Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Asthma
ASTHMA
A disease of the lungs characterized by reversible or partially reversible airway obstruction, airway inflammation, and airway hyper-responsiveness. The usual manifestations are wheezing, cough, and dyspnea, although any of the three can be the sole presenting complaint. It is the most common chronic disease and the most serious atopic disease in children.
I. Etiology
A. Hyper-reactivity and inflammation of the tracheobronchial tree to chemical mediators
B. Allergens
1. Environmental inhalants, such as dust, molds, animal dander, pollens
2. Food allergens, such as nuts, fish, cow’s milk, egg whites, and chocolate provoke asthma in about 10% of children with asthma.
3. Anaphylactic reaction
C. Upper and lower viral respiratory tract infections
1. Viral infections are more common in younger children, particularly those in day care, who may easily have more than 12 infections a year.
2. In the younger age group, viral infections are the primary cause of asthma attacks.
D. Exertion: Exercise-induced asthma
E. Rapid temperature changes, cold air, humidity
F. Air pollutants: Smog, smoke, paint fumes, aerosols
G. Emotional upsets: Fear, anxiety, anger
H. Gastroesophageal reflux
II. Incidence
A. Prevalence of asthma has been increasing. Asthma is the leading cause of chronic illness in children.
B. Asthma affects about 5% of children under 18 years of age and disproportionately affects poor and minority children.
III. Subjective data
A. Onset may be abrupt or insidious.
B. Generally preceded by several days of nasal symptoms (sneezing, rhinorrhea)
C. Allergic salute or rubbing tip of nose upward with palm of hand
D. Dry, hacking cough
E. Tightness of chest
F. Wheezing
G. Dyspnea
H. Anxiety, restlessness
I. Rapid heart rate
J. Pertinent subjective data to obtain
1. History of upper respiratory tract infections, particularly in infants
2. History of allergic rhinitis or atopic dermatitis
3. Family history of atopic disease (e.g., allergic rhinitis, bronchial asthma)
4. History of inciting factors that may have initiated current attack
5. Review of environment (e.g., pets, heating system)
6. History of bronchospasm occurring after vigorous exercise
7. History of recurrent pneumonia or bronchitis
8. Cough, especially at night
K. Clues to diagnosis in nonacute phase
1. Symptoms
a. Cough: Exercise-induced asthma may be manifested as a cough with no wheezing.
b. Episodic wheezing: Acute wheezing may indicate aspiration of a foreign body.
c. Shortness of breath
d. Tightness of chest
e. Excessive mucus production
2. Pattern of seemingly isolated symptoms
a. Episodic or continuous with acute exacerbations
b. Seasonal, perennial, or perennial with seasonal exacerbations
c. Frequency of symptoms
d. Timing: After exercise, consider exercise-induced asthma; during night, consider gastroesophageal reflux
3. Factors precipitating symptoms: Exposure to common triggers (i.e., allergens, viral infections, exertion, pollutants, emotional upheavals, cold air)
L. History: Absence of symptoms that would indicate other chronic diseases (e.g., cystic fibrosis, cardiac disease)
1. Wheezing associated with feeding
2. Failure to thrive
3. Sudden onset of cough or choking
4. Digital clubbing
IV. Objective data
A. Prolonged expiratory phase; exhales with difficulty
B. Bilateral inspiratory wheezing; sometimes expiratory wheezing as well, which reflects exacerbation of the process. Patient with severe respiratory distress may not have enough air exchange to generate wheezing.
C. High-pitched rhonchi
D. Rales; sibilant or sonorous throughout lung fields
E. Cough, especially at night
F. In infants, inspiratory and expiratory wheezing with tracheal rales
G. Hyperresonance to percussion
H. Tachypnea
I. Evidence of hyperinflation; child sits upright with shoulders hunched forward to use accessory muscles of respiration.
J. Fever, if concurrent infection
K. History or signs of atopic disease; rhinitis, flexural eczema
L. In infants, intercostal and suprasternal retractions
M. Flaring of alae nasi
N. Altered mental status; indicates impaired gas exchange
O. Examination may be negative in a child with mild or moderate asthma who presents between episodes, except for signs of allergic rhinitis (see protocol, p. 218)
P. Examination may be negative for clinical features suggesting other diseases: Failure to thrive, digital clubbing, cardiac murmur, unilateral signs.
