Presenting History
In children presenting with acute respiratory distress and suspected Severe Acute Asthma (Status Asthmaticus), rapidly assess severity, immediate triggers, and baseline disease control.
- Acute Exacerbation Characteristics:
- Onset & Duration: Sudden acute worsening or progressive deterioration over several days following an upper respiratory tract infection.
- Breathlessness: Inability to lie flat (prefers upright or tripod position); speaks in short phrases or single broken words.
- Cough & Wheeze: Continuous dry, hacking cough; loud musical expiratory wheezing audible from a distance.
- Response to Home Bronchodilators:
- Document exact dose, frequency, and delivery device used (MDI with spacer vs dry powder inhaler vs nebulizer).
- Did symptoms fail to improve or recur within 15-20 minutes of SABA inhalation?
- Trigger Factors:
- Preceding viral coryza, cold air exposure, exercise, indoor smoke, aerosols, pets, or non-steroidal anti-inflammatory drugs (NSAIDs).
- Assessment of Chronic Baseline Asthma Control (GINA 2024 - Preceding 4 Weeks):
- Daytime asthma symptoms $>2\text{ times/week}$?
- Any night waking due to asthma symptoms?
- Short-acting beta-2 agonist (SABA) reliever needed $>2\text{ times/week}$?
- Any activity limitation due to asthma?
- Scoring: None = Well Controlled; 1–2 = Partly Controlled; 3–4 = Uncontrolled.
- High-Risk Features for Fatal / Near-Fatal Asthma:
- Prior admission to PICU or history of mechanical ventilation for asthma.
- Hospitalization or emergency visit for asthma in the past 12 months.
- Current or recent oral corticosteroid burst.
- Overuse of SABA ($>1\text{ canister/month}$).
- Poor adherence to maintenance Inhaled Corticosteroid (ICS) controller therapy.
Negative History (3C 1D Framework)
| Category | Pertinent Negative Question | Rationale / Significance |
|---|---|---|
| Causes | Foreign Body Inhalation: No history of sudden acute choking, gagging, or coughing fit while eating peanuts or playing with toys. Infection: No history of high persistent fever, toxic appearance, or purulent sputum. | Excludes acute foreign body aspiration mimicking asthma. Differentiates acute bronchospasm from severe bacterial pneumonia. |
| Complaints (Severity & Red Flags) | Impending Respiratory Arrest: No history of cyanosis, drowsiness, confusion, or sudden cessation of wheezing ("silent chest"). Air Leak: No history of sudden sharp chest pain, neck swelling, or crackling sensation under the skin (subcutaneous emphysema). | Detects hypercapnic exhaustion requiring immediate intubation. Rules out pneumothorax or pneumomediastinum complicating acute asthma. |
| Complications | Anaphylaxis: No history of acute urticaria, angioedema of lips/tongue, stridor, vomiting, or exposure to insect sting or food allergens. Cardiac Wheeze: No history of congenital heart disease, gallop rhythm, or poor pulses. | Excludes multi-system anaphylactic bronchospasm. Differentiates bronchial asthma from left heart failure with pulmonary edema. |
| Differentials | Acute Bronchiolitis: Age $>12-24\text{ months}$? Croup: No history of barking cough, hoarseness, or inspiratory stridor. | Differentiates infant viral bronchiolitis from childhood asthma. Rules out upper airway laryngotracheal obstruction. |
Other Relevant History
- Atopic History: Personal history of atopic eczema, allergic rhinitis, food allergies; family history of asthma or atopy in first-degree relatives (mAPI criteria).
- Environmental Aeroallergen Exposure: Tobacco smoke exposure (first/second/third-hand smoke), biomass fuel exposure, damp walls, furry pets, cockroaches, mold.
- Controller Compliance: Exact daily dose of Inhaled Corticosteroid (ICS), device type, and spacer technique.
