Dr. Hive: Asthma

[Quad Shot Academy]

Does this sound right to you??? :bigear:

 

My 4.5 yob woke Sunday with a strange cough that woke us all up. After a couple hours the coughing had mellowed but he sounded like his chest was congested. He had no other symptoms. At 7:40 pm he started breathing very strangely. He was pushing out his belly and sucking in really hard (labored breathing). He said he was fine, his breaths were making no noise and he had no fever. After a call to the doc we took him to the ER.

 

At triage, his pulse ox was 93 and his respiration rate was 38 and he was wheezing on one lung every 10 breaths. When they finally got around to treating him his pulse ox was 91 and one lung was closed. After treating him with 3 nebs his pulse ox dropped to 86. He had a chest x-ray which showed airway disease (asthma). They gave several rescue inhaler doses and an oral steroid over the next 6 hours and discharged him with a pulse ox of 91. We got a rescue inhaler that we use every 4 hours and oral steroids. He starts having difficulty breathing at 3 hours.

 

This morning he had bad lung congestion and heavy breathing. We went to the ped and his pulse ox was 90, his respirations were 50 and he was wheezing (according to ped) with each breath in both lungs. She gave him the inhaler and said it greatly eased his breathing. She said if he worsened we would have to readmit him to the hospital. I asked her why he was worse now than before the treatment. She said that she thinks he got a funky virus that hit him wrong and now we are seeing the other effects of the virus (congestion, weird voice) other than the asthma. She thinks this will go on for five more days.

 

When we got home he was running around playing and got really upset with his sister. He started the labored breathing again, so I had him lay down and watch TV and then he was fine. He just came up stairs and his breathing was really bad again and he sounds like Kermit the Frog, but it is also time for the inhaler again.

 

I know nothing about asthma. He has never had an attack before. Is there really nothing else that can be done? Are they treating him correctly? Is this really asthma or are they missing something?? Is it really safe to run around and play when your resting pulse ox is 90?? :confused:

[Karen A]

The "rule" of our ped. is the child needs a SaO2 of 93% or greater to stay out of the hospital, and albuterol needed no more than every 4 hours.

 

I would not let my wheezing/poorly oxygenating child run around--but when my dd has a number like that, and its corresponding lung decompensation, she is distressed and not wanting to run...

 

If I were you I would encourage sedentary activity. Continue to watch the resp. rate, whether or not your ds is "retracting"--the skin kind of pulls in between the ribs/clavicles/sternum, and if you can, listen to the lungs/wheezing. If dd has RR >40 and/or retracting, we are sent to the ER.

 

In our experience asthma has required IV steroids, oxygen, and of course the albuterol.

 

:grouphug: --it can be scary, I know.

Edited October 5, 2010 by Karen A
add more detail

[wapiti]

If this is the first time he's experienced breathing trouble, I wouldn't necessarily call it asthma. Airway disease is vague (dd had this recently). Probably a viral bronchiolitis. Not that it really matters at this point.

 

Where I would be concerned is in the treatment plan. IMO, too young for an inhaler with a spacer, and in any event, IME, the treatment should be albuterol by nebulizer every four hours instead of the inhaler (along with the oral steroids that you got, probably a five-day (total) course of oral steroids). Whether to do an inhaled steroid on top of the oral one is debatable.

 

just my two cents (recently went through this exact situation with my 14-month-old, I have another one with asthma, and have two other kids who, on different occasions, have each been hospitalized on oxygen for bronchiolitis.)

 

I realize that the inhaler is supposed to be as effective as the nebulizer, but over the past 8 years, and six different kids having albuterol, in my experience the nebulizer is much more effective, especially when the breathing issue is serious. (FWIW, around here I'm happy if your SATs are over 90 :) ) Way too much room for user error with the inhaler in a child that young.

 

ETA: if he's falling apart at the 3-hour mark, I'd give him the albuterol at that point. It's not necessary to wait the full 4-hours. At our house, if they're really bad, I'll do it at about 2.5 hours if I need to, and if they look like they need it sooner than I'm willing to give it, they need to be seen.

 

I agree with the advice to look for retractions and listen for wheezing. I put my ear on their back to listen. Counting respiration is also excellent advice.