Q. Laboratory findings and diagnostic procedures
1. In mild or moderate acute attacks, laboratory studies are not generally indicated; diagnosis is generally clinical, depending on history and physical examination.
2. X-ray studies are not generally indicated except to rule out a foreign body or infectious process.
3. For recurrent episodes or mild asthma, skin testing and cytology may provide valuable data.
4. Oxygen saturation testing is useful in an acute episode.
5. Pulmonary function tests (PFT)
a. Spirometry: A 10% improvement in the forced expiratory volume in 1 second, or a 25% increase in the mean forced expiratory flow at 25% or 75% of vital capacity after inhaling a bronchodilator indicates reversible airway obstruction. Simple spirometry can be done in the primary care provider’s office.
b. Bronchial challenge tests: Refer to pulmonologist for testing and evaluation.
6. A complete blood count is generally not indicated for diagnosis, but if it is done, eosinophilia might indicate allergies. Blood gases should be analyzed with a severe episode.
V. Assessment
A. Acute asthma attack: Diagnosis clinical, dependent on history and physical examination (see Appendix M, p. 551)
B. Asthma
1. Diagnosis is generally made by history of symptoms and pattern of occurrence, physical examination, and if indicated, PFT.
2. Severity can then be classified clinically or with PFT.
a. Intermittent asthma (0–4 years)
(1) Symptoms that occur twice a week or more, with no nighttime awakenings
(2) No significant lifestyle disruptions
b. Intermittent asthma (5–11 years of age)
(1) Symptoms that occur twice a week or less, with nighttime awakenings 2 or fewer times per month
(2) No significant lifestyle disruptions
c. Mild persistent asthma (0–4 years)
(1) Daytime symptoms that occur two or more days per week but not daily, nighttime symptoms that occur one to two times per month
(2) Minor disruption of lifestyle
d. Mild persistent asthma (5–11 years)
(1) Symptoms that occur more than 2 times per week but not daily and nighttime awakenings 3–4 times per month
(2) Minor disruption of lifestyle
e. Moderate persistent asthma (0–4 years)
(1) Daily symptoms, symptoms that occur at night three to four times per month
f. Moderate persistent asthma (5–11 years)
(1) Daily symptoms with nighttime awakenings more than 1 time per week but not nightly
g. Severe persistent asthma (0–4 years)
(1) Continual daytime symptoms, nighttime symptoms more than one time per week
(2) Low-grade coughing and wheezing almost constantly
h. Severe persistent asthma (5–11 years)
(1) Symptoms throughout the day and often have nightly nighttime awakenings
(2) Extremely limited activity
C. Differential diagnosis
1. Bronchitis: Elevated temperature, poor response to epinephrine, negative family or patient history of atopy
2. Foreign body in trachea or bronchi: especially common in young children with negative history of atopy and unilateral wheezing. Confirm with bronchoscopy if history, physical examination, and x-ray studies are inconclusive.
3. Bronchiolitis: Most common in infants under 6 months, although it can occur in children up to 2 years of age. Temperature is variable; infant presents with paroxysmal cough, dyspnea, tachypnea, shallow respirations, marked hyperresonance, and markedly diminished breath sounds. A challenge with epinephrine usually does not cause improvement. Strongly suspect asthma if child has a second episode of bronchiolitis.
4. Pertussis: Rule out by history of exposure; nasopharyngeal cultures in children under 11 years or within 2 weeks of onset of symptoms, or serology in patients over 11 years with an illness of more than 2 weeks duration.
5. Cystic fibrosis: Rule out by previous history and, if indicated, by history and physical examination and sweat test.
6. Laryngotracheobronchitis: Usually seen in children under 3 years; characterized by insidious onset, with history of upper respiratory tract infection; harsh, barking cough with severe inspiratory stridor; slightly elevated temperature
VI. Plan
1. Bronchopneumonia: Dyspnea, tachypnea; rales or crackles may be present; expiratory wheezes generally not present; in advanced, consolidative phase, decreased breath sounds
A. Acute severe attack: Immediate treatment
1. Albuterol (nebulized), 5 mg/mL
a. Dosage: 0.10 to 0.15 mg/kg (up to 2.5 mg)
b. Frequency: Every 20 minutes, up to three doses
c. Observe at least 1 hour.
d. Refer stat if no response.
