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Management of Pediatric Medical Emergencies in the Dental Office

Course Number: 391

Acute Asthmatic Attack

Asthma is defined as a chronic inflammatory disorder that is characterized by reversible obstruction of the airways. Approximately 9.5% of children in the United States suffer from asthma. Asthma is the most chronic childhood disease that affects around 7.1 million children in the United States.13 Half of all cases develop before patients reach 10 years of age. It appears more frequently in African American and Hispanic populations. Most of the acute asthmatic episodes are usually self-limiting. In contrast, status asthmaticus is the most serious clinical condition that manifests with wheezing, dyspnea, and hypoxia. Patients with this condition do not respond to bronchodilators and it is considered as a true emergency.

Asthma is classified into 2 categories; extrinsic (allergic asthma) and intrinsic (non-allergic asthma).

Extrinsic asthma occurs more often in children. It is triggered by specific allergens such as pollens, dust, molds, and highly allergenic foods such as milk, eggs, fish, chocolate, shellfish, and tomatoes. Drugs and chemicals such as penicillin, vaccines, aspirin, and sulfites can trigger an allergic asthmatic attack. Approximately 50% of asthmatic children outgrow extrinsic asthma by late teens or early twenties.14

Intrinsic asthma usually develops in adults older than age 35 years. Attacks are precipitated by non-allergic factors, respiratory infection, physical exertion, environmental and air pollution. Psychological and physiologic stress can induce an attack. The stress of disciplinary action by a parent or entering the treatment area in a dental office can trigger an asthmatic attack in children and adults.

With either type of asthma the mechanism for initiating an attack is the same. The allergen or non-allergen factors stimulates the vagus nerve to release acetylcholine which produces constriction of the airways and increased glandular secretions which plug the small airways in the lungs leading to bronchial edema and airway obstruction.

The signs and symptoms of an acute asthmatic attack are:

  • Shortness of breath

  • Wheezing and coughing

  • Tightness in the chest

  • Hypoventilation

  • Cyanosis

  • Tachycardia

The management of an asthmatic patient begins with the pretreatment history. Ask the patient:

  • How attacks occur and their severity

  • What triggers attacks

  • What medications are taken

If the patient uses a self-administered bronchodilator aerosol during acute asthmatic attacks e.g., albuterol (Proventil, Ventolin) isoproterenol (Isuprel) or metaproterenol (Metaprel, Alupent), they should bring it to their appointment. The bronchodilators produce bronchial smooth muscle relaxation. Albuterol has the least side effects of all the bronchodilators and should be the drug of choice for inclusion in the emergency drug kit.(Figure 13).

Figure 13. Ventolin (Albuterol sulphate) for inhalation.

Figure 13. Ventolin (Albuterol sulphate) for inhalation.

The steps in emergency management of an acute asthmatic episode are:

  • Terminate treatment and remove all dental materials and instruments from the patient’s mouth.

  • Sit the patient upright or in a comfortable position with the arms thrown forward over a chair back.

  • Administer a bronchodilator supplied by the patient or from the emergency drug kit. The directions for use of the aerosol inhaler are:

    • The patient holds the inhaler 1 or 2 inches in front of their mouth.

    • The inhaler is placed in the mouth.

    • As the patient breaths in slowly through their mouth, they press down on the inhaler one time.

    • The patient continues breathing as deep as they can and holds their breath for 10 seconds.

    • Improvement should occur within 15 seconds.

    • If there is no improvement, the process should be repeated.

  • If after three doses of the bronchodilator there is no improvement, take additional measures:

    • Administer oxygen

    • Call for medical assistance

    • Administer epinephrine 1:1000 concentration for an adult, 1:2000 concentration for a child.

  • If possible, determine the cause of the attack (anxiety, air contaminants).

  • If the attack is resolved quickly, the patient may be discharged on their own. If medical assistance or the administration of epinephrine is necessary, the patient should be discharged to EMS for transport to the hospital.14