Which clinical manifestations are appropriate in a child with asthma experiencing severe?

Adults with asthma present with a spectrum of signs and symptoms that vary in severity from patient to patient, and within the same patient over time. Some patients complain of very few mild symptoms while others present with more severe symptoms despite having only mild airflow obstruction. Airway function should be measured routinely by tests such as forced expiratory volume in 1 second (FEV1) or peak expiratory flow (PEF).

The clinical manifestations of asthma include recurrent episodes of wheezing, chest tightness, cough and shortness of breath. The symptoms are often worse at night or on waking from sleep. Usually, they resolve spontaneously or with the inhalation of a reliever medication. In other cases, they may worsen over hours or minutes, leading to more severe airflow obstruction and an ‘attack’ or exacerbation of asthma that is relieved only by extra medication. Some very severe episodes are life-threatening, although death from asthma in adulthood is uncommon (figure 2) and in most European countries mortality rates are falling.

Exacerbations of asthma are mostly provoked by respiratory infections – usually viral in origin – and are especially common in winter and shortly after the return of children to school after the summer holiday. In adults with allergic asthma (as indicated by the co-presence of rhinitis and conjunctivitis), symptoms are provoked by exposure to the relevant allergen(s), commonly those in house dust or from pets, or encountered at work. Other common triggers include physical exertion (particularly in cold, dry air) and traffic pollution. Certain drugs such as β-adrenergic blockers and nonsteroidal anti-inflammatory agents can provoke asthma. A rare, but characteristic form of adult-onset asthma presents with nasal polyps and symptoms provoked by taking aspirin or similar nonsteroidal anti-inflammatory agents; its mechanism is unclear. Asthma exacerbations remain the main reason for admission of people with asthma to hospital. While rates of hospital admission have gradually fallen in recent years, they remain high, particularly in the UK, Spain and Belgium (figure 3).

One important type of disease that arises in adulthood is occupational asthma, which is induced by airborne agents encountered in the workplace. Occupations in which there is a high risk of occupational asthma include baking, spray painting, chemical processing,  detergent manufacture and hairdressing. In addition, adults with asthma of unknown origin may find that irritant exposures or physical exertion at work exacerbate their disease. It is estimated that, in these ways, some 15% of all adult asthma is ‘work related’ (see chapter 24).

See the entire Adult asthma Chapter

Is this your child's symptom?

• Your child is having an asthma attack
• Use this guide only if a doctor has told you your child has asthma

Symptoms of Asthma

• Symptoms of an asthma attack are wheezing, a cough, tight chest, and trouble breathing.
• Wheezing is the classic symptom. Wheezing is a high-pitched whistling or purring sound. You can hear it best when your child is breathing out.
• The diagnosis of asthma requires attacks of wheezing that recur. The diagnosis is rarely made before 1 year of age.

Causes (Triggers) of Asthma Attacks

• Infections that affect breathing (like colds or the flu)
• Pollens (trees, grass and weeds)
• Animals (like cats or rabbits)
• Tobacco smoke
• Irritants (such as smog, car exhaust, menthol vapors, barns, dirty basement)
• Food Allergy (Serious). Asthma attacks caused by food allergy can be life-threatening (anaphylaxis). Examples are nuts or fish.

Asthma Attack Scale

• Mild: No Shortness of Breath (SOB) at rest. Mild SOB with walking. Can talk normally. Speaks in sentences. Can lay down flat. Wheezes not heard or mild. (Green Zone: Peak Flow Rate 80-100% of normal rate)
• Moderate: SOB at rest. Speaks in phrases. Wants to sit (can't lay down flat). Wheezing can be heard. Retractions are present (ribs pull in with each breath). (Yellow Zone: Peak Flow Rate 50-80% of normal rate)
• Severe: Severe SOB at rest. Speaks in single words. Struggling to breathe. Wheezing may be loud. Rarely, wheezing is absent due to poor air movement. Retractions may be severe. (Red Zone: Peak Flow Rate less than 50% of normal rate)
• Peak Flow Meter: a peak flow meter measures Peak Flow Rates (PFR). It tells us how well a person can move air out of the lungs. A PFR can be used in children 6 years and older.

