What is the appropriate workup for a pediatric patient presenting to the outpatient office after an emergency room (ER) visit for a possible asthma exacerbation without a current diagnosis of asthma?

Outpatient Workup After ER Visit for Possible Asthma Exacerbation in Undiagnosed Pediatric Patient

The primary goal is to confirm or exclude asthma diagnosis through objective testing and detailed clinical assessment, while simultaneously evaluating for alternative diagnoses and establishing appropriate controller therapy if asthma is confirmed. 1

Immediate Assessment at Outpatient Visit

History Taking - Key Elements

• Duration and pattern of symptoms: Document when respiratory symptoms began, frequency of wheezing episodes, nocturnal cough or awakening, and exercise-induced symptoms 1

• ER visit details: Obtain specific information about treatments given (bronchodilators, systemic corticosteroids), response to therapy, peak flow measurements if obtained, and discharge medications 1

• Prior respiratory episodes: Number of previous unscheduled visits, ED visits, or hospitalizations for respiratory symptoms in the past year - this is critical as children with undiagnosed asthma commonly have significant prior morbidity 2

• Symptom triggers: Identify potential causes including viral infections, allergen exposures, exercise, cold air, or environmental tobacco smoke 1

• Family history: Asthma, allergies, eczema in first-degree relatives 1

• Current medication use: Whether any controller medications were prescribed at ER discharge and adherence to these medications 2

Physical Examination - Specific Findings

• Respiratory assessment: Listen for wheezing (though absence doesn't exclude asthma), assess work of breathing, respiratory rate, and use of accessory muscles 1

• Rule out alternative diagnoses: Look for signs of upper airway obstruction (inspiratory stridor, dysphonia, monophonic wheezing loudest over central airway), cardiac disease, or other chronic lung conditions 1

• Allergic features: Examine for allergic rhinitis, eczema, or other atopic conditions 1

Objective Testing for Diagnosis

Spirometry (Children ≥5 Years)

• Perform baseline spirometry: Measure FEV1 and FEV1/FVC ratio to assess for airflow obstruction 1

• Bronchodilator reversibility testing: Administer short-acting beta-agonist and repeat spirometry after 15 minutes; improvement of ≥12% and ≥200 mL in FEV1 supports asthma diagnosis 1

• Important caveat: Only 65% of children aged 5-18 years can complete spirometry during an acute exacerbation, but most can perform it when stable in the outpatient setting 1

Peak Flow Monitoring

• Establish personal best: Have the child perform peak expiratory flow measurements and provide a peak flow meter for home monitoring 1, 3

• Assess variability: Diurnal variability >20% supports asthma diagnosis 1, 3

For Children <5 Years

• Clinical diagnosis predominates: Spirometry is not feasible in this age group 1

• Trial of therapy approach: Consider empiric treatment with inhaled corticosteroids and reassess response over 4-8 weeks 4

Risk Stratification

Assess Risk Factors for Asthma-Related Death

Document presence of any high-risk features 1:

• Previous severe exacerbations: Prior intubation or ICU admission
• Frequent healthcare utilization: ≥2 hospitalizations in past year, ≥3 ED visits in past year, or any hospitalization/ED visit in past month
• Medication overuse: Using >2 canisters of short-acting beta-agonist per month
• Perception difficulties: Child or family has difficulty recognizing symptom severity
• Social factors: Low socioeconomic status, major psychosocial problems
• Comorbidities: Cardiovascular disease, other chronic lung disease

Determine Current Asthma Severity

Based on symptoms and lung function 1, 3:

• Mild intermittent: Symptoms ≤2 days/week, no nighttime awakenings, no interference with activities
• Mild persistent: Symptoms >2 days/week but not daily, 1-2 nighttime awakenings/month
• Moderate persistent: Daily symptoms, nighttime awakenings 3-4 times/month, some limitation of activities
• Severe persistent: Symptoms throughout the day, nighttime awakenings >1 time/week, extremely limited activities

Laboratory and Imaging Studies

When to Order Additional Testing

• Chest radiograph: Not routinely needed, but obtain if suspecting pneumonia, pneumothorax, pneumomediastinum, or alternative diagnosis 1

• Complete blood count: Consider if fever or purulent sputum present, though modest leukocytosis is common in asthma 1

• Allergy testing: Consider for persistent asthma to identify triggers, particularly sensitivity to Alternaria (a risk factor for asthma death) 1

Initiate Controller Therapy

For Confirmed or Highly Suspected Asthma

Start inhaled corticosteroids immediately - this is the critical intervention that distinguishes diagnosed from undiagnosed asthma patients 3, 2:

• Low-dose ICS: Begin with age-appropriate low-dose inhaled corticosteroid as first-line controller 3

• Dosing: Start low and titrate based on response; early treatment (within 6 months of symptom onset) provides greater lung function improvement 3

• Important: 79% of children with undiagnosed asthma are not on controller medications despite significant morbidity 2

Rescue Medication

• Short-acting beta-agonist: Prescribe albuterol/salbutamol for as-needed symptom relief 1, 3

• Ensure proper technique: Demonstrate and verify metered-dose inhaler technique with spacer/holding chamber 1, 5

Develop Written Asthma Action Plan

Provide an individualized written asthma action plan during this visit - this intervention reduces subsequent unplanned healthcare visits by more than 50% 5:

Three-Zone Action Plan Components 1, 3, 5

• Green zone (doing well): PEF >80% of personal best, no symptoms, continue daily controller medication

• Yellow zone (getting worse): PEF 50-80% of personal best, increased symptoms, increase bronchodilator use, may need to increase ICS or add oral corticosteroids

• Red zone (medical alert): PEF <50% of personal best, severe symptoms, take oral corticosteroids and seek immediate medical care

Key Elements to Include 1, 5

• Daily controller medication regimen
• When and how to use rescue inhaler
• Specific PEF values triggering action
• When to self-initiate oral corticosteroids (typically prednisolone 1-2 mg/kg, maximum 40 mg) 1, 3
• Emergency contact numbers and when to seek urgent care

Education and Follow-Up

Patient and Family Education 1, 3

• Medication roles: Explain difference between "relievers" (bronchodilators) and "preventers" (inhaled corticosteroids)
• Trigger avoidance: Review specific environmental triggers identified
• Symptom recognition: Teach recognition of worsening symptoms, especially nocturnal symptoms
• Peak flow monitoring: Demonstrate proper technique and interpretation

Scheduled Follow-Up 1, 6

• Initial follow-up: Schedule within 24-48 hours for high-risk patients or within 1 week for all others 1, 6

• Reassessment at 4-6 weeks: Evaluate response to controller therapy, adjust medications as needed, verify inhaler technique 1, 3

• Consider specialist referral if 1:

  • Diagnostic uncertainty persists
  • Symptoms continue despite appropriate controller therapy
  • History suggests severe or brittle asthma
  • Child required or is likely to require systemic corticosteroids
  • Multiple risk factors for asthma death present

Common Pitfalls to Avoid

• Underdiagnosis: 36% of children with asthma symptoms presenting to ED remain undiagnosed; younger children and those with non-English speaking parents are at highest risk 2

• Relying solely on bronchodilators: Failure to initiate inhaled corticosteroids is the most common management error in children with persistent asthma 1, 3

• Inadequate follow-up: Evening discharges without defined follow-up appointments within 24-48 hours predispose to relapses 6

• Missing alternative diagnoses: Always consider vocal cord dysfunction, foreign body aspiration, or upper airway obstruction in children with atypical presentations 1

• Overestimating family understanding: Verify inhaler technique and action plan comprehension before discharge; providing written action plans reduces return visits 5