History

The following information should be elicited:

Initiation of symptoms (More than a few days decreases the chance of quick reversal in the ED because of prolonged inflammation and mucous plug formation)
Upper respiratory tract infection (URI) symptoms, fever, and production of phlegm
Precipitating factors
Use of an bronchodilator inhaler; how often it was used in the past 24-48 hours prior to the ED visit; how often it was used over the past week or month
How many inhalers were used in the past month
How many puffs are being administered with each use and if the inhaler is being used with a spacer
Compliance with use of corticosteroid inhaler (Ask if it was used daily despite any symptoms of wheezing)
Date of last ED visit; how severe the current episode is compared with previous episodes^[13]
Date of the last hospital admission
Number of admissions in the past year; number of intensive care unit admissions
History of intubation and how long ago it was
Recent use of oral steroids
Factors that usually initiate symptoms
Whether this is a typical episode
Presence of any underlying cardiac, GI, or immunologic diseases
Other current medications
Exposure to tobacco smoke and allergens (ie, cat dander)
Ability to tolerate fluids
Recent mental status changes
Baseline peak expiratory flow rate (PEFR)
History of atopic dermatitis or other allergic skin conditions^[14]
Dry cough or wheezing that is often worse at night
History of recurrent wheezing and dyspnea
Wheeze or cough after active playing
Relationship to emotional expressions
Relationship to menses

Physical Examination

Physical examination findings that may be seen in patients with reactive airway disease include the following:

Fever
Tachycardia
Diaphoresis
Poor feeding
Flushing, cyanosis
Subcutaneous emphysema
Intercostal retractions
Increased anteroposterior diameter or pectus carinatum
Tachypnea, dyspnea
Wheezing
Coughing
Distant breath sounds, hyperresonance, poor air movement to result in wheezing ("silent chest")
Decreased peak expiratory flow rate
Inspiratory-to-expiratory ratio (normal ratios are 1:2 to 1:3)
Allergic shiner (dark semicircles of skin under the eyes)
Transverse nasal skin fold from repeatedly rubbing the nose
Flaring of nasal alae
Presence of nasal polyps and nasal secretions
Pulsus paradoxus (greater than a 10mm Hg difference in SBP during inspiration)
Murmur
Altered mental status
Clubbing

Differential Diagnoses

[Guideline] Expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee(CC), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. The Expert Panel Report 3 (EPR-3) Full Report 2007: Guidelines for the Diagnosis and Management of Asthma. August 28, 2007. [Full Text].
[Guideline] Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC)., Cloutier MM, Baptist AP, Blake KV, et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec. 146 (6):1217-70. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

Patient peak flow record.
This nomogram results from tests carried out by S. Godfrey, MD, and his colleagues on a sample of 382 healthy boys and girls aged 5-18 years. Each child blew 5 times into a standard Wright Peak Flow Meter, and the highest reading was accepted in each case. All measurements were completed within a 6-week period. The outer lines of the graph indicated that the results of 95% of the children fell within these boundaries.
Stepwise approach for managing asthma in children 0 to 4 years of age. National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. August 2007. NIH publication no. 07-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. 3 Accessed December 30, 2007. PRN, As necessary.

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Table 1. Peak Flow Rates in Liters per Minute^[16]

Table 1. Peak Flow Rates in Liters per Minute ^[16]

Height in Inches	Average Rate	Range*	Height in Inches	Average Rate	Range*
40	150	110-190	56	330	240-420
41	160	115-205	57	340	240-420
42	170	120-220	58	360	260-460
43	180	130-220	59	375	270-480
44	190	135-245	60	390	280-500
45	200	145-255	61	400	290-510
46	210	150-270	62	415	300-530
47	220	160-280	63	430	310-550
48	230	165-295	64	445	320-570
49	240	175-305	65	460	330-590
50	250	180-320	66	480	345-615
51	260	190-330	67	500	360-640
52	270	195-345	68	515	370-660
53	280	200-360	69	530	380-680
54	300	215-385	70	550	395-705
55	315	225-405	71	570	410-730
Includes 95% of white males aged 7-20 years. Derived and adapted from J Pediatr* 1979;95:192-6.

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Pediatric Reactive Airway Disease Clinical Presentation

History

Physical Examination

References

Tables

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