Edited October 5, 2010 by wapiti

[Quad Shot Academy]

What should they do at the hospital, that we can't do at home? We went to Children's and they just kept turning the alarm down when it would keep going off. At first it was set at 89, eventually they set it to 85!! :confused: I kept saying that they needed to treat him and they assured me that he would be fine if it was above 75. They said that certain pediatric heart patients are not allowed about 75 and they do just fine. I told them that my grandma gets loopy at 88 and they said that was because she was old. Finally a doctor was walking by, glanced in the room and came running in and put him on O2. He went up to 91.

 

 

My ped today (both of her sons have asthma) was fine with him going home with a resting resp rate of 50 and O2 level of 90.

 

His Kermit voice completely went away after his inhaler does.

 

What would you do if you were me and your ped thought it was fine and Children's hospital thought it was fine? I don't think telling them that the Hive disagrees with them will help!

[wapiti]

What should they do at the hospital, that we can't do at home? We went to Children's and they just kept turning the alarm down when it would keep going off. At first it was set at 89, eventually they set it to 85!! :confused: I kept saying that they needed to treat him and they assured me that he would be fine if it was above 75. They said that certain pediatric heart patients are not allowed about 75 and they do just fine. I told them that my grandma gets loopy at 88 and they said that was because she was old. Finally a doctor was walking by, glanced in the room and came running in and put him on O2. He went up to 91.

 

 

My ped today (both of her sons have asthma) was fine with him going home with a resting resp rate of 50 and O2 level of 90.

 

His Kermit voice completely went away after his inhaler does.

 

What would you do if you were me and your ped thought it was fine and Children's hospital thought it was fine? I don't think telling them that the Hive disagrees with them will help!

 

The only thing the hospital can do more of is O2 and measuring pulse/ox. If he's running around that's a good sign usually, but I have a stealth wheezer who can be running around and be in the 80's :glare:.

 

Listen for wheezing, look for retractions, count the respiratory rate. And give the albuterol when it looks like he needs it. Don't forget the nighttime. It's horrible to wake them up, but the SAT level tends to drop when they are in a deep sleep, so they often need albuterol at that time.

 

Also, after giving albuterol, encourage him to cough out the gunk if possible. Often it loosens and re-settles someplace else, but if there's a lot of gunk in there, it's blocking his ability to get air. In the middle of the night, I've had to smack ds on the back to make him cough more (per the doc).

 

The only other thing you could do would be ask the ped for a nebulizer. Our old ped used to rent them, even. (insurance usually pays, but regardless, I think it's a much more effective delivery than the inhaler ina 4 y.o who's very sick.)

Edited October 5, 2010 by wapiti

[Murmer]

Sounds exactly like what just happened to my dd today. Same exact prescription for what to do. But they said I had to call if it was more than every 4 hours for the inhaler.

[NoPlaceLikeHome]

Is this possibly croup, croup with asthma, or a cold with asthma? I would see a allergist/asthma (pediatric) specialist IMHO and bring copies of Er records, MD records with you IMHO. I would get your own nebulizer to keep on hand with albuterol or xopenex at all times. I would not rent the nebulizer and ask you insurance and doctor for purchase. You can purchase them on Amazon rather cheaply as well but ask your doctor for recommendations. I would also ask to keep Orapred on hand to give at the first sign of croupiness as ordered. YOu can also buy a pulse oximeter for about fifty dollars on Amazon but keep in mind to read all instructions since they can give false low readings often as in the case of cold fingers, low blood pressure states as in shock.

 

 

More importantly, if you son is not his normal self or has respiratory distress not relieved by nebulizer as ordered then go to the ER since more definitive treatment may be needed such as epinephrine treatments, breathing machines, etc. You should clarify with doctor about what constitutes a breathing emergency.

 

My son used to get frequent severe croup ( which is also a possible sign of asthma) and we would end up in the ER. I insisted on a nebulizer and albuterol and orapred which my doctor allowed and we still keep on hand. We even take these things on the road with us.

 

I used this one for my trip to Italy for myself:

 

http://www.amazon.com/Pari-Compact-Compressor-Combination-Rechargeable/dp/B001EIIR2A/ref=pd_sbs_hpc_16

:grouphug:

Edited October 5, 2010 by priscilla

[The Girls' Mom]

I would definitely ask for a nebulizer if he's having to dose before they want him too...it's obviously not as effective as it could be. At that age, there is a high probability that the inhaler isn't getting all the meds to his lungs. There are times that my 13 year old has to neb and use the inhaler, especially if she's fighting a respritory virus.

 

(add me to the list that was surprised he got sent home with a SAT of 90)

[Quad Shot Academy]

Is this possibly croup, croup with asthma, or a cold with asthma?

