Emergency department care usually begins with an assessment at triage to determine the level of illness. For asthma, this includes vital signs (temperature, pulse and breathing rates, and blood pressure) and pulse oximetry, a small clip that attaches to a child’s finger or toe to measure the oxygen content of the blood. This device can be frightening to young children, but it does not cause pain. The triage nurse will listen to a child’s chest to assess air movement and wheezing. This information will be combined into an overall assessment that is used to decide which patients need immediate care.
Assessment of asthma is subjective, and not all staff members may be familiar or comfortable with assessing young children. It is important to communicate your concerns about your child clearly to the triage nurse, but also recognize that nurses may be trying to treat a number of patients at once. Unfortunately, asthma flares tend to be seasonal and many asthmatic children may come in at the same time, taxing the resources of the hospital. Children with low pulse oximetry usually are brought back immediately to receive oxygen. The oximetry level at which oxygen is required varies by altitude, but it will definitely be required if it is below 90 percent. (Normal is 95 percent or greater.) Low oxygen levels typically are caused by mucus plugging the airways, leading to temporary collapse of areas of the lung (referred to as atelectasis). These areas will reexpand as mucus and airway obstruction improves.
Next, a physician, nurse practitioner, or other medical professional will evaluate your child. It is important to relate your child’s asthma history and response to treatment for past flares. Some children respond rapidly to treatment, while others take more time. Your child’s individual past experience may help the staff to plan for hospitalization or discharge.
Asthma flares in the emergency department are treated by using a combination of medicines that are inhaled and/or systemic (that is, given orally, intravenously, or as a shot). Inhaled treatments typically contain albuterol and other medicines that relax the muscles of the airway. These may be given by an inhaler or by nebulizer.
Typically, much higher and more frequent doses are given in the emergency room than are given at home. This is possible because your child is being monitored closely for side effects, such as a fast heart rate. Your child may feel jittery from the albuterol.
Steroid medicines in the emergency room are typically given by mouth in the form of prednisone or other preparations. Steroid medicines act to reduce inflammation in the lungs and have been shown to improve symptoms of a severe flare within two to four hours. Steroids may also be given in an injectable form, although research has not shown that medicine given by injection provides any clear benefit over medicines taken orally. But oral steroid preparations typically have a bitter taste and may cause vomiting. Newer forms are available (Orapred is an example) that taste better. Oral steroids can also cause temporary hyperactivity in some children and can irritate the stomach, but in general they are safe and effective for short periods of time to treat an asthma flare.
After the initial medicines are given, a child is usually observed for several hours to see how well she responds. This can be frustrating, but it’s necessary because the doses of albuterol given initially are higher than home doses, and your child’s condition may become worse as the effect decreases. If the response is good, your child will probably be discharged to go home with albuterol to use as needed and a short course of oral prednisone or another steroid.
After returning home, you should continue any regular asthma medicines and call your regular physician for an appointment. The fact that your child needed an emergency room visit suggests that it’s time to reexamine the management plan and consider whether changes are needed.