2. Oxygen as needed for O2 sat less than or equal to 92%
3. Poor response: Refer to emergency room.
4. Stable with good response after 1 hour of observation, normal respiratory rate, PEFR more than 70% to 90% baseline with no retractions or dyspnea
a. Discharge home.
b. Continue albuterol every 3 to 4 hours for 24 hours.
c. Continue routine medications.
d. Call stat if symptoms recur.
5. Incomplete response after first nebulizer treatment
a. Repeat nebulized albuterol.
b. Monitor heart and respiratory rate.
c. Consult with physician.
d. Consider nebulized ipratropium. Less than 20 kg: 250 mcg/dose every 20 minutes for 3 doses; more than 20 kg: 500 mcg/dose every 30 minutes for 3 doses
6. If improved after repeat nebulizer treatment, may go home with medications after 1 hour of observation
a. Prednisone or Orapred 1 to 2 mg/kg/d in three divided doses for 3–5 days
b. Dose need not be tapered.
c. Recheck again in 48 to 72 hours.
d. Initiate inhaled corticosteroids at that time.
7. If diminished consciousness or unable to generate PEFR
a. Administer epinephrine hydrochloride 1:1000 SC,
0.01 mg/kg (up to 0.3 mg), every 15 to 20 minutes for up to three doses.
b. Auscultate chest and heart after each dose. Do not repeat if pulse is over 180 beats/min.
c. Refer stat to emergency room for probable status asthmaticus.
B. With viral respiratory infection: Bronchodilator treatment every 4 to 6 hours up to 24 hours and then reevaluate; repeat for no more than once every 6 weeks because the increased need for bronchodilator treatment may necessitate the need to increase or initiate long-term therapy.
Patients are encouraged to begin use of bronchodilator at first sign of cold due to trigger effect of most upper respiratory infections (URI) on asthma. Patient should come in for evaluation.
C. Exercise-induced asthma
1. Inhaled beta-agonist, two puffs before exercise; repeat in 2 hours as needed if exercise sustained.
2. Alternative: Inhaled cromolyn sodium, two inhalations before exercise; lasts about 1 to 2 hours
3. If control not achieved, use inhaled beta-2 agonist, two inhalations, and inhaled cromolyn sodium, two inhalations 5 to 10 minutes after albuterol inhalation or salmeterol. Warming up before exercise may help to reduce bronchospasm.
D. Long-term treatment (see Appendix N, p. 558)
1. Goal of treatment is to control chronic symptoms, maintain normal activity levels, maintain normal or near-normal pulmonary function, and prevent acute episodes.
2. Frequency of exacerbations can be diminished by continuous therapy.
3. Side effects of prescribed drugs diminish with long-term administration.
a. Intermittent asthma
(1) Infants and children 0–11 years
(a) No daily medication needed; inhaled beta-agonist as needed for wheezing
(b) Reevaluate if a beta-2 agonist is needed on a daily basis. This usually indicates need for additional therapy.
b. Mild persistent asthma
(1) Infants and children younger than 4 years
(a) Low-dose inhaled corticosteroid (with nebulizer or metered-dose inhaler with a holding chamber with or without face mask or dry-powder inhaler)
(b) Alternative treatment: Cromolyn (nebulizer with holding chamber) or leukotriene receptor agonist
(c) Consider consultation
(2) Children older than 4 years
(a) Preferred treatment: Low-dose inhaled corticosteroids
(b) Alternative treatment: Cromolyn, leukotriene modifier, nedocromil, or sustained-release theophylline (Note: These are not necessarily in order of preference.)
(c) Consider consultation
c. Moderate persistent asthma
(1) Infants and children younger than 4 years
(a) Preferred treatments: Low-dose inhaled corticosteroids and long-acting inhaled beta-2 agonists or medium-dose inhaled corticosteroids
(b) Alternative treatment: Low-dose inhaled corticosteroids or leukotriene receptor antagonist
(c) For patients with recurring severe exacerbations: Preferred treatment, medium-dose inhaled corticosteroids and long-acting beta-2 agonists; alternative treatment, medium-dose inhaled corticosteroids and leukotriene receptor agonist
(2) Children older than 4 years
(a) Preferred treatment: Lowto medium-dose inhaled corticosteroids and long-acting inhaled beta-2 agonists
(b) Alternative treatment: Increase inhaled corticosteroids within medium-dose range or lowto medium-dose inhaled corticosteroids and either leukotriene modifier or theophylline (Note: These are not necessarily listed in order of preference.)
