Pediatric Asthma: A Guide for EMS Providers

Heather Scruton, MBA, MSN, RNC-OB, Assistant Director, Critical Care Transport

Children who have asthma are at increased risk for severe exacerbation, especially when weather changes dramatically and seasonal allergies are common.

Symptoms

Sometimes the only sign of childhood asthma is a lingering or recurring cough. There are four components of an asthma exacerbation, causing shortness of breath. These may be symptoms patients present at the scene:

Appropriate assessment and timely intervention may mean the difference between life and death for these patients. Of all pediatric asthma deaths, half occur in the out-of-hospital setting.

The impact of asthma on children who reside in our service area was significant in 2019:

• 155 children were transported by the Critical Care Transport team with the diagnoses of asthma, asthma exacerbation, respiratory distress r/t asthma, hypoxia r/t asthma or status asthmaticus.
• 728 children were diagnosed, treated or hospitalized at Children’s Mercy for asthma.

Disease characteristics

Asthma is a disease of the bronchial tubes, classifying it as a lower airway disease.

Common irritants or asthma triggers are:

• Allergies (dust mites, animal dander, molds, pollen, cockroach droppings)
• Tobacco or fumes
• Exercise-induced bronchoconstriction (EIB)
• Medications (NSAIDS, beta-blockers, migraine medications)
• Emotional anxiety, stress
• Viral or bacterial infections
• Exposure to weather changes

Asthma action plan

Patients who have been diagnosed with pediatric asthma should have an asthma management plan (also known as an asthma action plan; also available in Spanish). If you are transporting a patient who has asthma symptoms, be sure to ask their parent or guardian if they have a plan, and the progression of the child’s status (red, yellow or green). These plans are:

• Recommended by the National Asthma Guidelines to help individuals and families manage attacks and avoid triggers.
• Used to provide instructions during asthma exacerbations and guidance about emergency care.
• Ordered by the patient’s health care provider, typically a pediatric allergist/immunologist.

EMS response

If you are a first-responder in a pediatric asthma emergency, the following may be appropriate actions. Consult the emergency medicine team at the receiving hospital for further direction:

• Out-of-hospital treatment of asthma emergencies includes the use of bronchodilators and intramuscular (IM) epinephrine.
• Nebulized albuterol (2.5mg/3ml), an inhaled beta-2 agonist, may be initiated with or without ipratropium bromide (0.25-0.5mg), an inhaled anticholinergic, depending on agency-specific protocols.
• Additional doses of albuterol may be administered, but ipratropium bromide is recommended for a max of 3 doses.
• IM epinephrine (0.01mg/kg of 1 mg/ml concentration, 0.3ml max) may be warranted if a child is not tolerating nebulized treatments, or if bronchodilators are ineffective due to poor air movement with breathing.

Remember, asthma exacerbations create an air-trapping effect associated with severe bronchospasm. Assisted ventilation may be necessary in instances of respiratory failure, but may also be associated with complications and death.

If a child fails to respond to aggressive bronchodilator and high-flow oxygen therapy, consider assisting ventilation with slow rates and long expiratory times to minimize barotrauma and allow for exhalation of carbon dioxide.