:grouphug:

 

It is definitely not a croupy cough. All the doctors think this will be an isolated incident since he is so old and it is the first time. Would you still buy a nebulizer? I am sure it would be cheaper than going to the ER again. :tongue_smilie:

[sixpence1978]

If this is the first time he's experienced breathing trouble, I wouldn't necessarily call it asthma. Airway disease is vague (dd had this recently). Probably a viral bronchiolitis. Not that it really matters at this point.

 

Where I would be concerned is in the treatment plan. IMO, too young for an inhaler with a spacer, and in any event, IME, the treatment should be albuterol by nebulizer every four hours instead of the inhaler (along with the oral steroids that you got, probably a five-day (total) course of oral steroids). Whether to do an inhaled steroid on top of the oral one is debatable.

 

 

:iagree:

 

I think your best medication at this point is that oral steroid that he is on. I would also be bugging somebody about a nebulizer as well.

 

My DS has asthma and we still use the nebulizer at age 9 because it just works so much better. A 4.5 year old is not going to get much out of a regular inhaler IMO.

 

I am also surprised that he is home. Make sure he is resting a ton...not running around. And make sure he is drinking a lot...it can help thin the mucous secretions.

[Mom2J112903]

Is this possibly croup, croup with asthma, or a cold with asthma? I would see a allergist/asthma (pediatric) specialist IMHO and bring copies of Er records, MD records with you IMHO. I would get your own nebulizer to keep on hand with albuterol or xopenex at all times. I would not rent the nebulizer and ask you insurance and doctor for purchase. You can purchase them on Amazon rather cheaply as well but ask your doctor for recommendations. I would also ask to keep Orapred on hand to give at the first sign of croupiness as ordered. YOu can also buy a pulse oximeter for about fifty dollars on Amazon but keep in mind to read all instructions since they can give false low readings often as in the case of cold fingers, low blood pressure states as in shock.

 

 

More importantly, if you son is not his normal self or has respiratory distress not relieved by nebulizer as ordered then go to the ER since more definitive treatment may be needed such as epinephrine treatments, breathing machines, etc. You should clarify with doctor about what constitutes a breathing emergency.

 

 

:iagree:

 

We have an allergist whom is also an Asthma specialist. At the first sign of any type crud, we are to call him and get an appt for that day. He will give J an IM injection of steriods (as this is what works for J) and then we will watch him for 24hrs. If he is still requiring neb treatments every 4 hours, we are to be admitted for IV antibiotics (as in J's case it is bronchitis that gets him down) and monitoring. I should add J usually gets a *very* high temp, so he gets deyhrated very easily, so IV fluids would be needed as well if the steriods did not do their job.

[NoPlaceLikeHome]

This one looks like a good everyday one, but see if the doctor has any recommendations:

 

 

http://www.amazon.com/Omron-NE-C25-CompAir-Nebulizer-Compressor-System/dp/B000SSEX4I/ref=pd_sbs_hpc_1

 

I recommend the travel one only for the road:)

[NoPlaceLikeHome]

It is definitely not a croupy cough. All the doctors think this will be an isolated incident since he is so old and it is the first time. Would you still buy a nebulizer? I am sure it would be cheaper than going to the ER again. :tongue_smilie:

 

From what you describe I would want one. Honestly, if your son had this, it may reoccur. I would definitely try to see a specialist and see what they say. I know the nebulizer and orapred saved my son from the ER on multiple occasions as well as myself. My son has not been diagnosed with asthma (yet) but is at risk according to doctors since he had multiple severe episodes of croup.

[LizzyBee]

My oldest used to get sick like that when she was younger. Sometimes it was difficult to tell which was the primary culprit - virus or asthma. When she was 5, she had pneumonia and a bad asthma attack at the same time. She needed her albuterol as often as every two hours for a couple days and her fingernails and toenails turned blue at times, but she was not admitted to the hospital. She had an excellent pediatrician who was always on top of the asthma, but that time was really scary. I hope your ds starts getting better soon. :grouphug:

[Quad Shot Academy]

From what you describe I would want one. Honestly, if your son had this, it may reoccur. I would definitely try to see a specialist and see what they say.

 

If he wakes up bad tomorrow, I will call and ask for one. I might wake him up in the night like a pp suggested. They told me not to, but he was so bad this morning.

 

Ironically, he already has an appointment with an asthma/allergist specialist. He had a severe reaction to Keflex 1 month again and is now allergic to all antibiotics. I was told to make an appointment to see what they want to do next time he needs antibiotics.

