Sarah De los Santos

Chief Complaint
CC: 12 year old boy with a history of wheezes presents with wheezes, shortness of breath, chest pain x 2 day.
History of Presenting Illness
WF was in his usual state of health until yesterday where he bean to feel dyspneic, fe!erish "no te#perature ta$en% with a couh and
sore throat. &e reports decreased '( inta$e with one episode of post)tussi!e e#esis. (!erniht, he wo$e up because he was ha!in
trouble breathin and had chest pain, which continued onto the #ornin. &e went to school in the #ornin, but saw the school nurse
since he was wheezin and could not breathe well. *he nurse called +11, and he was brouht to the hospital.
&is couh is producti!e of a crea#y white #ucousy phle# for which he too$ ,obitussin this #ornin, which i#pro!ed his couh. &e
did not ta$e albuterol. &e also reports chest pain around the le!el of his diaphra# when he breathes in and out. &e also has had
rhinorrhea for the past few #onths due to seasonal alleries to the pollen for which he ta$es -oratidine nihtly for relief.
WF has a history of asth#a that is triered by .,/0s. *wo to three years ao, he had a cold with so#e wheezin and was prescribed
albuterol by his pediatrician, which brouht hi# relief. &e denies any prior episodes of dayti#e sy#pto#s, niht ti#e sy#pto#s, and
only reports occasional wheezin acco#panyin .,/s. &e denies any other history of difficulty breathin, hospital ad#issions, or
intubations. &e has ne!er been on a controller #edicine. &e has a history of alleries to season chane, pollen, and dust.
Emergency Department Course
'atient was tachypneic to hih 120s upon ad#ission with wheezin and labored breathin. &e was i!en 3 rounds of continuous
albuterol, 4tro!ent 1222 #c, 'rednisolone 32 #, *erbutaline 2.1 # in5ection, and then later 6 #inutes later 2 ra#s of 7 sulfate
and an /8 9S :olus with only #ild i#pro!e#ent in sy#pto#s. &e continued to ha!e sinificantly decreased breath sounds with
wheezes and chest pain, and re;uired continuous nebs so was ad#itted.
Review of Symptoms
< tactile fe!er, e#esis, couh, rhinorrhea, sore throat, decreased '(
) diarrhea, abdo#inal pain, constipation, head aches, decreased .('
Past Medical History
&istory of asth#a triered by .,/.
&istory of seasonal alleries to seasonal chane, rass and pollen.
&is only hospital !isit was durin day care when he was sent to the =, due to dyspnea and he was dianosed with pneu#onia.
9o history of ecze#a.
Medications, itamins, Supplements
-oratidine 12 # nihtly '(
,obutussin, earlier this 47
WF ta$es not other !ita#ins, o!er the counter #edicines or supple#ents.
!llergies
9o >nown Dru 4lleries
4lleric to bee stins ? nec$ swellin, resol!es with diphenhydra#ine
Immuni"ations
.p to date except has not had flu shot
#amily History
Stron paternal history of asth#a
7aternal and paternal history of D7
7aternal rand#other and dad of &ypertension
9o history of C8D, Stro$e, SC4, &-D, =cze#a, or 4lleries.
Physical E$am
itals
*e#p: +@.A BF 'ulse: 126 ,esp: 12 "2C)1A% :': 113)1C1DC@)6+ Sp(2E +3E after 1 #inutes off the nebulizer on ,4
Feneral: .nco#fortable, alert, so#e difficulty spea$in without supple#ental oxyen
&==9*: 9or#ocephalic, atrau#atic, extraocular #uscles intact, pupils e;ual round and reacti!e to liht, #oist #ucous #e#branes,
ood dentition, no tonsilar exudates or erythe#a, ty#panic #e#brane intact and noninfla##ed
9ec$: Supple. 9o thyroid#ealy or cer!ical adenopathy.
,espiration: Counted ,,: 12, so#e inspiratory and expiratory wheezes, di#inished breath sounds at the base with poor aeration
throuhout, head)bobbin, and abdo#inal breathin, nasal flarin when off the nebulizer, able to spea$ partial sentences with so#e
difficulty, 4sth#a Score A)@
Cardio!ascular: 9or#al S1 S2, *achycardic to 126 and rhyth#. 9o #ur#urs, rubs, or allops.
4bdo#en: 9or#al acti!e bowel sounds. 9on)tender, non distended, no uardin, rebound tenderness, or hepatospleno#ealy.
