Meets discharge criteria?
Meets ICU level criteria?
Factors increasing the likelihood of asthma
1 or more sign of poor hydration:
Discharge and follow up within 24 hours
Inhaled bronchodilator (albuterol) trial
Stage #3: Suction & WARM Score every 2 hours
Stage #4: Suction & WARM Score every 5 hours
Meets discharge criteria?
W.A.R.M Score
Variable | 0 points | 1 point | 2 points |
Wheeze | None | End expiratory | Entire expiratory / any inspiratory |
Air Exchange (assess all 4 chest areas: left/right front and left/right back) | Normal | One area decreased | More than one area decreased |
Respiratory Rate | |||
| ≤ 60 | > 60 | |
| ≤ 50 | > 50 | |
| ≤ 40 | > 40 | |
Muscle Use/Retractions | None | Subcostal or intercostal | 2 of the following: subcostal, intercostal, substernal OR nasal flaring, trachial tugging or abdominal breathing |
During stage 3 & 4:
Bronchiolitis and reactive airway disease / asthma are clinical diagnoses that should be differentiated prior to the decision to start therapy.
Symptoms of bronchiolitis = Viral symptoms AND:
Consider pediatric or pulmonary consult
Stage #2: Suction & WARM Score every 1 hour
Reassessment
Reassessment
Reassessment
Persistent O2 saturation < 90% awake OR 88% asleep?
Begin supplemental O2 at 1/2 L and titrate as needed
30 min obs
Suction and repeat WARM score
Reassessment
If any signs of clinical deterioration:
Systemic Glucocorticoids
Chest X-rays
High Flow Nasal Cannula
Apnea
Heliox
Consider for ICU admission
Complete WARM Score, nasal suctioning (upper pharynx)
Respiratory isolation, deep nasal suctioning (lower pharynx), continuous pulse oximetry ONLY when on supplemental O2 or acutely ill
PO challenge if tolerable level of respiratory distress
Consider high flow nasal cannula, off pathway
Discharge criteria
ED/Clinic specific
Inpatient specific
Any environment
Racemic Epinephrine
Nebulized Hypertonic Saline
Leukotriene-receptor antagonists (i.e Montelukast)
Chest Physiotherapy (CPT)
Antibiotics/Antivirals
Virologic studies
Discharge and follow up within 24 hours