an explanation
  • Discharging a patient with a high respiratory rate or with oxygen saturation less than 94%
  • Early intubation
  • Barotrauma after intubation due to inappropriate volumes

Special Concerns

  • Gastroesophageal reflux (GER) is common in asthmatic children. Proton-pump inhibitor therapy may help. In those with abnormal esophageal pH monitoring, severe persistent asthma and recurrent pneumonia, surgical therapy for GER may be an option. Infants may improve with alterations in feeding strategy.
 


More on Pediatrics, Reactive Airway Disease

Overview: Pediatrics, Reactive Airway Disease
Differential Diagnoses & Workup: Pediatrics, Reactive Airway Disease
Treatment & Medication: Pediatrics, Reactive Airway Disease
Follow-up: Pediatrics, Reactive Airway Disease
Multimedia: Pediatrics, Reactive Airway Disease
References
Further Reading
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Further Reading

Clinical guidelines

 Managing asthma long term in children 0-4 years of age and 5-11 years of age. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 281-325.

Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI). Global strategy for asthma management and prevention. Bethesda (MD): Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI); 2007. 92 p.

Managing exacerbations of asthma. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 373-417.

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Keywords

reactive airway disease in children, asthma, pediatric asthma, exercise induced asthma, exercise-induced asthma, asthma treatment, asthma assessment, asthma symptoms, asthma triggers, asthma causes, bronchospasm, obstructive airway disease, childhood asthma, hypersensitivity reaction, wheeze, wheezing, RAD, airway inflammation, upper respiratory infection, tachypnea, dyspnea, cyanosis, intercostal retractions, nasalpolyps, nasal secretions, diaphoresis, hyperresonance, pulsus paradoxus, decreased peak expiratory flow rate, pectus carinatum, clubbing, subcutaneous emphysema, respiratory syncytial virus infection, RSV infection, Mycoplasma pneumoniae, pet dander, cockroach allergen, dust mite allergen, molds, pollen, weather changes, bronchiolitis, gastroesophageal fistula, cystic fibrosis

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Contributor Information and Disclosures

Author

Eric S Chin, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Hospital, South San Francisco
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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