(c) For patients with severe exacerbations: Preferred treatment, increase inhaled corticosteroids within medium-dose range and add long-acting inhaled beta-2 agonists; alternative treatment, increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.
d. Severe persistent asthma: Referral to asthma specialist.
(1) Preferred treatment: High-dose inhaled corticosteroids and long-acting inhaled beta-2 agonists and if needed, corticosteroid tablets or syrup long-term (2 mg/kg/d, generally not to exceed 60 mg/d)
(2) Make repeated attempts to reduce system corticosteroids and maintain control with high-dose inhaled corticosteroids.
E. Peak flow monitoring program with moderate or severe asthma
F. Environmental control (see p. 291)
VII. Medications
(See charts in Appendix N, p. 558, for dosages for long-term control medications and comparative daily dosages for inhaled corticosteroids.)
A. Beta-2 agonists: Albuterol (Proventil, Ventolin), metaproterenol (Alupent)
1. Metered-dose inhaler: 2 to 4 inhalations every 4 to 6 hours depending on preparation
2. Dry-powder inhaler: One capsule every 4 to 6 hours
3. Nebulizer solution: Albuterol, 0.10 to 0.15 mg/kg every 4 to 6 hours, up to 2.5 mg
B. Cromolyn sodium (Intal)
1. Metered-dose inhaler: Adult, 2 to 4 inhalations, tid–qid; pediatric, 1 to 2 inhalations tid–qid
2. Dry-powder inhaler: One capsule, bid–tid
3. Nebulizer solution: One ampule, tid–qid
C. Theophylline
1. Less desirable as dosage based on serum level; should achieve serum concentration of 10 to 20 mcg/mL
2. Begin with low-dose and increase at 3to 4-day intervals, depending on clinical response and serum concentration.
3. Children’s dosage: 5–9 years, 20–24 mg/kg/d; 9–12 years, 16 mg/kg/d
4. Liquid, extended-release capsules, or tablets
a. 5 to 9 years: 16 to 22 mg/kg/d
b. 9 to 12 years: 16 to 20 mg/kg/d
c. 12 to 16 years: 16 to 18 mg/kg/d
D. Corticosteroids (see comparative daily doses in Appendix N, p. 558)
1. Metered-dose inhaler (beclomethasone [Beclovent, Vanceril]): 2 inhalations 4 times a day, or 4 inhalations every 12 hours
2. Oral (liquid [Pediapred] or tablets [prednisone]): 1 to 2 mg/kg/d (maximum: 60 mg/d for 3 to 10 days)
a. 1 year: 10 mg bid for 5 to 7 days
b. 1 to 3 years: 20 mg bid for 5 to 7 days
c. 3 to 13 years: 30 mg bid for 5 to 7 days
d. Over 13 years: 40 mg bid for 5 to 7 days
E. Epinephrine hydrochloride 1:1000; 0.01 mg/kg subQ; maximum of three doses at spaced intervals
1. 10 kg: 0.1 mL
2. 15 kg: 0.15 mL
3. 20 kg: 0.20 mL
4. 25 kg: 0.25 mL
5. 30 kg: 0.30 mL maximum dose
VIII. Education
A. Do not give antihistamines during an acute attack; they dry up respiratory secretions and may produce mucous plugs.
B. Try to keep child calm during acute attack: Anxiety can increase bronchospasm.
C. Postural drainage: Lie on bed with head hanging over the side.
D. Side effects of medications
1. Epinephrine: Tremor, tachycardia, anxiety, sweating
2. Theophylline: Irritation, nausea, vomiting, diarrhea, headache, palpitations, restlessness, insomnia
3. Albuterol: Palpitations, tachycardia, tremor, nausea, dizziness, headache, insomnia, drying or irritation of oropharynx
4. Cromolyn sodium: Cough, wheezing, nasal congestion, dizziness, headache, nausea, rash, urticaria
E. Theophylline
1. Metabolism varies among individuals and may be decreased by drugs such as cimetidine (Tagamet), ciprofloxacin (Cipro), and corticosteroids, causing an increase in serum concentrations.
