II. Criteria: Mild Exacerbation

  1. Symptoms
    1. Breathlessness while walking
    2. Able to lie supine
    3. Speaks in sentences
    4. Possible agitation
  2. Signs
    1. Increased Respiratory Rate
    2. No accessory muscle use or retractions
    3. End-Expiratory Wheezes
    4. Heart Rate <100
    5. Pulsus Paradoxus absent (<10 mmHg difference)
  3. Diagnostics
    1. Peak Expiratory Flow (PEF) >70% of predicted or of personal best
    2. O2 Sat >95% on room air
    3. Arterial Blood Gas (Not typically indicated)
      1. PaO2 normal on room air
      2. PCO2 <42mmHg

III. Criteria: Moderate Exacerbation

  1. Symptoms
    1. Breathlessness while walking and at rest (infant with softer, shorter cry)
    2. Prefers sitting to lying supine
    3. Speaks in phrases
    4. Agitation
  2. Signs
    1. Increased Respiratory Rate
    2. Accessory muscle use and retractions
    3. Loud Wheezes throughout expiration
    4. Heart Rate 100-120
    5. Pulsus Paradoxus possibly present (10-25 mmHg difference)
  3. Diagnostics
    1. Peak Expiratory Flow (PEF) 40-69% of predicted or of personal best
    2. O2 Sat >90-95% on room air
    3. Arterial Blood Gas (Not typically indicated)
      1. PaO2 >60 mmHg on room air
      2. PCO2 <42mmHg

IV. Criteria: Severe Exacerbation

  1. Symptoms
    1. Breathlessness at rest (infant does not feed)
    2. Sits upright
    3. Speaks in words
    4. Agitation
  2. Signs
    1. Increased Respiratory Rate >30/minute
    2. Accessory muscle use and retractions
    3. Loud Wheezes throughout inspiration and expiration
    4. Heart Rate >120
    5. Pulsus Paradoxus present (>25 mmHg difference in adults and 20-40 mmHg difference in children)
    6. Cyanosis may be present
  3. Diagnostics
    1. Peak Expiratory Flow (PEF) <40 of predicted or of personal best
    2. O2 Sat >90% on room air
    3. Arterial Blood Gas (Respiratory failure)
      1. PaO2 <60 mmHg on room air
      2. PCO2 >42mmHg

V. Criteria: Life-Threatening Exacerbation with imminent respiratory arrest

  1. Symptoms
    1. Includes severe symptoms as above
    2. Drowsy
    3. Confused
  2. Signs
    1. Includes severe signs as above
    2. Paradoxical thoracic and abdominal muscle excursion
    3. Wheezing absent
    4. Bradycardia
    5. Pulsus Paradoxus absent (secondary to respiratory muscle Fatigue)
  3. Diagnostics
    1. Includes severe exacerbation diagnostic results as above
    2. Peak Expiratory Flow (PEF) <25% of predicted or of personal best (or unable)

VI. References

  1. Fuchs and Yamamoto (2011) APLS, Jones and Bartlett, Burlington, p. 66-7
  2. (2007) National Asthma Education and Prevention Program Guidelines, U.S. HHS NIH, 07-4051

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