Pediatrics · Year 3 · from Pediatrics

Case 3: Acute Asthma Exacerbation

Patient Demographics

  • Age: 7-year-old female
  • Sex: Female

Chief Complaint

"She's having an asthma attack and her inhaler isn't working."

History of Present Illness

A 7-year-old female with known asthma presents with progressive shortness of breath and wheezing for 2 days, worsening significantly today. She developed cold symptoms 4 days ago with runny nose and cough. She has been using her albuterol MDI every 2-3 hours with minimal relief. This morning she could not complete sentences without stopping to breathe. She has been coughing frequently, especially at night. She has a history of 2 prior ED visits for asthma in the past year, with one requiring a short course of oral steroids. She uses a daily inhaled corticosteroid (fluticasone) but admits to missing doses frequently. No recent fever. History of environmental allergies. Family history of asthma in mother.

Growth Parameters

  • Weight: 25 kg (50th percentile)
  • Height: 122 cm (50th percentile)

Physical Examination

  • General: Anxious, sitting upright, speaking in short phrases (3-4 words), using accessory muscles
  • Vital signs: T 37.4C, HR 128, RR 32, BP 108/70, SpO2 90% on room air
  • HEENT: Nasal congestion, clear rhinorrhea
  • Neck: Suprasternal retractions, no cervical lymphadenopathy
  • Cardiovascular: Tachycardia, no murmur
  • Respiratory:
  • Moderate respiratory distress
  • Accessory muscle use (sternocleidomastoid, intercostal)
  • Decreased air entry bilaterally
  • Diffuse expiratory wheezes bilaterally, scattered inspiratory wheezes
  • I:E ratio 1:3 (prolonged expiration)
  • No paradoxical breathing
  • Skin: No cyanosis, mild diaphoresis
  • Neurologic: Alert, anxious

Workup

  • Peak flow: 120 L/min (50% predicted - moderate obstruction)
  • SpO2: 90% on room air (92% on 2 L NC)
  • Chest X-ray: Hyperinflation, no infiltrates, no pneumothorax
  • Blood gas (if severe): Not obtained for this severity

Diagnosis

Moderate-severe acute asthma exacerbation (viral-induced)

Clinical Reasoning

This child has a moderate-severe asthma exacerbation based on: speaking in phrases (not sentences), accessory muscle use, SpO2 90-95%, peak flow 50% predicted, and poor response to home bronchodilator therapy. Viral URI is the most common trigger. Risk factors for severe exacerbation include prior ED visits, prior oral steroid use, and poor adherence to controller medication. The prolonged expiratory phase and decreased air entry indicate significant airflow obstruction.

Management

  1. Immediate treatment:
  • Oxygen via nasal cannula to maintain SpO2 >94%
  • Continuous nebulized albuterol (0.5 mg/kg/hour, max 15 mg/hour) OR albuterol MDI 4-8 puffs every 20 min x 3
  • Ipratropium bromide 0.5 mg nebulized with first 3 albuterol treatments
  • Systemic corticosteroids: Prednisone 2 mg/kg PO (max 60 mg) or methylprednisolone IV if unable to tolerate PO
  1. Reassess after initial treatment:
  • Peak flow, work of breathing, SpO2
  • If improving: Space bronchodilators to every 1-2 hours
  1. If severe/refractory:
  • Magnesium sulfate 50 mg/kg IV (max 2 g) over 20 min
  • Consider terbutaline infusion
  • ICU for impending respiratory failure
  1. Disposition:
  • Admit if requiring oxygen or frequent bronchodilators after 4-6 hours
  • Discharge criteria: Peak flow >70% predicted, SpO2 >94% on RA, symptoms controlled with q4h bronchodilator
  1. Discharge medications:
  • Prednisone 1-2 mg/kg/day x 5 days (no taper needed)
  • Albuterol MDI with spacer every 4-6 hours as needed
  • Resume/optimize controller medication
  1. Asthma action plan review and follow-up in 1-2 weeks

Clinical Image

Image Description: Chest radiograph demonstrating hyperinflation with flattened diaphragms characteristic of acute asthma exacerbation.

Source: Radiopaedia URL: https://radiopaedia.org/cases/asthma-acute-exacerbation License: CC BY-NC-SA 3.0

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