A child’s death following an acute asthma attack occurred after each of six easy-to-use, nationally established guidelines had been compromised.

Asthma is the most common chronic illness in childhood. In the United States, there are approximately 26 million people with asthma; nearly one third of them (8.6 million) are children under 18 years of age.1 In 2000, asthma accounted for 1.8 million emergency department (ED) visits, 10.4 million medical office visits, and 465,000 hospitalizations among persons of all ages.2 An estimated 250 children and 5,000 adults die from asthma each year in the United States,3 and most of these mortalities are preventable. This case study describes a common scenario that precedes ED admissions nationwide. Each of the six components described in the widely available “Practical Guide for the Diagnosis and Management of Asthma,” summarized here, had been compromised.

Childhood Asthma Fatality
The patient was a 9-year-old male diagnosed with asthma at age 3. His asthma was triggered by upper respiratory infections (URIs) and more recently by cats. He was hospitalized with hypoxia at ages 3 and 4. He had six steroid bursts, two in the past 3 years. He began using a long-acting beta agonist twice daily 2 years ago; he used an inhaled steroid during URIs only.

On the evening of November 20, 2002, the patient was dropped off at a friend’s house for a sleepover. The caregivers owned a cat and were unaware the patient had asthma or sensitivity to cats. The patient had no preceding illness, had engaged in active outdoor play, and had pizza for dinner. He used his beta-agonist inhaler at about 5 pm and several times thereafter. At 1 am the caregivers found him hunched over the toilet, appearing cyanotic and with a very tight chest. He had vomited. Emergency medical services was called, and by 2 am the caregivers, told that he may have croup, were instructed to take him to the front porch. By the time a police officer arrived at the scene, the parents had begun CPR. Emergency response personnel arriving 20 minutes later were unable to revive him.

The patient had owned a peak flow meter but was not using it routinely. He had never undergone spirometry testing. He had experienced cyanosis and vomiting during asthma attacks, but the pediatrician was unaware of this because his parents assumed they were a normal response. The patient had different primary care physicians over time; his family received minimal asthma education and did not have an action plan for treating exacerbations. The patient was using only a beta agonist on a regular basis; the pediatrician was unaware that the patient was experiencing increased symptoms without using an inhaled steroid. There was no record of the large number of inhalers the patient received as samples, or the number he was actually using. The physician knew only the number of times the prescription had been refilled.

Following the loss of their child, the parents said, “We knew he had asthma, but we didn’t realize he could die from it.”

Clinical Practice Guidelines
The National Institutes of Health: National Heart, Lung, and Blood Institute’s “Practical Guide for the Diagnosis and Management of Asthma” provides clinical practice guidelines for the diagnosis and clinical treatment of asthma in chronic and acute care settings. It outlines six components for effective asthma management. This case study examines how essential elements of all six of these components were violated, resulting in a tragic asthma fatality of a 9-year-old boy.

1) Initial assessment and diagnosis. The patient was correctly diagnosed with asthma based on his history and presence of episodic symptoms of airflow obstruction. However, patients and health care providers frequently underestimate the severity of asthma. Many patients classified with “mild intermittent” asthma may have “moderate persistent” or “severe persistent” asthma. Spirometry was never performed, and reversibility of airflow obstruction was not documented. Patient education after diagnosis was minimal and undocumented. The “General Guidelines for Referral to an Asthma Specialist” were not followed. Patients should be referred to an asthma specialist when they are not meeting the goals of therapy, when a life-threatening exacerbation has ever occurred, or when they have used more than two bursts of oral steroids in 1 year.

2) Pharmacological therapy: managing asthma long term. Quick-relief beta-agonist medications were used to provide prompt treatment of acute airflow obstruction and accompanying symptoms. However, inhaled steroids were used only during acute exacerbations. The underlying inflammatory condition was not treated daily with low-to-medium doses of inhaled steroids. The guidelines use four criteria to classify the severity of asthma. These are: days with symptoms; nights with symptoms; PEF of FEV1; and PEF variability. The patient’s asthma severity was not classified according to the “Stepwise Approach for Managing Asthma,” and his asthma was not managed according to the guidelines.

3) Control of factors contributing to asthma severity. Cats were a trigger known to the child and his parents. But caregivers at the sleepover home were not aware the child had asthma or that their cat might aggravate his condition.

4) Periodic assessment and monitoring. The patient saw a physician about once a year, never an asthma specialist. Further, he did not have an action plan. All patients should be taught to recognize symptoms and should have an asthma action plan (which is provided in the guidelines as a patient handout). While the patient had been given a peak flow meter at one point, he was not using it, and no one had ever asked about his monitoring or had him demonstrate proper technique. Long-term daily peak flow monitoring is recommended for those with moderate or severe persistent asthma, or patients with a history of severe exacerbations.

5) Education for partnership in asthma care. The patient had received instructions on using an MDI and a peak flow meter. However, he did not have a written action plan incorporating routine peak flow meter use. He had not been asked to demonstrate proper technique for peak flow meter and inhaler use, and it is unclear whether he had a spacer or knew how to use it.

6) Managing asthma exacerbation. The ability to recognize and treat exacerbation early is essential to successful management, and the guidelines provide a specific plan of action for managing acute episodes. This includes treatment with nebulized beta agonists, systemic steroids, and oxygen, and close observation. The patient was unable to benefit from an emergency protocol due to the rapid onset of the attack and the inability of caregivers to identify and treat it. EMS dispatch was unable to assess the situation correctly because the caregivers did not indicate that the child was cyanotic or that he may be experiencing a severe asthma attack.

Conclusion
Several key lessons can be learned from this experience. Comprehensive asthma education must be provided, repeated, and tracked by competent medical staff. Free MDI samples need to be tracked along with pharmacy refills. Parents need to let teachers and caregivers know that a child has asthma, and provide them with the child’s asthma action plan.

Learn and apply the “Rules of Two™” for assessing severity, developed by Mark Millard, MD, a pulmonologist and medical director at Baylor Asthma and Pulmonary Rehabilitation Center in Dallas: Do you use your quick-relief inhaler more than two times per week? Do you awaken at night with asthma more than two times per month? Do you refill your inhaler prescription more than two times per year? Patients answering yes to any of these questions should discuss a care plan with their physician.

The tools and techniques for effective asthma management are readily available, and respiratory therapists are in a good position to promote their implementation. Every respiratory therapy department should have a copy of the “Guidelines for the Diagnosis and Management of Asthma,” which provides state-of-the-art information on treating asthma at all severity levels. It is available from the National Institutes of Health’s National Heart, Lung, and Blood Institute.4

John A. Wolfe, RRT, is a member of the RT editorial advisory board. He thanks Janet Seeley, MD, for help with this article.

References
1. American Lung Association. Prevalence based on revised national health interview survey. 1998. Available at: www.lungusa. org/data/data_ 102000.html.
2. Centers for Disease Control and Prevention’s National Center for Health Statistics. Asthma Prevalence, Health Care Use and Mortality 2000-2001. Available at: www.cdc.gov/ nchs/products/pubs/pubd/hestats/asthma/asthma.htm.
3. Centers for Disease Control and Prevention’s National Asthma Control Program. Asthma’s Impact on Children and Adolescents. 2002. Available at: www.cdc.gov/nchs/products/ pubs/pubd /hestats/asthma/asthma.htm.
4. Guidelines for the Diagnosis and Management of Asthma. Expert Panel Report 2. NIH publication No. 97-4015. Bethesda, Md: 1997.