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most obvious symptom, some patients may primarily have cough without
significant wheeze. Asking the family about typical symptoms for the child can
provide clarification.
Asthma is generally a clinical diagnosis, and some clinicians hesitate to
diagnose asthma in children younger than 24 months. However, an asthma
diagnosis is appropriate if the child has compatible history suggesting the
characteristic
features
of
lower
airway
obstruction,
bronchial
hyperresponsiveness, and reversible bronchospasm. Airway inflammation levels
and formal pulmonary function testing are uncommonly measured in the acute
setting.
The prevalence of “lifetime” asthma (ever diagnosed) is estimated at 13% for
U.S. children, with 6.1 million having active disease, and 53% having ≥1
exacerbation per year according to 2016 data. Children younger than 4 years old
have the highest rates of ED visits, ambulatory visits, and hospitalizations.
Asthma disproportionately affects minority children, those living in urban areas,
and those of lower socioeconomic status.
Triage
Prompt determination of the severity of respiratory distress will help direct
appropriate therapy. Level of severity can be generally categorized as mild,
moderate, severe, or impending respiratory failure. There are several validated
severity scoring tools, including the Pediatric Asthma Severity Score, Modified
Pulmonary Index, and Pulmonary Score. Many clinical guidelines utilize such
scores to outline severity-based therapy. These scores also allow physicians and
nurses to communicate about severity and response to therapy using a standard
language.

Initial Assessment/H&P
In addition to determining level of severity, obtaining asthma-specific history is
helpful to inform emergent care and disposition. Important history includes
information about the current exacerbation (duration, course, home medications
administered and response to treatment, and likely trigger) as well as chronic
severity of asthma (number of exacerbations during prior 12 months, number of
hospitalizations, number of ICU admissions, need for intubation, use of controller
therapies).
Chronic asthma severity reflects asthma control, often considered to include
assessment of asthma risk (prior exacerbations requiring unscheduled visits, use
of systemic corticosteroids, and hospitalizations) and impairment (asthma