Pediatric emergency medicine trisk 2775 2775

Noninvasive ventilatory support (CPAP or BiPAP) may benefit patients tiring
from increased work of breathing and with impending respiratory failure.
Pediatric studies are limited but suggest that it is generally well tolerated. While
some studies suggest that it may reduce need for ICU admission, in practice, most
patients who require noninvasive ventilatory support are treated in an ICU setting.
CXRs are not routinely indicated for acute asthma exacerbations in children.
Wheezing is a common symptom of asthma and pneumonia in children, therefore
determining which patients warrant imaging can be challenging. Data regarding
children of all ages with wheezing and fever who had CXR for possible
pneumonia, suggest that approximately 5% will have radiographic findings of
pneumonia. However, the potential risks of CXR include radiation exposure and
false-positive results leading to unnecessary antibiotic therapy. In general,
patients with a typical asthma exacerbation do not routinely need imaging given
this low rate of abnormal findings. In a patient with mild to moderate respiratory
distress, the decision to perform a CXR may be deferred until reassessment after
initial treatment; focal abnormal breath sounds may have improved suggesting
atelectasis as opposed to pneumonia.
Clinical Indications for Discharge or Admission
In general, children requiring frequent albuterol (generally defined as more
frequent than every 2 to 4 hours) or having persistent hypoxemia require
admission. Other reasons for admission include significant dehydration, infection
requiring inpatient treatment or monitoring, or medical history that may impact
the respiratory system (e.g., cardiac disease, neuromuscular disorder, or metabolic
disorder). Most patients requiring frequent inhaled bronchodilator therapy or
adjunctive therapy (e.g., parenteral bronchodilators) will require hospitalization.
Protocols regarding which therapies require an ICU setting vary by institution.
Patients discharged should be encouraged to follow up with their primary care
providers (PCPs) within 1 to 3 days. Discharge instructions should include
information about care following the acute visit and may include formulation of
an asthma action plan. This provides an opportunity to assist patients with
management during future exacerbations and to encourage partnership with PCPs

for ongoing discussions and modifications of asthma care.
Inhaled steroids should be continued for patients currently taking them, and
clinicians should strongly consider prescribing them from the ED when indicated.
Patients with 2 or more days/nights of symptoms and/or albuterol use per week
likely have chronic asthma severity in the “persistent” range and inhaled steroids
are recommended. Data suggest that many patients treated for acute asthma in