Rarely warranted in most asthma exacerbations
- Clinical symptoms consistent with asthma exacerbation
- 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
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.
Multiple findings concerning for pneumonia?
Asthma Education and Action Plan, Discharge with follow up within 24 hours
Severe distress?
Meets ICU level criteria?
Stage #3: Reassess Q2 hrs
Reassessment
Reassessment
Reassessment
Reassesment
Reassessment
Off pathway
Stage #5: Reassess Q4 hrs
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?
Begin supplemental O2 at 1/2 L and titrate as needed
Albuterol MDI 8 puffs, repeat RS after 1 hr (or sooner if in extreme distress)
Consider pulmonary or ENT consults
Calculate Respiratory Score
Stage #4: Reassess Q4 hrs
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
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)
Consider pulmonary consultation
PO challenge if tolerable level of respiratory distress
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)
Heliox
- Not routinely recommended, but may be useful in severe or refractory asthma
