Asthma — Determine Severity Level of Asthma Exacerbation — Clinical Pathway: Primary Care

Asthma — Determine Severity Level of Asthma Exacerbation — Clinical Pathway: Primary Care

Asthma Assessment — Key Points

Variability Asthmatic children show acute airway obstruction differently depending on many factors including age and baseline lung function. One set of criteria cannot define asthma severity accurately across this wide spectrum of disease. Assignment of acute asthma severity is based on an overall integrated assessment of available signs, symptoms and (if able) lung function.
Spirometry/Peak Flow Pulmonary function tests are objective measures to directly assess airway obstruction. Valid measurement requires good effort by the patient and should be interpreted based on baseline lung function (when available) or a value predicted by height.
PASS Pediatric Asthma Severity Score (range 0-6, see below) includes key exam elements (wheezing, work of breathing, prolongation of expiration) that correlate with the overall assessment to follow trends over time.
Pulse Oximetry Assessment for hypoxemia is important, as it may not be apparent on physical examination. It most often reflects ventilation-perfusion mismatch due to mucus plugging or bronchospasm which may not correlate with asthma severity. This effect may be temporarily worsened by bronchodilator therapy. Decisions about oxygen therapy should be based on overall saturation trends. Continuous pulse oximetry should be withdrawn as patients improve.

Determine Severity Level of Asthma Exacerbation

Key Exam Elements

Mild Moderate Severe Respiratory Arrest
Imminent
Wheezing None or mild (0)
None or end of
expiration only		 Moderate (1)
Throughout expiration		 Severe (2)
Inspiratory/expiratory or absent due to poor air exchange		 Diminished due to poor air exchange
Work of Breathing None or mild (0)
Normal or minimal retractions		 Moderate (1)
Intercostal retractions		 Severe (2)
Suprasternal retractions, abdominal breathing		 Tiring, inability to maintain work of breathing
Prolonged Expiration None or mild (0)
Normal or minimally prolonged		 Moderate (1) Severe (2) Severely prolonged

Other Exam Elements

Mild Moderate Severe Respiratory Arrest
Imminent
Breath Sounds/Aeration Normal Decreased at Bases Widespread Decrease Absent/Minimal

Symptoms

Mild Moderate Severe Respiratory Arrest
Imminent
Breathlessness With activity or agitation
  • While at rest
  • For infants:
    • Soft or shorter cry
    • Difficulty feeding
    • Prefers sitting
  • While at rest
  • For infants:
    • Stops feeding
    • Sits upright
Talks In Sentences Phrases Words
Alertness Alert May be agitated Agitated Drowsy, confused

Measurements

Mild Moderate Severe Respiratory Arrest
Imminent
Pulse Oximetry > 94% 91-94% < 91% Variable
PEF (% of Predicted by Height) ≥ 70% 40-69% < 40%

Guide to Breathing and Heart Rates in Awake Children

Age Normal Respiratory Rate
(per Minute)		 Normal Heart Rate
(per Minute)
< 2 mos < 60 < 160
2-12 mos < 50 < 160
1-2 yrs < 40 < 120
2-5 yrs < 40 < 110
6-8 yrs < 30 < 110