What’s Your Diagnosis? Pediatric Acute Asthma

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on An Evidence-Based Review of Life-Threatening Secondary Headaches in Pediatric Patients in the Emergency Department right.

Case Presentation: Emergency Department Management of Pediatric Acute Asthma: An Evidence- Based Review 

A 3-year-old girl presents to the ED with cough, rhinorrhea, and increased work of breathing…  

The child’s parents report she has had mild upper respiratory infection symptoms for the past 3 days that worsened overnight. The girl has a home nebulizer with albuterol for “wheezing” episodes, but she has not been formally diagnosed with asthma. Her breathing initially improved with 2 treatments overnight, but now her parents say she seems worse. They report no vomiting, and the girl is tolerating oral intake. The girl’s past medical history is significant for intermittent eczema and hospitalization for RSV bronchiolitis at 9 months of age. The girl was born at full term without complications. She currently attends day care. Her father smokes but “not in the house.” 

On examination, the child is fussy but consolable and alert. She is febrile to 38°C, tachypneic to the 40s, with subcostal retractions and expiratory wheezes throughout all lung fields, with fair air movement. The girl’s oxygen saturation is 94% on room air. 

Do you believe this girl likely has asthma? If so, what are her risk factors? What is your approach to this child’s management? If she responds to treatment, what criteria would you use for potential discharge? 

Case Conclusion

The girl presented with mild respiratory distress with tachypnea, subcostal retractions, and prolonged expiratory wheezes, but her oxygen saturation was maintained. Although she had not been formally diagnosed with asthma, given her history of RSV infection and recurrent wheezing responsive to SABA and intermittent atopy, you were suspicious for an acute asthma flare triggered by concurrent viral illness. You administered albuterol via an MDI/spacer with mask and noted improvement in the girl’s work of breathing and air movement, although she still had mild tachypnea and prolonged wheezing in her posterior lung fields.

You decided to administer another albuterol treatment and oral dexamethasone and performed serial reassessment with continuous pulse oximetry. Over the next hour, she continued to improve, with resolution of her tachypnea. Only faint end-expiratory wheezes were heard at her bases, air movement was normal, and her oxygen saturation was 98%. With a PRAM score of 1, she was able to be safely discharged with asthma home-care instructions and primary care follow-up within the next week. 

Click to review Pediatric Emergency Medicine Practice, Safe Use of Opioids

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Last Updated on August 24, 2023

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