History Summary
"Master/Miss `Patient Name`, a `Age` old `male/female` child, `Birth Order` born of `consanguineous/non-consanguineous` parents from `City, State`, with a known background of `controlled/uncontrolled` bronchial asthma and atopy, presented with acute onset of severe breathlessness, continuous dry cough, and audible wheezing for `Duration in hours` hours, with inability to speak in sentences and poor response to home Salbutamol inhaler puffs, triggered by `viral infection / cold air / allergen exposure`, without history of foreign body aspiration or cyanosis.
In view of the acute severe bronchospasm, inability to complete sentences, and failure of home SABA therapy, I would like to consider a provisional diagnosis of Severe Acute Exacerbation of Bronchial Asthma (Status Asthmaticus), in a child with `Uncontrolled / Partly Controlled` baseline asthma."
General & Head-to-Toe Examination
- Child Behavioral State Assessment:
- Document child state (e.g., Prechtl State 4: conscious, anxious, upright in tripod position, speaking in single words or short phrases, tachypneic).
- Vitals:
- Heart Rate: Sinus tachycardia.
- Respiratory Rate: Marked tachypnea.
- Pulsus Paradoxus: Measure systolic drop during inspiration ($>10-15\text{ mmHg}$ indicates severe obstruction).
- Blood Pressure: Normal or elevated due to stress.
- Oxygen Saturation ($SpO_2$): Room-air saturation ($<92\%$ indicates severe exacerbation).
- Signs of Respiratory Distress:
- Accessory muscle use: Scalene and sternocleidomastoid muscle contraction.
- Retractions: Suprasternal, intercostal, and subcostal indrawing; tracheal tug.
- Allergic stigmata: Allergic shiners, Dennie-Morgan lines, transverse nasal crease.
Systemic Examination
Respiratory System
- Inspection:
- Hyperinflated chest contour with increased anteroposterior diameter.
- Markedly prolonged expiratory phase with active abdominal muscle contraction ($I:E = 1:3\text{ to } 1:4$).
- Palpation:
- Trachea midline.
- Chest expansion symmetrically reduced.
- TVF symmetrically decreased due to air-trapping. Rhonchial fremitus palpable.
- Percussion:
- Diffusely hyperresonant percussion note over all lung fields.
- Obliteration of cardiac dullness and downward displacement of hepatic dullness.
- Auscultation:
- Vesicular breath sounds with marked expiratory prolongation.
- Wheezing: High-pitched, polyphonic, musical expiratory and inspiratory wheezes heard diffusely throughout all lung zones.
- Silent Chest Alert: If breath sounds and wheezes become inaudible despite severe retractions, recognize impending respiratory arrest!
- Objective Severity Scoring: Calculate the Pediatric Respiratory Assessment Measure (PRAM Score) (Score 8–12 = Severe Asthma Exacerbation).
Other Systems
- Cardiovascular System: Marked tachycardia, muffled heart sounds from hyperinflated lungs, no murmurs.
- Abdomen: Soft, non-tender; liver edge felt below costal margin due to depressed diaphragm (normal liver span).
- Central Nervous System: Assess for agitation (hypoxia) or lethargy/drowsiness (hypercapnia).
Final Summary & Diagnosis
"Master/Miss `Patient Name`, a `Age` old `male/female` child, presented with acute onset of severe breathlessness, continuous dry cough, and poor response to home bronchodilators following a viral upper respiratory infection.
Physical examination reveals tachypnea, tachycardia, pulsus paradoxus ($>10\text{ mmHg}$), room-air $SpO_2 < 92\%$, marked accessory muscle use, hyperresonant lung fields, diffuse polyphonic wheezing, and a PRAM score of `Score / 12`.
Final Diagnosis Format:
"Severe Acute Exacerbation of Bronchial Asthma (Status Asthmaticus / PRAM Score `8-12`), triggered by a viral respiratory infection, complicated by `Hypoxemia / Severe Airflow Obstruction`, in a child with `Uncontrolled` baseline atopic asthma.""