Acute Asthma Pathway - Advocate Doctors

1 Acute Asthma Pathway _____ Month/Year Published: December 2015, Revised March 2016 Owners: , Inclusion: Children experiencing Acute Asthma exacerbation 24 months to 18 years of age with a diagnosis of Asthma Patients with a previous history of Asthma (Consider differential diagnosis for infants and young children up to 24 months) Exclusion: Patients in impending respiratory failure or requiring intubation and ventilator support Diagnosis of Bronchiolitis or viral pneumonia (See Viral Bronchiolitis Pathway ) Co-morbidities, cardiovascular disease, cystic fibrosis, BPD, and immunodeficiency syndrome Implement treatment protocol and monitor response to therapy: Vitals per protocol, PEFR (age dependent), continuous pulse oximetry, and level of fatigue.

2 Use Pediatric Asthma Score to guide interventions and document response to treatment. PEDIATRIC Acute Asthma SCORE ( ) GUIDELINES Score 0 1 2 3 PAAS Action Guide Oxygen Saturation on room air >97% 94% to 96% 91%-93% <90% Respiratory Rate 2-3 years 4-5 years 6-12 years >12 years 18-26 16-24 14-20 12-18 27-34 25-30 21-26 19-23 35-39 31-35 27-30 24-27 40 or greater 36 or greater 31 or greater 28 or greater Auscultation Normal Breath Sounds Minimal to mild expiratory wheeze Moderate to severe expiratory wheeze Inspiratory and expiratory wheeze and/or diminished breath sounds Accessory Muscle Use None Intercostal only Intercostal and sub-sternal Intercostal, sub-sternal and supraclavicular Cerebral Function Normal Slightly decreased Lethargic Unresponsive Asthma Score.

3 Normal 0 - 4, Mild exacerbation 5 - 7 Moderate exacerbation 8 - 11 Severe exacerbation 12 -15 Peak Flow (not counted in the PAAS, but can be used to assist in determining severity of the exacerbation) Severity Mild Moderate Severe Imminent Respiratory Arrest Peak Flow % predicted > 70% 40-69% 25-39% <25% If PAAS is: >7 and worsens by 2 or more 12 or more worsens by more than 2 within 1 hour after advancing therapy Notify Physician If PAS had not improved by at least 2 or is 12 or more, the patient is worsening. Acute Asthma Pathway _____ Month/Year Published: December 2015, Revised March 2016 Owners: , Acute MANAGEMENT GUIDELINES Initiate Therapy Initial Assessment Weaning Discharge Criteria MILD PAAS: 5-7 Initiate corticosteroids Albuterol MDI 4-8 puffs Q 20 minutes x 3 doses then Q 1-4 hours May use albuterol nebulizer Q 20 minutes x3 doses at physician s discretion.

4 1 hour continuous albuterol nebulizer at physicians discretion *ipratropium not used regularly in every asthmatic for inpatient setting, recommended for use in the ED to decrease admission rate (3 doses in 1 hr) Assess for improvement of PAAS within 2 hours of initiating therapy. If score is improving, may begin to wean therapy. If response is sustained for 1 hour post treatment, reassess every 3-4 hours To wean, albuterol dose must be no greater than mg. Must score a 1 in every category except oxygen saturation (may score a 2) Should stay on current therapy if the PAAS is 7-8 or if the score is >1 in any category except for oxygen saturation. If score is > 9 or 3 in any category begin Moderate Exacerbation Pathway .

5 Q4 hour albuterol x2 (per attending discretion) Oxygen saturation > 90% room air x6 hours No evidence of respiratory distress PAAS of 6 or less Provided patient/ family education (MDI teaching, use of rescue versus control MDIs) Medication reconciliation Follow up appointment with primary care provider MODERATE PAAS: 8-11 Begin therapy with - 5mg albuterol neb (or 4-8 puffs albuterol MDI) q1 to q2hour x3 OR initiate 10mg continuous albuterol nebulizer Initiate corticosteroids if not already given Consider magnesium sulfate for persistent symptoms Assess for transfer to a Children s Hospital or PICU for cardio-respiratory monitoring (PICU should be contacted if score is 11.) Assess for improvement of PAAS within 2 hours of initiating therapy.

6 If score is improving, may begin to wean therapy. If response is sustained for 1 hour post treatment, reassess every 2-3 hrs If good response, decrease dosage and frequency of albuterol to Q2 -3 hrs. Reassess patient every 2 hours. If response is sustained for 2 hours, decrease frequency to Q3-4 hrs and reassess patient every 3 hours. If poor response, increase frequency to Q1-2 hrs or initiate continuous albuterol and Acute Asthma Pathway _____ Month/Year Published: December 2015, Revised March 2016 Owners: , * ipratropium not used regularly in every asthmatic for inpatient setting, recommended for use in the ED to decrease admission rate (3 doses in 1 hr) consider IV steroids if on oral Reassess patient response to treatment every 2 hours.

