pulmonary disease Acute asthma exacerbations in pediatrics

Asthma is the most common chronic disease affecting children worldwide. According to international consensus, asthma is defined as a chronic inflammatory disorder associated with variable airflow obstruction and bronchial hyper-responsiveness. Globally, ~۱۱-۱۴% of all children report asthma symptoms, with increasing prevalence reported worldwide. Measured by school absences, Emergency Department (ED) visits, hospitalization and parental work absence, paediatric asthma is a major burden on childhood and family health worldwide. Poorly controlled childhood asthma is associated with a lower quality of life, lower cardiovascular fitness, increased missed school days in children and decreased caregiver productivity. These human and economic impacts are critically apparent when children experience acute asthma exacerbations (AAEs). AAEs or 'flare-ups' are defined as acute or subacute episodes of progressive increases in asthma symptoms associated with airflow obstruction. AAEs are associated with high morbidity and, on rare occasions, mortality, particularly with children from visible minorities and living in socioeconomically disadvantaged environments. As such, AAEs are one of the most common reasons children seek ED care worldwide. The goals of care for managing children with AAEs are generally understood and shared across multiple guidelines. These goals are the basis of a stepwise approach to managing paediatric AAEs and are (۱) immediate and objective assessment of AAE severity; (۲) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (۳) appropriate disposition of patient and (۴) a safe discharge home plan. The majority of this review is organized around this stepwise approach. A focused history and physical examination are recommended to (۱) confirm the diagnosis of an AAE, (۲) determine aetiology, (۳) determine AAE severity and (۴) estimate the risk factors for intensive care unit (ICU) admission. In order to provide appropriate and effective treatment, it is crucial to promptly determine the severity of the AAE. Children with a critical AAE should not have their treatment delayed. Pertinent clinical information includes previous asthma history, exposure to triggers and asthma medications administered (adherence, dose, timing of medications, social barriers to care). Of critical importance are questions on risk factors for fatal asthma. Children with these risk factors require caution and specialist involvement with their care.