Treatment Variability of Asthma Exacerbations in a Pediatric Emergency Department Using a Severity-Based Management Protocol

Abstract

Acute asthma exacerbations are one of the most frequent reasons for emergency department visits and the most frequent reason for hospitalization of children in North America. Appropriate management and disposition decisions are dependent on accurate assessment of exacerbation severity, and severity scores are frequently used for this purpose. To our knowledge the variability of exacerbation management when a severity score is used to guide treatment has not been reported. There are a variety of published acute asthma severity scores. In 2000, Chalut et al published the Preschool Respiratory Assessment Measure (PRAM)1. The PRAM consists of five variables: wheezing, air entry, contraction of scalenes, suprasternal retraction, and oxygen saturation. It was standardized against respiratory resistance as measured by forced oscillation. In 2012, Arnold published the Acute Asthma Intensity Research Score (AAIRS)2. The AAIRS is similar to the PRAM, but substitutes scalene muscle retractions with visual observation of intercostal and subcostal retractions as well as auscultation for expiratory phase prolongation. Our tertiary children’s hospital uses the 15-point pediatric asthma score (PAS)3. The PAS is used by clinicians and respiratory therapists for scoring pediatric asthma exacerbation severity in our emergency department (PED). The PED utilizes an acute asthma exacerbation management pathway derived from National Asthma Education and Prevention Program (NAEPP) guidelines, with four recommended treatment tiers corresponding to ranges of the PAS4. Our objective was to evaluate adherence to the recommended management pathway in our pediatric ED.