Clinical Asthma Pathway



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Clinical Asthma Pathway

Resp Score 1

  • Discharge with albuterol

ED PHASE 1B: Reassessment (2nd Hour)

  • Repeat Respiratory Score

O2 sat <92% on 2LNC or 40%FM?

Consider BiPAP, magnesium sulfate, chest X-ray, continuous albuterol, and/or PICU consult

Phase #2

Phase #4

Phase #3

Resp Score 1-4

  • Discharge with albuterol + steroid (if started in the ED)

Resp Score 1-4

  • Advance after one treatment in this phase

Resp Score 9-12

  • Continuous albuterol and Magnesium Sulfate
  • Consider SQ/IM Terbutaline or Epinephrine, BiPAP, chest X-ray, PICU consult.

Resp Score 9-12

  • Step back to previous phase or escalate care (see Escalation box)

Resp Score 9-12

  • Step back to previous phase or escalate care (see escalation box)

Resp Score 9-12

  • Step back to previous phase or escalate care (see escalation box)

Resp Score 1-4

  • Advance after one treatment in this phase

Signs of Clinical Decline

  • Drowsiness
  • Agitation
  • Confusion
  • Silent chest exam

Notify MD and consider PMET activation

Escalation - Notify MD

  • Albuterol+Ipratromium bromide: 3 treatments q20mins over 1 hour
  • Magnesium sulfate
  • Reassess after interventions

Consider PMET activation

Resp Score 2-5

  • Albuterol x 1
  • Reassess in 20-60 min (max 3 doses)
  • Consider steroids based on historical/clinical information.
  • Consider ipratropium if more than one dose of Albuterol is needed.

Phase #1

INPATIENT: PHASE 2

  • Albuterol q2hrs
  • Respiratory score q2hrs
  • Initiate Discharge Plan (part of the asthma order set)

Medication Dosing

ALL MEDICATION REQUIRE AN MD ORDER

**ED & Inpatient

Albuterol dosing:

  • <20 kg: 4 puff MDI or 2.5 mg nebulized
  • ≥20 kg: 8 puff MDI or 5 mg nebulized

Continuous albuterol via nebulizer:

  • <20 kg: 10 mg/hr | ≥20 kg: 15 mg/hr

Ipratropium bromide: 500 mcg nebulized

Prednisone or Prednisolone (oral):

  • First dose: 2 mg/kg/day (max dose 60 mg/day)
  • Subsequently: 1-2 mg/kg/day

Dexamethasone: 0.3 mg/kg (max 10 mg)

Methylprednisolone:

  • First dose: 2 mg/kg (max- 60mg)
  • Then: 1 mg/kg IV Q6h (max 125 mg/day)
  • Indications for IV/IM steroids: Inability to tolerate PO or concern for inadequate (not adequate) GI absorption.
  • *Consider steroids if using albuterol q4 hours at home without clinical improvement or cough > 1 week

Discharge/Home

Albuterol dosing:

  • <20 kg: 2 puff MDI or 2.5 mg nebulized
  • ≥20 kg: 4 puff MDI or 2.5 mg nebulized

Adjunct Therapies

  • Magnesium sulfate IV: 50-75 mg/kg (max 2 gms) over 20 minutes (Consider administration of Normal Saline bolus)
  • Epinephrine (1:1000 = 1 mg/ml) or terbutaline (1 mg/ml): 0.01 ml/kg terbutaline) given SQ or IM q10-20min

RN/RT to Notify MD

  • For all phase transitions
  • Failure to advance on pathway after 12 hours in all inpatient phases
  • Persistent O2 requirement in Phase IV
  • An increase in respiratory score

Resp Score 5-8

  • Continue therapy in this phase

Resp Score 6-12

  • Albuterol + ipratopium (max 3 doses)
  • Prednisone, dexamethasone or methylprednisolone
  • Consider adjunct therapies

Resp Score 5-8

  • ADMIT

INPATIENT: PHASE 4

  • Albuterol q4hrs
  • Respiratory score q4hrs

ED PHASE 1A: Initial Assessment (1st Hour)

  • Initial Respiratory Score (see calculator)
Inclusion Criteria
  • Age ≥ 2 years
Exclusion Criteria
  • Chronic lung disease (e.g. cystic fibrosis, restrictive lung disease, broncopulmonary dysplasia)
  • Congenital and acquired heart disease
  • Airway issues (e.g. vocal cord paralysis, tracheomalacia, tracheostomy dependent)
  • Medically complex children
  • Immune disorders
  • Sickle cell anemia

Resp Score 1-4

  • Discharge after one treatment in this phase

Resp Score 5-8

  • Continue therapy in this phase

Discharge Plan

  • Completion of online education
  • Pharmacy education on use of spacer
  • Modification of home medications (if indicated)
  • Asthma Action Plan
  • Appointment with PMD
  • Appointment with subspecialty (if indicated)

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clinical Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.

INPATIENT: PHASE 3

  • Albuterol q3hrs
  • Respiratory score q3hrs

Resp Score 5-8

  • Continue therapy in this phase




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