=xtre#ities: 9o clubbin, cyanosis, or erythe#a. War# and well perfused, ood cap refill G 2 sec
S$in: War# and dry, clear except for a 1.6 pale burn scar on his left anterior forear#
7S>: Full rane of #otion, #o!ed all extre#ities, #ild chest pain at lower sternal border upon palpation
Sarah De los Santos
9euro: 4lert and oriented to person, place, and ti#e, C9//)H/H intact, no focal defects
%a&s
:7' in 'rocess
Micro&iology
9one
Radiology
Chest H ,ay
Findins: *he luns are clear, without e!idence of focal consolidation or pleural effusion. Cardio#ediastinal silhouette is within nor#al
li#its. :ones and soft tissues are unre#ar$able.
/#pression: 9or#al Chest
!ssessment
WF is a 12 year old boy with a history of asth#a who presents with dyspnea, wheezes, and chest pain x 2 days #ost li$ely due to
status asth#aticus. &e has a history of asth#a that is triered with .,/ and is relie!ed by albuterol. &e also has a history of seasonal
alleries that are triered by season chane and pollen, which are also asth#a triers. &is sy#pto#s ha!e i#pro!ed slihtly with
treat#ent by steroids, albuterol, terbutaline, and # sulfate, thouh he still re#ains tiht with di#inished breath sounds. &is physical
exa# represents a picture of an asth#atic with wheezin, retractions, and tachypnea. *his is less li$ely a bacterial or !iral pneu#onia
since he does not show sins or sy#po#s, such as fe!er, sore throat, producti!e couh, or focal lun findins, and his chest xray is
clear.
Plan
4sth#a =xacerbation:
) continuous 4lbuterol treat#ent, space to I1&)I2& when tolerated
) /8 #ethylprednisolone 2.6 #D$ I3&, transition to '( prednisone when spaced to I2&
) 4sth#a 4ction 'lan, add controller of Flo!ent CC #c /9& 2 puffs :/D
Chest 'ain
) 4ceta#inophen 322 # '( ',9 for chest pain
F=9DF/
) 9'(, transition to reular diet when spaced to I2&
) D6 J 9S < 22 #e; >Cl for #aintenance
) /8 ,antidine for F/ 'rophylaxsis
Flu Shot
) ad#inister before dischare
Dispo Criteria
) 9o (2 re;uired
) 4lbuterol x2 IC&
) Sp(2 K +1E
) *oleratin '(
) 44' Co#plete
!sthma
Definition of !sthma
4sth#a is a chronic lun disease that is characterized by infla##ation of the airways, bronchial hypersensiti!ity to sti#uli causin
bronchoconstriction, and airway of obstruction. /t is differentiated fro# Chronic (bstructi!e 'ul#onary Disease by history of course of
disease and re!ersibility of sy#pto#s.
Pathogenesis'
Asthma is a disease characterized by chronic airway inflammation. A number of different
inflammatory cells are involved: neutrophils, eosinophils, lymphocytes, and mast cells with complex
mediator pathways, involving various cytokines and T cells (predominantly T!"!mediated response#.
Airway inflammation and airway (or bronchial# hyper!responsiveness to various inhaled stimuli lead to
symptoms related to reversible airway obstruction and altered lung function, and may evolve into a
variety of phenotypes. Airway obstruction is caused by bronchospasm (smooth muscle contraction#
and inflammatory changes such as airway wall edema and mucus hypersecretion.
$elative contributions may differ between individuals and between episodes depending on the
precipitating factor. Airway narrowing occurs in a heterogeneous manner in both the large and the
Sarah De los Santos
small airways. %mpaired ability to expel air results in audible wheezing and increased work of
breathing, potential gas trapping, clinical hyperinflation, and alveolar hypoventilation. %n a proportion
of cases chronic structural changes occur, and may be present by early childhood.&'() These include
thickening of the epithelial reticular basement membrane (due to collagen deposition#, hypertrophy
and airway smooth muscle hyperplasia, extracellular matrix deposition, and hypertrophy of mucus!
secreting glands. These changes may influence asthma outcome and predispose to a more severe
irreversible asthma phenotype.
