Pediatric Asthma Pathway (JMH, VC)



100
75% 100% Zoom 125%


Export to PDF
Contribute Edits
Pediatric Asthma Pathway (JMH, VC)

3rd Hour (ED/PICU)

Phase Ic

Consider pulmonary or critical care consultation

1st Hour (ED)

Phase Ia

Phase V: Inpatient

  • Albuterol MDI 4 puffs q4hr
  • Assessment q4hr
  • Minimum 2 treatments prior to discharge

RS 6-12

  • Albuterol continuous neb 20mg/hr x1
  • Ipratropium neb 0.75mg
  • Dexamethasone PO/IM 0.6mg/kg (max 16mg)

RS 9-12

  • Albuterol continuous neb 20mg/hr x1
  • If not yet given:
  • Ipratropium neb 0.75mg
  • Age ≥2yo: Magnesium sulfate IV 50mg/kg (2g max)
  • Admit to pediatric ward on Phase II or PICU if not improving

2nd Hour (ED)

Phase Ib

RS 1-5

  • Albuterol MDI 8 puffs
  • Dexamethasone PO/IM 0.6mg/kg (max 16mg)

RS 5-8

  • Admit to pediatric ward on Phase III

RN to notify MD:

  • For all phase transitions
  • Failure to advance after 3 hours in Phase II, 8 hours in Phase III, or 12 hours in Phase IV
  • Persistent O2 requirement

RS 9-12

  • Albuterol continuous neb 20mg/hr x1
  • Ipratropium neb 0.75mg (if not yet given)
  • Age ≥2yo: Magnesium sulfate IV 50mg/kg (max 2g)
  • Admit to pediatric ward on Phase II or PICU if not improving

Respiratory Score (RS)

Variable

0 points

1 point

2 points

3 points

RR

18-23 mo

≤ 40

41 - 44

≥ 45

2-3 years

≤ 34

35 - 39

≥ 40

4-5 years

≤ 30

31 - 35

≥ 36

6-12 years

≤ 26

27 - 30

≥ 31

> 12 years

≤ 23

24 - 27

≥ 28

Retractions

None

Subcostal or intercostal

2 of the following: subcostal, intercostal, substernal OR nasal flaring (infant)

3 of the following: subcostal, intercostal, substernal, suprasternal, supraclavicular OR nsasal flaring / head bobbing (infant)

Dyspnea

18 - 23 mo

Normal feeding, vocalizations and activity

1 of the following: difficulty feeding, decreased vocalization or agitated

2 of the following: difficulty feeding, decreased vocalization or agitated

Stops feeding, no vocalization or drowsy and confused

2-4 years

Normal feeding, vocalizations and play

1 of the following: decreased appetite, increased coughing after play, hyperactivity

2 of the following: decreased appetite, increased coughing after play, hyperactivity

Stops eating or drinking, stops playing, OR drowsy and confused

> 4 years

Counts to ≥ 10 in one breath

Counts to 7 - 9 in one breath

Counts to 4 - 6 in one breath

Counts to ≤ 3 in one breath

Auscultation

Normal breathing, no wheezing present

End-expiratory wheeze only

Expiratory wheeze only (greater than end expiratory wheeze)

Inspiratory and expiratory wheeze OR diminished breath sounds OR both

Phase II: Inpatient

  • Albuterol continuous neb 20mg/hr
  • Assessment q1hr
  • Advance after 1hr if RS 1-8

Phase III: Inpatient

  • Albuterol MDI 8 puffs q2hr
  • Assessment q2hr

Discharge Planning:

  • A completed Asthma Discharge Summary and Home Management Plan of Care is required for all discharges
  • In the Discharge Navigator tab, use the ‘Asthma Action Plan’ button under Discharge Documentation (JMH only)
  • Indicate dose of controller medications if prescribed for patient
  • Print Asthma Action Plan with After-Visit Summary; MD to review document with family prior to discharge

Assess Respiratory Score (RS) every 1hr

Note: Often patients will develop a decrease in their oxygen saturation after the onset of bronchodilators due to V-Q mismatch from the vasodilatory effect of the beta-agonist bronchodilators in previously non-perfused portions of the lungs.

Inclusion Criteria
  • 18mo-18yo with asthma exacerbation admitted to pediatrics OR with known diagnosis of asthma in the ED
Exclusion Criteria
  • Toxic appearance
  • History of airway anatomical or functional abnormality
  • Complex neurologic disease, hypotonia or neuromuscular disorder
  • Immunodeficiency
  • Sickle Cell Anemia
  • Chronic lung disease (e.g. cystic fibrosis, bronchopulmonary dysplasia, restrictive lung disease)
  • Congenital or acquired cardiac disease
  • Airway issues (e.g. vocal cord paralysis, tracheomalacia, tracheostomy dependence)
  • Other medically complex children

Phase IV: Inpatient

  • Albuterol MDI 8 puffs q4hr
  • Assessment q4hr

Inpatient Steroid Treatment

  • Transition to prednisone tablets or prednisolone liquid 2mg/kg PO daily for total course 5-10 days depending on severity of exacerbation.

Discharge criteria

  • Well defined disease process with improvement
  • Asthma action plan in place
  • Prescriptions for outpatient meds
  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 1-3 days
  • Patient/Caregivers comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

RS 1-4

  • Discharge if criteria met

RS 5-8

  • Albuterol continuous neb 5mg x1
  • Observe for 1 hour

RS 1-4

  • Discharge

Phase II-V Progression

  • RS 1-4: Advance after 1 treatment at this phase
  • RS 5-8: Continue therapy at this phase
  • RS 9-12: Step back to previous phase