Overview
Definition:
Respiratory Therapist-driven (RT-driven) protocols for asthma management are standardized treatment plans initiated and modified by respiratory therapists based on patient assessment, typically in emergency departments or inpatient settings
These protocols aim to optimize bronchodilator delivery, oxygenation, and other supportive care measures for pediatric patients experiencing asthma exacerbations, ensuring timely and evidence-based interventions
They empower RTs to make critical treatment decisions within defined parameters, enhancing efficiency and patient outcomes.
Epidemiology:
Asthma is a prevalent chronic respiratory disease in children, affecting millions globally
In India, prevalence varies by region but is significant, leading to substantial healthcare utilization, including emergency department visits and hospitalizations
RT-driven protocols are particularly relevant in busy pediatric emergency departments where prompt assessment and initiation of treatment are crucial.
Clinical Significance:
Implementing RT-driven protocols standardizes care, reduces variability in treatment, and ensures rapid initiation of appropriate interventions for pediatric asthma exacerbations
This can lead to improved patient outcomes, shorter lengths of stay, and more efficient use of healthcare resources
For DNB and NEET SS aspirants, understanding these protocols is vital for managing common pediatric emergencies effectively.
Age Considerations
Infants And Toddlers:
Exaggerated or muffled wheezing
Difficulty feeding due to dyspnea
Irritability and poor feeding
Respiratory rate may be difficult to accurately assess due to crying.
Preschool Children:
Audible wheezing, especially on expiration
Cough, often worse at night
Chest tightness
Tachypnea and retractions become more pronounced.
School Aged Children And Adolescents:
Typical symptoms of wheezing, cough, dyspnea, and chest tightness
May report reduced exercise tolerance and frequent awakenings at night
Ability to communicate symptoms clearly.
Neonatal Considerations:
Asthma-like symptoms in neonates are rare and often indicate other underlying conditions like bronchiolitis, pneumonia, or congenital anomalies
Diagnosis should be approached with caution, and RT-driven protocols are less common in this age group due to diagnostic uncertainty.
Clinical Presentation
Symptoms:
Wheezing, particularly expiratory
Persistent cough, often worse at night or with exercise
Chest tightness or pain
Shortness of breath or dyspnea
Difficulty speaking in full sentences.
Signs:
Tachypnea
Increased respiratory rate
Accessory muscle use (supraclavicular, intercostal, subcostal retractions)
Prolonged expiratory phase
Audible wheezing on auscultation
Decreased breath sounds in severe exacerbations (indicating poor air movement)
Cyanosis in severe cases
Tachycardia.
Diagnostic Criteria:
Diagnosis of asthma in children is primarily clinical, based on recurrent episodes of wheezing and airflow obstruction that is at least partially reversible
Specific criteria like the GINA (Global Initiative for Asthma) guidelines or national consensus statements are used
RT-driven protocols often rely on objective parameters like SpO2, respiratory rate, and clinical assessment of work of breathing.
Diagnostic Approach
History Taking:
Focus on pattern of symptoms: frequency, duration, triggers (allergens, infections, exercise, cold air)
Past medical history: previous asthma diagnosis, hospitalizations, intubations
Family history of atopy (asthma, eczema, allergic rhinitis)
Medications used and response
Presence of prodromal symptoms
Red flags: poor feeding in infants, inability to speak, cyanosis, altered mental status.
Physical Examination:
Assess general appearance: distress, alertness, ability to speak
Vital signs: respiratory rate, heart rate, SpO2, blood pressure
Auscultation: presence and character of wheezing, rhonchi, rales
air entry
prolonged expiratory phase
Palpation: assess for accessory muscle use and chest wall expansion
Percussion: hyperresonance may be present.
Investigations:
Pulse oximetry (SpO2): essential for assessing oxygenation, target SpO2 usually >92-94%
Arterial blood gas (ABG): may be indicated in severe exacerbations to assess pCO2 (normal or low in mild-moderate, rising in severe impending respiratory failure) and pH
Chest X-ray: usually not indicated in typical asthma exacerbations unless pneumonia, pneumothorax, or other complications are suspected
Spirometry/Peak Expiratory Flow Rate (PEFR): useful in older children (>5-6 years) to assess severity and response to treatment, but often difficult during acute exacerbations.
Differential Diagnosis:
Bronchiolitis (especially in infants <2 years)
Pneumonia
Viral-induced wheeze
Foreign body aspiration
Cystic fibrosis
Tracheomalacia/Bronchomalacia
Allergic bronchopulmonary aspergillosis
Vocal cord dysfunction.
Management
Initial Management:
Assess severity using standardized scales (e.g., modified Pulmonary Index Score, Pediatric Asthma Severity Score)
Administer supplemental oxygen to maintain SpO2 >92-94%
Administer short-acting beta-agonist (SABA) via nebulizer or metered-dose inhaler (MDI) with a spacer
Continuous or frequent intermittent nebulization of SABA (e.g., Albuterol/Salbutamol 2.5 mg for <25 kg, 5 mg for >25 kg every 20 minutes for 3 doses) is common in RT-driven protocols
Monitor response closely.
