Acute Asthma Exacerbation



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Acute Asthma Exacerbation

Rarely warranted in most asthma exacerbations

X-ray Chest, 1 view
Inclusion Criteria
  • Clinical symptoms consistent with asthma exacerbation
Exclusion Criteria
  • Toxic appearance
  • Chronic lung disease
  • History of airway anatomical or functional abnormality
  • Complex cardiac disease
  • Complex neurologic disease, hypotonia or neuromuscular disorder
  • Immunodeficiency
  • Sickle Cell Anemia

Stage #2: Albuterol continuous neb 20 mg (over 1 hr), reassess Q1 hrs

If no improvement after one hour:

  • No clinical response despite optimal therapy
  • Continued severe respiratory distress
  • Signs of clinical deterioration

Then: Physician reevaluation, consider rapid response team (RRT) or code team depending on patient status

  • Admission
  • Transition to prednisone or prednisolone 1 mg/kg per dose BID for 5 days (first dexamethasone dose counts as day #1)
  • Change from continuous to spot check pulse oximetry monitoring once respiratory score < 5 or off supplemental O2

If any signs of clinical deterioration

  • No clinical response despite optimal therapy
  • Altered mental status
  • Drowsiness/Confusion
  • Greater than 3 hours on continuous albuterol
  • > 12 hours at any stage
  • New oxygen requirement

Then: Physician reevaluation, consider rapid response team (RRT) or code team depending on patient status

Findings concerning for pneumonia

  • Fever > 39 C (102.2 F)
  • Focal exam findings
  • Severe respiratory distress
  • Chest Pain
  • Tachypnea
  • Hypoxemia
  • Uncertain diagnosis

Repeat RS after 1 hour

Albuterol MDI

1 or more sign of poor hydration:

  • No oral intake
  • Minimal urine output
  • Clinical signs of severe dehydration
  • Severe respiratory distress

Findings concerning for airway foreign body

  • History of choking
  • Cough, tachypnea and stridor
  • Focal monophonic wheezing
  • Decreased air entry
  • Lack of improvement with treatment

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

Ipatroprium neb

Multiple findings concerning for pneumonia?

Asthma Education and Action Plan, Discharge with follow up within 24 hours

Severe distress?

Admit to Floor

Meets ICU level criteria?

Stage #3: Reassess Q2 hrs

Albuterol MDI

Reassessment

Reassessment

Reassessment

Reassesment

Reassessment

Off pathway

Admit to ICU

Admit to Floor

Stage #5: Reassess Q4 hrs

Albuterol MDI

Reassessment

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

May consider supplemental O2 only if patient is < 88% asleep?

Repeat RS after 1 hour

Meets discharge criteria?

O2 saturation?

Concern for airway foreign body?

NS Bolus
NS infusion

Begin supplemental O2 at 1/2 L and titrate as needed

Oxygen Therapy

Albuterol MDI 8 puffs, repeat RS after 1 hr (or sooner if in extreme distress)

Albuterol MDI

Consider pulmonary or ENT consults

X-ray Chest, 2 view

Dexamethasone injection

Calculate Respiratory Score

Stage #4: Reassess Q4 hrs

Albuterol MDI

Meets discharge criteria?

Asthma Education and Action Plan, Discharge with follow up within 24 hours

Terbutaline IV 10 mcg/kg loading dose over 10 minutes and then an infusion of 0.1 microgram/kg per minute(titrate), consider BIPAP/HFNC/anxiolysis

Terbutaline injection

Transition to prednisone or prednisolone 1 mg/kg per dose BID for 5 days (first decamethasone dose counts as day #1)

Blood Gas (ABG/VBG)

  • Rarely changes management. Not routinely recommended.

Inhaled Glucocorticoids

  • No conclusive evidence. Not routinely recommended.

Ketamine

  • Drug of choice for sedation, analgesia and rapid sequence intubation (RSI). No evidence of benefit for bronchodilatation of non-intubated patients.

Intubation

  • High risk, but necessary in some cases. Consider fluid bolus beforehand. Consider using ketamine for sedation for RSI.

Subcutaneous/Intramuscular beta-agonists (epinephrine or terbutaline)

  • May be useful in severe asthmatics or patients without IV access

Peak flow

  • Difficult in the acute setting and useful only if compared to patient's baseline

Albuterol continuous neb 20 mg (over 1 hr), Ipatroprium neb 0.75 mg, repeat RS after 1 hr (or sooner if in extreme distress)

Albuterol neb
Ipatroprium neb

Consider pulmonary consultation

PO challenge if tolerable level of respiratory distress

PO Challenge

Chest PT

  • Not routinely indicated for asthma exacerbation patients

Leukotriene-receptor antagonists (i.e Montelukast)

  • No evidence of benefit in pediatric patients

Magnesium Sulfate IV 50 mg/kg (max 2 grams) over 20 min, 20 ml/kg NS IV bolus if not contraindicated (no need to check Mg or Ca levels)

Magnesium sulfate infusion

Heliox

  • Not routinely recommended, but may be useful in severe or refractory asthma



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