Definition

• Child is having an asthma attack
• Don’t use this guideline unless the child was previously diagnosed as having asthma, asthmatic bronchitis or reactive airway disease by a physician

Main symptom

• A wheeze or whistling (purring) sound on breathing out is the classic symptom
• Coughing may be the first symptom of an asthma attack

Causes (triggers) of asthma attacks

• Viral respiratory infections
• Animal contact (especially cats)
• Tobacco smoke or menthol vapors
• Pollens
• Air pollution (e.g., barn, circus, wood stove, dirty basement)

Severity of an asthma attack

• Mild: no shortness of breath (SOB) at rest, mild SOB with walking, speaks normally in sentences, can lie down flat, wheezes only heard by stethoscope (GREEN Zone: Peak Flow Rate 80-100% of baseline level or personal best)
• Moderate: SOB at rest, speaks in phrases, prefers to sit (can’t lie down flat), audible wheezing (YELLOW Zone: Peak Flow Rate 50-80% of baseline level)
• Severe: severe SOB at rest, speaks in single words (struggling to breathe), usually loud wheezing or sometimes minimal wheezing because of decreased air movement (RED Zone: Peak Flow Rate less than 50% of baseline level)

See more appropriate topic (instead of this one) if

• No previous asthma diagnosis or use of asthma medicines, see wheezing

When to Call Your Doctor

Call 911 Now (Your Child May Need an Ambulance) If

• Severe difficulty breathing (struggling for each breath, unable to speak or cry because of difficulty breathing, making grunting noises with each breath)
• Your child passed out or has bluish lips/tongue
• Wheezing started suddenly after medicine, an allergic food or bee sting

Call your doctor now (night or day) if

• Your child looks or acts very sick
• Looks like he did when hospitalized before with asthma
• Difficulty breathing not resolved 20 minutes after neb or inhaler
• Peak flow rate lower than 50% of baseline level (personal best) (RED Zone)
• Peak flow rate 50-80% of baseline level after using neb or inhaler (YELLOW Zone)
• Wheezing (heard across the room) not resolved 20 minutes after using neb or inhaler
• Continuous (nonstop) coughing that keeps from playing or sleeping and not improved after using neb or inhaler
• Severe chest pain
• Asthma medicine (neb or inhaler) is needed more frequently than every 4 hours
• Fever over 104° F (40° C) and not improved 2 hours after fever medicine
• You think your child needs to be seen urgently

Call your doctor within 24 hours (between 9 a.m. and 4 p.m.) if

• You think your child needs to be seen, but not urgently
• Mild wheezing persists over 24 hours on treatment
• Sinus pain (not just congestion
• Fever present for more than 3 days
• Fever returns after gone for over 24 hours

Call your doctor during weekday office hours if

• You have other questions or concerns
• Don’t have written asthma action plan
• Uses an inhaler, but doesn’t have a spacer
• Missing more than 1 day of school/month for asthma
• Asthma limits exercise or sports
• Asthma attacks frequently awaken from sleep
• Uses more than 1 inhaler/month
• No asthma check-up in over 1 year

Parent care at home if

• Mild asthma attack and you don’t think your child needs to be seen

Home Care Advice for Asthma Attack

Asthma rescue medicine

• Start your child’s quick relief medicine (e.g., albuterol inhaler or nebs) at the first sign of any coughing or shortness of breath (don’t wait for wheezing). (Reason: Early treatment shortens the asthma attack).
• The best “cough medicine” for a child with asthma is always the asthma medicine.
• Follow your child’s action plan for asthma attacks.
• For albuterol inhalers, give 2 puffs separated by a few minutes, every 4 to 6 hours.
• Caution: if the inhaler hasn’t been used in over 7 days or is new, test spray it twice into the air before using it for treatment.
• Continue the asthma rescue medicine until your child has not wheezed or coughed for 48 hours.
• Spacer: Always use inhalers with a spacer. It will double the amount of medicine that gets to the lungs.

Asthma controller medicine

If your child is using a controller medicine (e.g., inhaled steroids or cromolyn), continue to give it as directed.

Hay fever

For nose allergy symptoms, it’s OK to give antihistamines. (Reason: poor control of nasal allergies makes asthma symptoms worse)

Fluids

Encourage drinking normal amounts of clear fluids (e.g., water) (Reason: keeps the lung mucus from becoming sticky)

Humidifier

If the air is dry, use a humidifier (Reason: to prevent drying of the upper airway)

Avoid or remove allergens

Give a shower to remove pollens, animal dander, or other allergens from the body and hair. Avoid known triggers of asthma attacks (e.g., tobacco smoke, feather pillows). Avoid exercise during the attack.

Expected course

If treatment is started early, most asthma attacks are quickly brought under control. All wheezing should be gone by 5 days

Call your doctor if

• Difficulty breathing occurs
• Inhaled asthma medicine (neb or inhaler) is needed more often than every 4 hours
• Wheezing persists over 24 hours
• Your child becomes worse

And remember, contact your doctor if your child develops any of the “Call Your Doctor” symptoms.

References

1. Alario AJ, Mansell A, Mansell C: Management of acute asthma in the pediatric office. Pediatr Ann 1999;28:19-28.
2. Cuff S, Loud K. Exercise-induced bronchospasm: keeping our patients active. Contemp Pediatr. 2008;25(9):88-94.
3. Delgado A, Chou KJ, Silver EJ, Crain EF. Nebulizers vs. metered-dose inhalers with spacers for bronchodilator therapy to treat wheezing in children aged 2 to 24 months in a pediatric emergency department. Arch Pediatr Adolesc Med. 2003;157:76-80.
4. Gayle MO and Kissoon N. Assessment of respiratory distress in the asthmatic child: When should we be concerned? Pediatr Ann. 1996;25:128-134.
5. Guill MF. Asthma update: clinical aspects and management. Pediatr Rev. 2004;25(10):335-343.
6. Gupta RS, Weiss KB. The 2007 national asthma education and prevention program asthma guidelines. Pediatrics.2009;123:s193-s198.
7. Hill VL, Wood PR. Practical management of asthma. Pediatr Rev.2009;30(10):331-336.
8. Lasley MV. New treatments for asthma. Pediatr Rev. 2003;24(7):222-232.
9. Morris A, Mellis C. Asthma. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Publishing Group; 2000. p. 206-214
10. NAEPP Expert Panel Report 3. Guidelines for the diagnosis and management of asthma. Washington, DC, August 2007.
11. Phipatanakul, W. Environmental factors and childhood asthma. Pediatr Ann. 2006;35(9):647-656.
12. Richman MJ, Scott P, Kornberg A. Partnership for excellence in asthma care: Evidence-based disease management. Pediatr Ann. 1998;27:563-568.
13. Sherman FM and Capen CL. Red alert program for life-threatening asthma. Pediatrics. 1997;100:187-191.
14. Turcios NL. What you need to know about pediatric asthma pharmacology. Contemp Pediatr. 2001;18(1):81-101.
15. Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children. Arch Pediatr Adolesc Med. 2008;162(2):157-163.

Disclaimer

This information is not intended to be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D. Clinical content review provided by Senior Reviewer and Healthpoint Medical Network.

Last Review Date: 6/1/2011

Last Revised: 8/1/2011 2:47:46 PM

Content Set: Pediatric HouseCalls Symptom Checker

Version Year: 2012

Copyright 1994-2012 Barton D. Schmitt, M.D.