Status Asthmaticus

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Patho/ Background:
Asthma flare-ups have two stages: early and late. They start when IgE antibodies produced by certain cells react to triggers such as pollen, dust, animals and many more. These antibodies attach to cells, causing the release of substances like histamines. This release tightens the airways making it harder to breathe. Certain immune cells play a crucial role in producing interleukins that communicate and sustain inflammation. These interleukins support the survival of specific cells and involve remodeling of the tissue. In the later phrase, various cells act in the lungs, causing breathing difficulties. Mast cells play a key role in transporting late-phrase reactants to inflamed areas. Recognizing these processes is essential for effective therapy, especially considering the impact on breathing. Interestingly, people with thicker airways tend to have longer-lasting issues. Inflammation and narrowing of the airways lead to breathing difficulties:

• Air trapping
• Lung hyperinflation
• Increased RR to compensate for increased pulmonary dead space
• Large negative inspiratory pressures --> increased afterload on LV causing a decrease in cardiac output (pulsus paradoxes)
• Gas exchange abnormality (V/Q mismatch)

Between 2020-2023, there were about 250-340 cases reported annually for asthma in the PICU.
 
Treatment Algorithm:
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Emergency Room:

• Back to back duonebs x3
• Inhaled short-acting beta-agonists (SABAs) have a rapid onset of action. These bronchodialtors work by relieving smooth muscle constriciton and relaxing the airway. Atrovent also provides smooth muscle relaxation in combination with albuerol. These therapies are administered up to 3 times back to back or at 20-30 minute intervals. 
• Systemic corticosteroids 
• Decrease airway inflammation
• Early administration has been shown to decrease hospital admission rates (administer ASAP)
• Continuous albuterol
• Magnesium
  • It is thought that magnesium relaxes the smooth muscle, but the exact mechanism of action is unknown. 

PICU:

• Take note of prior ICU admissions for status asthmatics
• Increased CO2 can cause mental status changes/ fatigue
• Child may feel sense of impending doom
• Oxygen: Assist with correcting VQ mismatch
• Fluids: Increased insensible losses
• Medications:
  • Inhaled beta agonists
  • Corticosteroids: decrease inflammation and mucous production
  • IV Beta Agonists: terbutaline
  • Anticholinergics: Bronchodilator without inhibition of mucous clearance, use in conjunction with beta agonists and steroids
  • Magnesium Sulfate
  • Ketamine
  • Isoflurane
  • Intubation (air trapping)
    • Can cause emergency air leak syndromes
      • pneumothorax
      • pneumomediastinum
      • pulmonary interstitial emphysema

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References:

Kline-Tilford, A. M., & Haut, C. (2020). Cases in pediatric acute care: Strengthening clinical decision making. Wiley-Blackwell.

Additional Resources:

PICU Essentials on the App Store (apple.com)

PICU Essentials - Apps on Google Play