For the second part of the Asthma Guideline Podcast Chris Connolly and Becky Maxwell focus on its application in Paediatric Emergency Departments. Nikki Abela has already done a great blog on this for RCEM which is worth a read (and it provides more detail than these show notes).
Just like for adults, the Guideline gives a long list of clinical parameters to ascertain whether the child in front of you falls into the mild, moderate, severe or life threatening category. These are important to know for exams but in reality on the shop floor we tend to use a checklist or protocol to remind ourselves of them! It is worth noting that the features of life threatening asthma are similar in children and adults – cyanosis, silent chest etc.
Important things to remember when treating the asthmatic child:
- Beta agonists: If less than 2 years old and they don’t get better with bronchodilators delivered appropriately in hospital – rethink the diagnosis – this is what Edward Snelson often talks about with beta agonists in the under 1. It’s not ‘that beta agonists don’t work, it’s that the diagnosis is wrong’.
- What’s your approach to an asthmatic child? If the child falls into the moderate category or above start with 10 puffs x3, 20 mins apart and review the kids 5 mins between them and then at 20 mins afterwards.
- The Guideline recommends if the patient is hypoxic (<92%) use nebulisers. Add ipratropium 250mcg every 20mins for the first 2 hours if refractory to beta agonists.
- Consider adding 150 mg magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children with a short duration of acute severe asthma symptoms presenting with an SpO2 <92%. This was something that was news to us, evidence for this advice comes from the MAGNETIC Trial – which did not show a improvement in the asthma severity score when nebuliser magnesium was added but did demonstrate a clinical response in those children with SpO2 <92%.
- Consider adding IV Magnesium in these children 40mg/Kg (but remember it may take a while to work so start drawing up the next drug……..)
- Second line is IV salbutamol – bolus dose – 15mcg/kg over 10mins followed by a continuous infusion. In our opinion this is the point we would consider getting our critical care colleagues down to the ED!
When/how to discharge the asthmatic child:
Discharge those who have been observed and are now requiring 2-4 hourly inhalers. Make sure you have follow up in 48 hours and provide a written asthma plan ( we are much better at this in children than in adults!)
There are two big ‘social’ treatments we should explore in the ED are the smoking cessation and obesity. Chris Connolly is happy with addressing smoking cessation but really struggles with telling parents their children are overweight. The thing is; as awful as this is, it has to be part of our job, we aren’t doing our job properly unless we discuss the issue – perhaps bringing parent away from child to have a discussion in private is more sensitive than discussing weight issues in front of the child.
- For us nothing major has changed in terms of treatment interventions or diagnostic categories other than adding nebulised Magnesium in children whose SpO2 < 92%
- It is really all about doing the simple stuff well, the importance of appropriate follow up and written plan and the importance of addressing smoking and obesity cannot be underestimated
- Chris Connolly to date is still working on his social awkwardness…..