Differential Diagnosis of whee"ing with dyspnea
*he top dianoses on WF0s differential is: Status 4sth#aticus, 'neu#onia "7ycoplas#aa pneu#onia, Strep pneu#onia% or .pper
,espiratory /nfection. /n order to dianose his asth#atic exacerbation, a ood history, physical exa#, and chest xray were done. &e
presents with classical sy#pto#s for an acute asth#a exacerbation: acuteness of the episode, couh, wheezin with labored breathin
with retractions, shortness of breath that bean in the #iddle of the niht. *he etioloy of his exacerbation could be due to se!eral
factors: #ost li$ely the sudden chane to cold weatherL .,/, less li$ely thouh he reports feelin fe!erish with a sore throatL and
possibly exposure to other allerens, he has a history chronic rhinorrhea and has had no new acute exposure to allerens. &is past
#edical history include a pre!ious episode of asth#a triered by a .,/, for which he was treated with albuterol by his pediatrician. &e
reports other episodes of wheezin with other colds, but has only been treated with albuterol once.
4sth#a is often referred to as part of a triad of: asth#a, atopy, and ecze#a. WF has a history of alleries to seasonal chane, rass,
and pollen. (ften in asth#a, his alleric triers also cause an infla##atory response in the airways, causin asth#a. &e also has a
stron fa#ily history of asth#a on his paternal side, which is one of the ris$ factors for asth#a.
*o dianose the se!erity of his asth#a, analysis of his current exacerbation and history were ta$en into consideration. *houh he
reports occasional wheezin alon with .,/0s. &e denies any other episodes of difficulty breathin. &e does not ha!e any reular
sy#pto#s, niht ti#e awa$enins and does not use a S4:4 use for sy#pto#s relief. &is daily acti!ity durin this episode was li#ited
by the se!erity of his disease, but does not reularly occur to cause any reular i#pair#ent. 9or#ally this would put hi# into the
inter#ittent asth#a cateory since he has not reported enouh episodes, but the clinical picture of his current exacerbation was ta$en
into consideration. &e ca#e in with se!ere sy#pto#s that were only #ini#ally relie!ed by the standard treat#ent of albuterol, steroids,
and atro!ent. &e re;uired ad5unct therapy to help open his airways. &e was on continuous nebulizers for o!er 12 hours. &e was
ad#inistered *erbutaline, 7anesiu# Sulfate, and also =pinephrine, with so#e sy#pto#atic relief but his lun exa# with still positi!e
for di#inished breath sounds with inspiratory and expiratory breath sounds with tachypnea. :ased on this presentation, a se!ere lun
exa# with his appearance al#ost appearin close to baseline, it is #ost li$ely possible that his other episodes were #issed and not
treatedL therefore, he is cateorized as a persistent, #oderate, poorly controlled asth#atic
(reatment ) Management
WF was initially treated in the =, for his status asth#aticus with continuous albuterol, nebulizers, 4tro!ent, 'rednisolone, *erbutaline,
7 Sulfate, with an /8 9S :olus.
,eferences:
1. 9ational &eart, -un, and :lood /nstitute "2211%. M4sth#a.N http:DDwww.nhlbi.nih.o!DhealthDhealth)
topicsDtopicsDasth#aDtreat#ent.ht#l
Sarah De los Santos
Key diagnostic factorshide all
FHx of asthma (common)
The ma*ority of children with asthma have a positive family history of asthma. The risk of developing asthma is greater if there
is a maternal history of asthma in comparison with a positive paternal history. &"+)
hx of passive and active tobacco smoking (common)
,nvironmental tobacco smoke is a recognized risk factor for impaired lung growth, infantile wheeze, and asthma exacerbation.
&-) &"") &".)
%n!utero tobacco smoke reduces airway function in infants, which increases wheezing illness. /assive and active smoking
causes poor asthma control, as well as increasing other respiratory symptoms such as cough, wheeze, and dyspnea.
wheezing episode triggers (common)
0actors, in addition to respiratory infection, that may trigger episodes of wheeze include change in weather, environmental
tobacco smoke, exercise, and emotion.
increased work of breathing (common)
1uring symptomatic episodes tachypnea, recessions (or retractions#, and accessory muscle recruitment may be present
depending on the severity of the episode.
features of atopic disease (common)
0eatures of atopic disease on exam include flexural eczema. 2ther nonspecific features, such as edema and tearing of the
con*unctivae, and boggy nasal mucous membranes, are nonspecific. &+()
history of response to treatment within appropriate time frame(common)
%mprovement in symptoms or lung function in response to ade3uate therapy. &.4) 5ack of response should be interpreted as
evidence of an alternative diagnosis.