[Quad Shot Academy]

When she was 5, she had pneumonia and a bad asthma attack at the same time. She needed her albuterol as often as every two hours for a couple days and her fingernails and toenails turned blue at times, but she was not admitted to the hospital.

 

I can't even imagine! :grouphug:

[Jennifer in MI]

Wow--I am surprised they didn't keep him with numbers that low. I know our doctor would. I know myself, I get worse with viruses or physical exertion. So if he does have a virus, it could be bringing on the asthma symptoms. The voice changing could have to do with the steroidal inhalers. They make me hoarse when I use them.

 

The "rule" of our ped. is the child needs a SaO2 of 93% or greater to stay out of the hospital, and albuterol needed no more than every 4 hours.

 

I would not let my wheezing/poorly oxygenating child run around--but when my dd has a number like that, and its corresponding lung decompensation, she is distressed and not wanting to run...

 

If I were you I would encourage sedentary activity. Continue to watch the resp. rate, whether or not your ds is "retracting"--the skin kind of pulls in between the ribs/clavicles/sternum, and if you can, listen to the lungs/wheezing. If dd has RR >40 and/or retracting, we are sent to the ER.

 

In our experience asthma has required IV steroids, oxygen, and of course the albuterol.

 

:grouphug: --it can be scary, I know.

 

WOW!! My ds would have been admitted at 92%.

 

:iagree:

 

I think your best medication at this point is that oral steroid that he is on. I would also be bugging somebody about a nebulizer as well.

 

My DS has asthma and we still use the nebulizer at age 9 because it just works so much better. A 4.5 year old is not going to get much out of a regular inhaler IMO.

 

I am also surprised that he is home. Make sure he is resting a ton...not running around. And make sure he is drinking a lot...it can help thin the mucous secretions.

 

In our experience, it takes around 24 hours for the steroid to take effect. I hope it starts working soon. And, yes. I'd be bugging someone for a nebulizer!!! It works SOOOO much better than just the inhaled meds. :grouphug::grouphug::grouphug:

[wapiti]

I might wake him up in the night like a pp suggested. They told me not to, but he was so bad this morning.

 

I hate waking them at night, and there have been plenty of times that I have skipped it, but it can really make a difference if they're struggling. It might only be necessary for a couple of nights - it depends.

 

Last time dd had retractions, a few weeks ago, the ped emphasized doing the middle of the night treatments (every 4 hours) (as has been emphasized in other situations with other kids many, many times over the years). That was only for a couple nights. When she was feeling better, I just did one nighttime treatment instead of the two (usually I'd stay up a little late, and do it around 11 or 12:00), for another three nights or so until I was sure she was much better. The middle of the night always seems to be a tough time for the breathing.

 

If he's not doing much better by tomorrow, and the ped won't give you a nebulizer, call the allergist's office where you have the upcoming appointment and see if they can squeeze you in for a sick appointment. Good luck, hope he feels better!

[LizzyBee]

If he wakes up bad tomorrow, I will call and ask for one. I might wake him up in the night like a pp suggested. They told me not to, but he was so bad this morning.

 

 

 

IIRC, we used to give dd her inhaler (using a spacer) at night without waking her up. You could try it and see if it seems like he's getting most of the medicine in.

 

When they gave him the neb tx at the hospital, did it seem to work better than the inhaler? My dd with asthma might just be an oddball, but an inhaler worked better for her than a nebulizer, so we never bought a nebulizer. The pediatrician had a couple of nebulizers at her office that she'd use if I brought the kids in with an acute attack, but at home we only used inhalers (plus the oral steroids when needed).

[Quad Shot Academy]

IIRC, we used to give dd her inhaler (using a spacer) at night without waking her up. You could try it and see if it seems like he's getting most of the medicine in.

 

When they gave him the neb tx at the hospital, did it seem to work better than the inhaler? My dd with asthma might just be an oddball, but an inhaler worked better for her than a nebulizer, so we never bought a nebulizer.

 

He was 90 when they did the neb and he dropped to 85 a half hour afterward. So, yeah, I wasn't impressed, but everyone here loves it so I figured it was just a coincidence.