Vaping and Lung Damage

• Talk with your teen about the dangers of vaping.
• Vaping can cause severe lung damage. It can become permanent.
• Vaping can even cause death (50 in the US in 2019).
• Vaping tobacco also causes nicotine addiction.
• For these reasons, the legal age to purchase vaping products is 21 in the US.
• Encourage your teen to not start vaping or to give it up.
• Warning: home-made or street-purchased vaping solutions are the most dangerous.

When to Call for Asthma Attack

Call 911 Now

• Wheezing and life-threatening allergic reaction to similar substance in the past
• Start to wheeze suddenly after a bee sting, taking medicine, or eating an allergic food
• Severe trouble breathing (struggling for each breath, can barely speak or cry)
• Passed out (fainted)
• Lips or face are bluish when not coughing
• You think your child has a life-threatening emergency

Call Doctor or Seek Care Now

• Lips or face have turned bluish during coughing
• PEFR is 50-80% of normal rate after using nebulizer or inhaler (Yellow Zone)
• Wheezing not gone 20 minutes after using neb or inhaler
• Breathing is much faster than normal
• Nonstop coughing not better after using nebulizer or inhaler
• Severe chest pain
• Need to use asthma medicine (neb or inhaler) more often than every 4 hours
• Fever over 104° F (40° C)
• Your child looks or acts very sick
• You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

• Mild wheezing lasts more than 24 hours on neb or inhaler treatments
• Sinus pain (not just congestion)
• Fever lasts more than 3 days
• Fever returns after being gone more than 24 hours
• You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

• Don't have written asthma action plan from your doctor
• Use an inhaler, but don't have a spacer
• Miss more than 1 day of school per month for asthma
• Asthma limits exercise or sports
• Asthma attacks wake child up from sleep
• Use more than 1 inhaler per month
• No asthma check-up in more than 1 year
• You have other questions or concerns