Other diagnostic factorshide all
age ! years (common)
Transient infantile wheezing may be difficult to distinguish from asthma during the initial few years of life. %n transient infantile
wheezing, symptoms resolve in the preschool years. &'-)
dry nighttime cough (common)
6ough may accompany wheeze during symptomatic episodes. The presence of a dry nighttime cough is suggestive of
asthma, but isolated cough (i.e., absence of other symptoms# is rarely asthma.
A moist cough suggests an alternative diagnosis or a concurrent viral or bacterial infection.
dyspnea on exertion (common)
1yspnea may accompany wheeze and cough during symptomatic episodes but is rarely present on its own.
expiratory wheezing (common)
1uring symptomatic episodes a widespread polyphonic wheeze is typically present. 5ocalized wheeze suggests an alternative
diagnosis such as inhaled foreign body.
chest wall deformity (uncommon)
%n persistent asthma, chest wall deformity (arrison sulci or hyperinflation# may be present although this is now rarely seen.
"isk factorshide all
#trong
allergic sensitization
,xposure and sensitization to aeroallergens and certain foods is a recognized risk factor. A positive skin prick test to
aeroallergens such as house dust mites, alternaria, and 7ermuda grass is associated with an increased risk of developing
asthma. &'-)
atopic disease
Sarah De los Santos
The presence of atopic disease such as eczema, atopic dermatitis, allergic rhinitis, and food allergy is strongly associated with
asthma. &"8) The progression from eczema9atopic dermatitis to allergic rhinitis to subse3uent asthma has been termed :the
allergic march.: 1ata suggest this allergic march may not be seen in girls. &"') Atopy is associated with increased asthma
severity. &-) &"") &".) &"4)
wheezing triggered by nonviral$nonallergic environmental factors
,pisodic viral!induced wheeze (typically from respiratory syncytial virus and parainfluenza virus# is a common finding in early
childhood (present in one third of the Tucson birth cohort before . years of age#. &'-) owever, in the ma*ority (almost ;8<#,
wheezing did not persist into later childhood. The presence of additional wheeze triggers, such as change in weather,
environmental tobacco smoke, exercise, and emotion, are associated with an increased risk of developing asthma. &-) &"") &".)
respiratory viral infections in early life
Although the link between respiratory syncytial virus ($=># and asthma has long been debated, &'+) prospective cohort data
suggest that having an infection with $=> or human rhinovirus (h$># in early life increases the likelihood of developing asthma
in those at risk. &';)
serum eosinophilia (%& or greater)
=erum eosinophilia may be a marker of atopy and allergic sensitization, which are recognized risk factors for developing
asthma. &'-)
FHx of asthma
The ma*ority of children with asthma have a positive family history of asthma. The risk of developing asthma is greater if there
is a maternal history of asthma in comparison with a positive paternal history. &"+)
passive and active tobacco smoking
,nvironmental tobacco smoke is a recognized risk factor for impaired lung growth, infantile wheeze, and asthma
exacerbation. &-) &"") &".)
%n!utero tobacco smoke reduces airway function in infants, which increases wheezing illness. /assive and active smoking
causes poor asthma control, as well as increasing other respiratory symptoms such as cough, wheeze, and dyspnea.
abnormal lung function and airway hyper'responsiveness
yper!responsiveness and abnormal lung function are associated with an increased risk of asthma. &-) &"") &".)
(eak
female gender
Associated with an increased risk of asthma. &-) &"") &".)
outdoor air pollution
Associated with an increased risk of asthma. Also an important cause of asthma exacerbation and loss of asthma symptom
control. %mprovements in air pollution can improve lung function in asthmatic people. &";)
obesity
Associated with an increased risk of asthma. &"-) &"?)
)ast updated* Oct +%, -+.!
/op
medium'dose inhaled corticosteroid
The beneficial effect of inhaled corticosteroids (%6=#
has been established. &-+) %t is important to appreciate
the change in delivered dose with hydroxyfluoroalkane
(0A# inhalers, which have replaced older inhalers.
Sarah De los Santos
There are concerns over systemic adverse effects,
particularly at higher doses.&A ,vidence) 5ocal adverse
effects are avoided, particularly if delivered via a
spacer, limiting oropharyngeal
deposition. &-;) &--) &-?) Adverse effects may be
minimized by using the lowest dose to achieve good
control, with a spacer, and by rinsing the mouth after
medication delivery. @ewer %6= medications, such as
mometasone and ciclesonide, which are currently only
licensed for children ages '" years and older, were
thought to have more favorable side!effect profiles.