2. Smoking may increase theophylline metabolism and decrease its effectiveness.
F. Cromolyn sodium
1. Prevents and reduces inflammation.
2. Prevents allergenor exercise-induced bronchoconstriction.
3. Action comparable to that of theophylline or inhaled corticosteroids
4. No bronchodilating activity; useful only for prophylaxis and does not work for acute attacks
G. Albuterol
1. Produces bronchodilation with less cardiac stimulation than older sympathomimetics
2. Provides the most rapid relief of acute asthma symptoms with fewest adverse side effects
3. Improvement should be noted within 15 minutes of use.
4. Do not exceed recommended dosage; action may last up to 6 hours.
H. Tablets are less expensive than liquids or chewables.
I. Metered-dose inhalers
1. Shake inhaler
2. Breathe out, expelling as much air from lungs as possible.
3. Place mouthpiece in mouth, holding inhaler upright.
4. While breathing deeply, depress top of metal canister, then remove from mouth.
5. Hold breath as long as possible.
6. If two inhalations are prescribed, wait several minutes and repeat steps 1 to 5.
7. Clean plastic case and cap in warm water after each use.
J. Aerosol-holding chambers (Aerochamber)
1. Consider using Inspirease or Aerochamber with metered-dose inhaler.
2. Improves delivery for children who cannot inhale all medication in one breath and provides more efficient delivery to the lungs.
3. Eliminates need to synchronize actuation and inhalation.
4. Clean chamber periodically with soap and water.
K. Dry-powder inhaler
1. Drug products designed to dispense powders for inhalation. DPI contains active ingredient(s) alone or with a suitable excipient(s). A DPI product may discharge up to several hundred metered doses of drug substance(s). Current designs include pre-metered and device-metered DPIs, both of which can be driven by patient inspiration alone or with power-assistance of some type.
L. Peak flow meter
1. Used to detect airflow obstruction before child is symptomatic
2. PEFR will have decreased by 25% or more before wheezing can be detected by auscultation.
3. PEFR should be measured each morning before taking medication.
4. Monitoring before and after medication in the morning and at bedtime yields the best information.
5. Healthy children generally have a PEFR 90% or above predicted value.
6. Measurements below 80% of predicted value suggest obstruction that requires treatment; measurements 50% or lower herald a severe attack.
M.Avoid offending allergens.
N. Environmental control (see p. 291)
O. Encourage child to participate in all activities that he or she is capable of doing.
P. There is no cure for asthma, but child should be symptom-free with proper medication (see Appendix M, Stepwise Approach, p. 551).
Q. Without adequate treatment to control asthma, life-threatening pulmonary complications may develop.
R. Parents or health care provider should maintain working relationship with school personnel.
1. Ensure that school nurse has information on child’s medications, including side effects. Request that nurse share this information with teachers.
2. Identify allergen and irritant exposures in the classroom (e.g., animals, carpeting, chalk dust, plants).
3. Periodic hearing impairment is common in allergic child. Suggest periodic audiometric evaluations and preferential seating if indicated.
S. Give patient or parent written instructions for plan of care. Include medications, use of peak flow meter, graphs, indications for returning to office, use of metered-dose inhaler, and Aerochamber.
1. One-Minute Asthma by Thomas F. Plaut, M.D. is a highly-rated, excellent educational tool.
2. Helpful to give individual informational sheets, which you can develop
IX. Follow-up
A. Call immediately if:
1. Breathing difficulty worsens.
2. Skin or lips turn blue.
3. Restlessness or sleeplessness occurs.
4. Cough or wheezing persists, or chest pain or fever develops.
5. Presence of side effects from medication (e.g., nausea, vomiting, irritability, palpitations).
B. Measure theophylline level 2 to 3 days after initiating oral therapy and every 2 to 3 months while on medication.
C. Return visit indicated for medication adjustment if asthma is not wellcontrolled
D. Routine follow-up every 6 months
E. When asthma is stable or under control, measure PEFR in office.
X. Complications
A. Pulmonary infections (especially in children under 5 years)
B. Status asthmaticus
C. Atelectasis
D. Emphysema (after recurrent attacks)
E. Death
XI. Consultation/referral
A. Severe asthma
B. Initial episode
C. Acute attack unresponsive to treatment
D. Wheezing in an infant or toddler
E. Side effects from medication
F. Persistent wheezing
G. Secondary infection (bacterial, viral, or fungal)
H. For respiratory therapy
I. For allergy testing if indicated
J. References and resources