Evaluation

To avoid delays in treatment, a brief physical examination should be performed before a detailed history is obtained. Treatment with inhaled b 2 agonists should not be withheld while the initial evaluation is in progress, even if the patient is in the triage area owing to lack of availability of a treatment room. Examination of vital signs should include respiratory rate, pulse, blood pressure, temperature, and pulse oximetry (Sa o2). Pulse oximetry, "the fifth pediatric vital sign," is an excellent noninvasive device for detecting severe airway obstruction. A room-air oxygen saturation of less than 91 percent in an infant may predict the need for hospitalization. Oxygen supplementation should never be delayed for any child in apparent respiratory distress for the sake of obtaining a pulseox. Oximetry may also be inaccurate in states of poor perfusion and fails to reflect a decrease in Pa co2 until the value of 80 mmHg is reached.

After initial stabilization, the health care provider must perform a complete exam, trying not to upset the child further. Children who are nonverbal and in respiratory distress may cry and be excessively clingy. The patient's chest must be visible for complete examination. Inspection and auscultation should be performed to assess alertness, accessory muscle use, and work of breathing. The severity of disease may be underestimated in the silent or "quiet wheezer," in whom the expiratory phase is usually prolonged and wheezing is absent due to extreme air trapping.

The "tripod position" is a significant indicator of distress: the child sits forward, hands over knees, on the edge of the bed. The nostrils should be inspected for presence or absence of nasal flaring, foreign bodies, and concurrent sinusitis. Hallmark "musical" polyphonic inspiratory and expiratory wheezes may not always be present on lung exam and are not prognostic of severity of disease. Extremities should be inspected to assess cyanosis and clubbing. Insensible fluid losses may result in delayed capillary refill and poor skin turgor. Pulsus paradoxus in severe exacerbation is usually 20 to 40 mmHg and may be reflected by significant jugular venous distention, which is otherwise difficult to appreciate in the pediatric examination.

Parents should be asked specifically if the child has previously had spells of wheezing (asthma attacks) and of what severity ( Table 1..20-2). A history of asthma may be denied because pediatricians who are reluctant to give the diagnosis of asthma use reactive airway disease as alternative nomenclature. History of previous hospitalizations, intubation, and tracheostomy should be actively sought, including old records when the parent is unable to give information owing to a language barrier or ignorance of the situation. History of prematurity, bronchopulmonary dysplasia (BPD), and oxygen requirement is especially significant. Specific questions should be asked of information that the parent may not automatically volunteer—for example, regarding a stay in the neonatal intensive care unit (NICU) (see Table.. 120-2). In the adolescent, specific questions regarding, for example, use of inhalants, tobacco, or drugs (especially amphetamine and cocaine) should be asked, as well as over-the-counter purchases of bronchodilators that their parents may not be aware they have been using. History of aspiration or choking, as well as possible ingestion should be included for all ages. Family history of asthma and allergy can also give a sense of whether or not the parent or caretaker will be able to continue treatment once the ED visit terminates.

Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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