Aore recent evidence has shown that the benefit of
ciclesonide, compared with budesonide and
fluticasone, could not be demonstrated or refuted. &?4)
Bhen starting therapy, initial low dose is as effective
as initial high dose and subse3uent down titration. &?")
0rimary Options
fluticasone inhaled : (44, ''8, or ""8 micrograms9dose
metered!dose inhaler# ";4!448 micrograms9day
O"
budesonide inhaled : ((8, '?8, or "88
micrograms9dose dry powder inhaler# ;88!'"88
micrograms9day
O"
beclomethasone inhaled : (48 or ?8 micrograms9dose
metered!dose inhaler# "48!4?8 micrograms9day
O"
ciclesonide inhaled : (?8 or ';8 micrograms9dose
metered dose inhaler# ';8!."8 micrograms9day
O"
mometasone inhaled : ("88 micrograms9dose metered!
dose inhaler# 488 micrograms9day
plus
&C)
short'acting beta'- agonist when re1uired 2 education
%ncreasing use of short!acting beta agonists may
indicate inade3uate control and the need to step up
treatment.
,ducation is fundamental to pediatric asthma
management, and should include training in the
optimal use of medications, inhaler techni3ue review
(including spacers in young children#, and
Sarah De los Santos
individualized written asthma management plans.
,ducation strategies have been shown to improve
asthma outcomes, although no benefit in 3uality of
life has been shown. &''") &''.) ,ducation should
focus on both the child and caregiver. &''4)
Britten management plans targeting symptom!based
management are targeted to reduce exacerbation
rates. &''.) &''+) &'';)
ealthcare workers for patients of their own ethnic
groups may be beneficial.&''-)
Allergic rhinitis (A$# may coexist with asthma. A
unified approach to the treatment of the airway
inflammation of both conditions is
recommended. &'88)
0rimary Options
albuterol inhaled : ((8 micrograms9dose metered!
dose inhaler# '?8 micrograms (" puffs# + minutes
before exercise or every 4!; hours when re3uired
O"
levalbuterol inhaled : (4+ micrograms9dose metered!
dose inhaler# (8 micrograms (" puffs# + minutes
before exercise or every 4!; hours when re3uired
"nd low'dose inhaled corticosteroid 2 long'acting beta'-
agonist or leukotriene modifier or theophylline
Dse of an ad*unctive medication in combination with
a low!dose inhaled corticosteroid is recommended.
Ad*unctive therapies include long!acting beta!"
agonists (e.g., salmeterol, formoterol#, leukotriene
receptor antagonists&A ,vidence) (e.g., montelukast,
&6 ,vidence) &6 ,vidence) zafirlukast#, or theophylline.
&A ,vidence) &7 ,vidence) @ewer %6= medications,
such as mometasone and ciclesonide, which are
currently only licensed for children ages '" years and
older, were thought to have more favorable side!
effect profiles. Aore recent evidence has shown that
the benefit of ciclesonide, compared with budesonide
and fluticasone, could not be demonstrated or
refuted. &?4)
Eileuton, another leukotriene modifier (+!
lipoxygenase inhibitor#, may also be of benefit.
owever, due to limited efficacy data, need for
Sarah De los Santos
fre3uent dosing, and potential liver toxicity,
leukotriene receptor antagonists are preferred in
children.&A ,vidence) 5iver function tests should be
monitored when giving zileuton.
5ong!acting beta!" agonists, despite the lack of
evidence in young children, are commonly used.&6
,vidence) The response in young children is different
from that in adults and should not be extrapolated.
The response seen in adolescent asthma is similar to
that seen in adults.&7 ,vidence)$ecommendations
should be strictly adhered to.