Medical Management:
Short-acting beta-agonists (SABAs): Albuterol (Salbutamol) is the first-line bronchodilator
Dosing typically based on weight: 0.15 mg/kg/dose (minimum 2.5 mg, maximum 10 mg) every 20 minutes for up to 3 doses initially, then every 1-4 hours as needed
Anticholinergics: Ipratropium bromide (0.025 mg/kg/dose, max 2.5 mg) can be added to SABAs, especially in moderate-to-severe exacerbations, given every 20 minutes for 3 doses
Systemic corticosteroids: Oral or intravenous corticosteroids (e.g., Prednisolone, Methylprednisolone) are indicated for moderate-to-severe exacerbations to reduce inflammation
Dosing varies but often 1-2 mg/kg/day of Prednisolone, or equivalent
Magnesium sulfate: Intravenous magnesium sulfate (25-75 mg/kg/dose, max 2g) may be considered for severe exacerbations not responding to initial treatment
IV fluids: Maintain adequate hydration, especially if oral intake is poor due to dyspnea.
Supportive Care:
Continuous cardiorespiratory monitoring: heart rate, respiratory rate, SpO2
Frequent reassessment of respiratory status and response to therapy
Provide calm environment to reduce anxiety
Encourage rest
Maintain hydration
Avoid sedatives unless absolutely necessary and with extreme caution due to risk of respiratory depression.
Rt Driven Protocol Components:
RTs assess patient: lung sounds, work of breathing, SpO2, ability to use MDI
Initiate SABA therapy as per protocol based on severity
Titrate oxygen to maintain target SpO2
Administer ipratropium if indicated
Assess response after each treatment
If no improvement, escalate care (e.g., add ipratropium, consider corticosteroids, notify physician)
If significant improvement, transition to less frequent SABA dosing
Protocols often include specific criteria for notifying the physician, escalating care, or initiating specific medications like magnesium or corticosteroids
They also define discharge criteria.
Complications
Early Complications:
Respiratory failure: leading to hypoxemia and hypercapnia
Pneumothorax: spontaneous or barotrauma-related
Atelectasis: due to mucus plugging
Vomiting: common with aggressive nebulization.
Late Complications:
Status asthmaticus: a severe, prolonged asthma attack unresponsive to usual treatment
Respiratory muscle fatigue
Hospital-acquired pneumonia
Long-term airway remodeling and fixed airflow obstruction (less common in pediatric asthma compared to adult).
Prevention Strategies:
Adherence to controller medications for persistent asthma
Regular follow-up with healthcare providers
Education on proper inhaler technique and trigger avoidance
Prompt recognition and management of early signs of exacerbation
Effective implementation of RT-driven protocols to ensure timely interventions.
Prognosis
Factors Affecting Prognosis:
Severity of initial exacerbation
Age at onset
Presence of comorbidities
Adherence to treatment plan
Access to timely and appropriate medical care
Effectiveness of trigger avoidance strategies.
Outcomes:
With prompt and appropriate management, most pediatric asthma exacerbations resolve successfully, leading to symptom improvement and discharge
However, severe exacerbations can lead to prolonged hospitalization, ICU admission, and in rare cases, mortality
Long-term prognosis depends on achieving good asthma control and preventing frequent exacerbations.
Follow Up:
Regular follow-up appointments with pediatrician or pulmonologist are essential to monitor asthma control, adjust medications, reinforce education on trigger avoidance, and assess adherence
Children with recurrent severe exacerbations may require more frequent monitoring and specialist care
Spirometry follow-up is recommended once the child is able to cooperate with the testing.
Key Points
Exam Focus:
Understand the role and decision-making points of RT-driven protocols
Dosing of SABAs (Albuterol/Salbutamol) and ipratropium
Indications for systemic corticosteroids and magnesium sulfate
Criteria for escalating care and notifying physicians
Interpretation of SpO2 and ABG in asthma
Differential diagnosis of wheezing in children.
Clinical Pearls:
Always assess the child's work of breathing and ability to speak, not just SpO2
Continuous nebulization is often more effective than intermittent for severe exacerbations
Monitor for paradoxical bronchospasm with SABA overuse
Be cautious with sedatives in asthmatic patients
Remember that a rising pCO2 in a child with asthma is a sign of impending respiratory failure.
Common Mistakes:
Underestimating the severity of an exacerbation
Delayed administration of SABAs or corticosteroids
Inadequate oxygenation targets
Over-reliance on chest X-rays for diagnosis of simple asthma exacerbations
Failure to consider alternative diagnoses when treatment is ineffective
Lack of clear communication between RTs and physicians leading to delayed escalation.