 

That is a good idea for nighttime. Thanks! :001_smile:

[momtotkbb]

Sometimes it can be the type of meds that cause the probs too. W/ my youngest who has been treated since he before he was even a year old --albuterol did nothing. It wasn't until they switched him to xeopenex that he ever got relief. We do a combo treatment of xeopenex and pulmacort. When it's really bad we do a round of oral steroids --the only thing he can take is ora-pred (NOT THE GENERIC--he's actually allergic to the generic and it cause his symptoms to get much, much worse. I didn't even know there was a generic or that I had been given it until he'd been on it for 3 days and we were in the ER.) For me - I prefer the inhaler ---but for my youngest the nebulizer does work better for him. We use the xeopenex inhaler as a quick rescue med when we're out. We've also gotten relief for him by taking him outside when it's really cold out at night if he's bad --for my asthma and dd's the cold would trigger a coughing/wheezing binge, but for ds it calms his.

[Quad Shot Academy]

We did his inhaler all through the night and he woke up 95% better! :001_smile: I hope it lasts all day! Thank you for all the information everyone!

[Quad Shot Academy]

He is continuing to do better, but is still not well. I took him to the acupuncturist today and he refused to treat him because he was so unwell. :confused: His last dose of oral steroids was this morning. How fast can I expect those to wear off? Should I be concerned that we are on day five and he still needs the inhaler every 4-6 hours and now the oral steroids are ending?

[The Girls' Mom]

I would take him back. The steroids should have made him much better within a day or two.

[Jennifer in MI]

I'd go back in too. In our experience, ds is better within a day after taking the steroids. Significantly better. By the end of the round, he's completely normal.

:grouphug::grouphug::grouphug:

[NoPlaceLikeHome]

I'd go back in too. In our experience, ds is better within a day after taking the steroids. Significantly better. By the end of the round, he's completely normal.

:grouphug::grouphug::grouphug:

 

:iagree::iagree::iagree:

[Quad Shot Academy]

I decided to call the doctor before the weekend since people think he should be better. She said that she would have liked to see him if I had called earlier. She has office hours tomorrow and told me that if he is at all worse tomorrow to bring him in. She also called in a script for more oral steroids. She told me not to give it to him unless he really needs it. I asked her if she was worried about how long it was taking him to recover and she said he is on the edge of a slow recovery time and will be worried on Tuesday if he is not much better. Thanks for all the advice everyone!

[Susan in KY]

in my experience the nebulizer is much more effective, especially when the breathing issue is serious....Way too much room for user error with the inhaler in a child that young.

:iagree: Nebulizer is the way to go with one so young and that kind of decompensation. I am so surprised the hospital didn't use one!

[Quad Shot Academy]

:iagree: Nebulizer is the way to go with one so young and that kind of decompensation. I am so surprised the hospital didn't use one!

 

The hospital did give him 3 treatments, but they just didn't send us home with one.

[kalphs]

The "rule" of our ped. is the child needs a SaO2 of 93% or greater to stay out of the hospital, and albuterol needed no more than every 4 hours.

 

I would not let my wheezing/poorly oxygenating child run around--but when my dd has a number like that, and its corresponding lung decompensation, she is distressed and not wanting to run...

 

If I were you I would encourage sedentary activity. Continue to watch the resp. rate, whether or not your ds is "retracting"--the skin kind of pulls in between the ribs/clavicles/sternum, and if you can, listen to the lungs/wheezing. If dd has RR >40 and/or retracting, we are sent to the ER.

 

In our experience asthma has required IV steroids, oxygen, and of course the albuterol.

 

:grouphug: --it can be scary, I know.

:iagree:

As a respiratory therapist I am surprised they discharged your son instead of admitting him to the hospital.

I like the suggestion of finding a pediatric physician who specializes in asthma.

Having a physician who understands the disease and methods of diagnosis/treatment can make a world of difference for you child.

Edited October 8, 2010 by kalphs

[Quad Shot Academy]

:iagree:

As a respiratory therapist I am surprised they discharged your son instead of admitting him to the hospital.

 

I have to admit I am really upset and horified especially since reading people's responses here. I don't understand, especially since this was his frist attack ever! I am worried sick about what could be causing this. If I knew he had a history of asthma, had attacks before and recoverd, I would feel much better. When his o2 was 86 I kept asking for him to be put on oxygen and they wouldn't. He had been laboring for 6 hours and even if 86 doesn't cause brain damage, wouldn't it have been kind to give his muslces a break? :confused: I drove him 45 minutes to Denver to take him to the main Children's Hospital to get good treatment; seems I should have just gone to my local ER! They even discharged me w/o the right prescriptions. If I had not called my ped. that afternoon, who knows what would have happened!