0rimary Options
fluticasone inhaled : (44, ''8, or ""8
micrograms9dose metered!dose inhaler# ??!";4
micrograms9day
or
budesonide inhaled : ((8, '?8, or "88
micrograms9dose dry powder inhaler# '?8!;88
micrograms9day
or
beclomethasone inhaled : (48 or ?8 micrograms9dose
metered!dose inhaler# ?8!"48 micrograms9day
or
ciclesonide inhaled : (?8 or ';8 micrograms9dose
metered dose inhaler# ?8!';8 micrograms9day
or
mometasone inhaled : ("88 micrograms9dose
metered!dose inhaler# "88 micrograms9day
'' 345 ''
salmeterol inhaled : (+8 micrograms9dose dry powder
inhaler# +8 micrograms (' puff# twice daily
or
formoterol inhaled : ('" micrograms9dose dry powder
inhaler# '" micrograms (' puff# twice daily
#econdary Options
fluticasone inhaled : (44, ''8, or ""8
micrograms9dose metered!dose inhaler# ??!";4
micrograms9day
or
budesonide inhaled : ((8, '?8, or "88
Sarah De los Santos
micrograms9dose dry powder inhaler# '?8!;88
micrograms9day
or
beclomethasone inhaled : (48 or ?8 micrograms9dose
metered!dose inhaler# ?8!"48 micrograms9day
or
ciclesonide inhaled : (?8 or ';8 micrograms9dose
metered dose inhaler# ?8!';8 micrograms9day
or
mometasone inhaled : ("88 micrograms9dose
metered!dose inhaler# "88 micrograms9day
'' 345 ''
montelukast : '8 mg orally once daily
or
zafirlukast : "8 mg orally twice daily
or
zileuton : ;88 mg orally four times daily
/ertiary Options
fluticasone inhaled : (44, ''8, or ""8
micrograms9dose metered!dose inhaler# ??!";4
micrograms9day
or
budesonide inhaled : ((8, '?8, or "88
micrograms9dose dry powder inhaler# '?8!;88
micrograms9day
or
beclomethasone inhaled : (48 or ?8 micrograms9dose
metered!dose inhaler# ?8!"48 micrograms9day
or
ciclesonide inhaled : (?8 or ';8 micrograms9dose
metered dose inhaler# ?8!';8 micrograms9day
or
mometasone inhaled : ("88 micrograms9dose
metered!dose inhaler# "88 micrograms9day
'' 345 ''
theophylline : '8 mg9kg9day orally initially, increase
according to response and serum drug level,
maximum '; mg9kg9day
Aore
plus short'acting beta'- agonist when re1uired 2 education
Sarah De los Santos
&C) %ncreasing use of short!acting beta agonists may
indicate inade3uate control and the need to step up
treatment.
,ducation is fundamental to pediatric asthma
management, and should include training in the
optimal use of medications, inhaler techni3ue review
(including spacers in young children#, and
individualized written asthma management plans.
,ducation strategies have been shown to improve
asthma outcomes, although no benefit in 3uality of
life has been shown. &''") &''.) ,ducation should
focus on both the child and caregiver. &''4)
Britten management plans targeting symptom!based
management are targeted to reduce exacerbation
rates. &''.) &''+) &'';)
ealthcare workers for patients of their own ethnic
groups may be beneficial.&''-)
Allergic rhinitis (A$# may coexist with asthma. A
unified approach to the treatment of the airway
inflammation of both conditions is
recommended. &'88)
0rimary Options
albuterol inhaled : ((8 micrograms9dose metered!
dose inhaler# '?8 micrograms (" puffs# + minutes
before exercise or every 4!; hours when re3uired
O"
levalbuterol inhaled : (4+ micrograms9dose metered!
dose inhaler# (8 micrograms (" puffs# + minutes
before exercise or every 4!; hours when re3uired
@ational Asthma 6ouncil, Australia. Asthma management handbook. "88;. http:99www.nationalasthma.org.au9 (last accessed "+
=eptember "8'.#.
http:99www.nationalasthma.org.au9handbook
@ational %nstitute of ealthF @ational eart, 5ung, and 7lood %nstitute. Guidelines for the diagnosis and management of asthma. "88-.
http:99www.nhlbi.nih.gov9 (last accessed "+ =eptember "8'.#.
http:99www.nhlbi.nih.gov9guidelines9asthma9index.htm
@ui*sink A. 5ong!term asthma treatment guided by airway hyperresponsiveness in children: A randomised controlled trial. ,ur $espir
H. "88-F.8:4+-!4;;.
http:99us.bestpractice.bm*.com9best!practice9openDrl.htmlCmedline%dI'-+.---8
7est /ractices
Sarah De los Santos
http:DDus.bestpractice.b#5.co#Dbest)practiceD#onoraphD12+@Dbasics.ht#l
Diagnosis of asthma in adolescents and adults
Acute asthma exacerbations in children: Inpatient management
Identifying patients at risk for fatal asthma