Self Care at Home

• Mild asthma attack

Care Advice for Asthma Attack

1. What You Should Know About Asthma:
   • Over 10% of children have asthma.
   • Your child's asthma can flare up at any time.
   • When you are away from your home, always take your child's medicines with you.
   • The sooner you start treatment, the faster your child will feel better.
   • Here is some care advice that should help.
2. Asthma Quick-Relief Medicine:
   • Your child's quick-relief (rescue) medicine is albuterol or xopenex.
   • Start it at the first sign of any wheezing, shortness of breath or hard coughing.
   • Give by inhaler with a spacer (2 puffs each time) or use a neb machine.
   • Repeat it every 4 hours if your child is having any asthma symptoms.
   • Never give it more often than 4 hours without talking with your child's doctor.
   • Coughing. The best "cough med" for a child with asthma is always the asthma medicine. Caution: don't use cough suppressants. If over 6 years old, cough drops may help a tickly cough.
   • Caution: if the inhaler hasn't been used in over 7 days, prime it. Test spray it twice into the air before using it for treatment. Also, do this if it is new.
   • Use the medicine until your child has not wheezed or coughed for 48 hours.
   • Spacer. Always use inhalers with a spacer. It will get twice the amount of medicine into the lungs.
3. Asthma Controller Medicine:
   • Your child may have been told to use a controller drug. An example is an inhaled steroid.
   • It's for preventing attacks and must be used daily.
   • During asthma attacks, keep giving this medicine to your child as ordered.
4. Allergy Medicine for Hay Fever:
   • For signs of nasal allergies (hay fever), it's okay to give allergy medicine. Reason: poor control of nasal allergies makes asthma worse.
5. Fluids - Offer More:
   • Try to get your child to drink lots of fluids.
   • Goal: keep your child well hydrated.
   • Reason: it will loosen up any phlegm in the lungs. Then it's easier to cough up.
6. Humidifier:
   • If the air in your home is dry, use a humidifier. Reason: dry air makes coughs worse.
7. Avoid Tobacco Smoke:
   • Tobacco smoke makes asthma much worse.
   • Don't let anyone smoke around your child.
8. Avoid or Remove Triggers:
   • Shower to remove pollens or other allergens from the body and hair.
   • Avoid known causes of asthma attacks (such as smoke or cats).
   • During attacks, reduce exercise or sports if it makes your child's asthma worse.
9. What to Expect:
   • If treatment is started early, most asthma attacks are quickly brought under control.
   • All wheezing should be gone by 5 days.
10. Inhaler With a Spacer: How to Use
    • Step 1. Shake the inhaler well. Then attach it to the spacer (holding chamber).
    • Step 2. Breathe out completely and empty the lungs.
    • Step 3. Close the lips and teeth around the spacer mouthpiece.
    • Step 4. Press down on the inhaler. This will put one puff of the medicine in the spacer.
    • Step 5. Breathe in slowly until the lungs are full.
    • Step 6. Hold a deep breath for 10 seconds. Allow the medicine to work deep in the lungs.
    • If your doctor has ordered 2 or more puffs, wait 1 minute. Then repeat steps 1-6.
11. Metered Dose Inhaler (MDI): How to Use Without a Spacer (if you don't have one)
    • Step 1. Shake the inhaler well.
    • Step 2. Breathe out completely and empty the lungs.
    • Step 3. Close the lips and teeth around the inhaler mouthpiece.
    • Step 4. Press down on the inhaler to release a puff. Do this just as your child starts to breathe in.
    • Step 5. Breathe in slowly until the lungs are full.
    • Step 6. Hold a deep breath for 10 seconds. Allow the medicine to work deep in the lungs.
    • If your doctor has ordered 2 or more puffs, wait 1 minute. Then repeat steps 1-6.
    • Ask your doctor for a spacer if you don't have one. It will help send more medicine into the lungs.
    • Older children who don't like a spacer can be prescribed an albuterol dry powder device.
12. Home Nebulizer: How to Use:
    • A nebulizer machine changes a liquid medicine (med) into a fine mist. The fine mist can carry the med deep into the lungs. This is called a nebulizer (neb) treatment.
    • Step 1. Prepare the medicine. First, wash your hands with soap and water. For pre-mixed single dose vials, just add one vial to the neb holding cup. For multi-dose vials, you need to do the mixing. First, add the correct amount of normal saline to the neb cup. Then carefully measure and add the correct amount of medicine to the saline.
    • Step 2. Connect the nebulizer to the air compressor tubing. The air compressor is run by electricity. Portable ones run on a battery. Compressors make the jet of air that turns the medicine into a fine mist.
    • Step 3. Turn on the air compressor. It will start making the fine mist that your child needs.
    • Step 4 for an Older Child. Place the mouthpiece between your child's teeth and seal with the lips. Ask your child to breathe slowly and deeply. Ask your child to hold a deep breath for 10 seconds once a minute.
    • Step 4 for a Younger Child. If your child refuses the mouthpiece, use a face mask. It should cover the nose and mouth. It should fit snugly.
    • Step 5. Continue the treatment until the med is gone. If the med sticks to the side of the cup, shake it a little. An average neb treatment takes 10 minutes.
    • Step 6. After each treatment, take the nebulizer apart. Rinse and clean it as directed. Reason: it can't produce mist if it becomes clogged up.
    • Caution: closely follow your doctor's instructions. Use the exact amount of med your doctor ordered. Don't give a neb treatment more often than every 4 hours.
13. Call Your Doctor If:
    • Trouble breathing occurs
    • Asthma quick-relief medicine (neb or inhaler) is needed more than every 4 hours
    • Wheezing lasts over 24 hours
    • You think your child needs to be seen
    • Your child becomes worse

And remember, contact your doctor if your child develops any of the 'Call Your Doctor' symptoms.

Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.

Last Reviewed: 10/16/2022

Last Revised: 01/13/2022

Copyright 2000-2022. Schmitt Pediatric Guidelines LLC.

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