Clerkship Ready: Pediatrics

Asthma is a common chronic disease of childhood that affects 1 in 12 children in the United States. It can range from mild respiratory symptoms to life threatening respiratory failure, with a range of treatment options in-between from the primary care setting to the pediatric ICU. In this episode, we will discuss the underlying pathophysiology, diagnosis, evaluation, and management of patients with asthma, along with some useful clinical pearls to help you take care of these patients!

1. Cause of asthma
   
   
   1. Genetics: “Atopic triad” of asthma, atopic dermatitis or eczema, and allergic rhinitis
   
   
   2. Prenatal and childhood environmental factors: maternal smoking and allergen exposure
   
   



2. Pathophysiology and diagnosis
   
   
   1. AAP definition: “episodic and reversible airway constriction and inflammation in response to infection, environmental allergens, and irritants. It is a complex, multifactorial, and immune-mediated process that presents with various clinical phenotypes.”
   
   
   2. Airway hyperreactivity leads to inflammation of bronchi, increased mucus production, bronchial smooth muscle contraction
   
   
   3. Key elements of the history – recurrent episodes of cough, wheeze, difficulty breathing, nighttime symptoms, consistent trigger, atopic personal or family history, improvement with asthma treatment.
   
   
   4. Identification of triggers is important. Common triggers include respiratory infections, mold or pet dander, pollen, intense crying or laughing, exercise, pollution, and cold air.
   
   
   5. Children from minority and lower-income backgrounds experience an increased asthma burden, likely closely tied to a complex interaction of factors such as decreased access to healthcare, increased rates of obesity, and poor air quality in the areas in which they live.
   
   



3. Classification of asthma: determined by the frequency and severity of symptoms when they are not receiving preventative treatment.


4. New 2022 guidelines for asthma treatment
   
   
   1. Albuterol or other beta 2 agonist as needed for symptoms - relaxes bronchial smooth muscles
   
   
   2. Daily controller medication (usually inhaled steroid) if symptoms more than twice weekly - inhaled steroid decreases inflammation
   
   
   3. Inhaled steroid + long-acting beta 2 agonist combination inhaler preferred for those >5 years
   
   
   4. Asthma action plan should be given to every patient
   
   



5. Treatment of acute asthma attack
   
   
   1. Quick assessment and stabilization of patient is important
   
   
   2. Treat acute symptoms first, then address chronic control of asthma
   
   
   3. Albuterol or ipratropium-albuterol, systemic steroids are generally first lines of treatment
   
   
   4. Supplemental oxygen as needed
   
   
   5. Other options for medications: magnesium, terbutaline, theophylline, epinephrine
   
   
   6. Frequent reassessment is needed
   
   

Resources:

Global Initiative for Asthma, Pocket Guide for Asthma Management and Prevention for Adults, Adolescents and Children 6-11 Years. Updated 2023. https://ginasthma.org/wp-content/uploads/2023/07/GINA-2023-Pocket-Guide-WMS.pdf