7 If response improved, wean dosage back to Q4. SEVERE PAAS: 12-15 No improvement in score one hour after advancing or patient condition is deteriorating Oxygen saturation<90 on 40% Oxygen, PCO2>42, depressed sensorium Notify Physician (Admit to PICU) Initiate corticosteroids if not already given Continuous albuterol therapy and adjunct therapies (MgSO4, terbutaline) Consider High Flow Oxygen, heliox therapy, CPAP/BIPAP, 100% Oxygen in severe Acute situations if in ED or pending transfer to Children s hospital or PICU Consider intubation, mechanical ventilation Acute Asthma Pathway _____ Month/Year Published.

8 December 2015, Revised March 2016 Owners: , Hospital Based Medications Medication Child Dose (2-12yo) Adolescent Dose (>12yo) Inhaled Short Acting Beta-2 Agonists (SABA) Albuterol MDI 90mcg/puff 4-8 puffs every 20 minutes for 3 doses then every 1-4 hrs. as needed 4-8 puffs every 20 minutes for up to 4 hrs. then every 1-4 hrs. as needed Albuterol Nebulizer ( , ) to 5mg every 20 min for 3 doses then ever 1-4 hrs. as needed Continuous: 10mg per hour Continuous for PICU and ED: 5-10kg, 10mg per hour 10-20kg, 15mg per hour >20kg, 20mg per hour to 5 mg every 20 minutes for 3 doses then every 1-4 hours as needed Continuous: 10mg per hour Continuous for PICU and ED: 5-10kg, 10mg per hour 10-20kg, 15mg per hour >20kg, 20mg per hour Anticholinergics (*decreased admission rate seen when 3 doses of ipratropium bromide given in ED) Ipratropium Bromide MDI (17mcg/puff) 4-8 puffs every 20 minutes as needed for the first 3 hours 8 puffs every 20 minutes as needed for the first 3 hours Ipratropium Bromide Nebulizer (500 ) 500 mcg with the first 3 doses of albuterol not to exceed 1500 mcg in the first hour of treatment 500 mcg with the first 3 doses of albuterol not to exceed 1500 mcg in the first hour of treatment SABA/Anticholinergic combination Duoneb Nebulizer ( ipratropium and albuterol/3mL)

9 3 mL every 20 minutes for 3 doses 3 mL every 20 minutes for 3 doses Systemic Corticosteroids Prednisone ( mg tablets) 1-2 mg/kg daily for 5 days maximum 60 mg daily (QD or BID) 60 mg daily for 5 days (QD or BID) Methylprednisolone (40mg/mL IV, 125mg/2mL IV) 1-2 mg/kg daily for 5 days maximum 60 mg daily (QD or BID) 60 mg daily for 5 days (QD or BID) Prednisolone (15mg/5mL, 10mgODT, 15mgODT) 1-2 mg/kg daily for 5 days maximum 60 mg daily (QD or BID) 60 mg daily for 5 days (QD or BID) Dexamethasone mg/kg once daily (max 16 mg/dose) mg/kg once daily (max 16 mg/dose) Others Magnesium Sulfate (IV) 50mg/kg/dose (25-50mg/kg/dose)-max 2 grams-administer over 20 minutes 50mg/kg/dose (25-50mg/kg/dose)-max 2 grams-administer over 20 minutes Terbutaline Load: 10 mcg/kg over 10-20 minutes Continuous: mcg/kg/min Load: 10 mcg/kg over 10-20 minutes Continuous: mcg/kg/min Acute Asthma Pathway _____ Month/Year Published: December 2015, Revised March 2016 Owners: , References Acute Asthma Guidelines, Cincinnati Children s Hospital Medical Center, Evidence Based care Guidelines For Management of Acute Asthma Exacerbation in Children.

10 Guidelines 4, pages 1-35 September 16, 2010. Gorelick M, Stevens M, Schultz T., and Scribano V. Performance of a Novel Clinical Score, the Pediatric Asthma Severity Score (PASS), in the Evaluation of Acute Asthma . Academy of Emergency Medicine, Vol. 11, Issue 1, pages 10-18, January 2004 National Heart Lung and Blood Institute, Managing Exacerbation of Asthma -National Education and Prevention Program NAEPP. Expert Panel 3: guidelines for the diagnosis and management of Asthma . National guidelines Clearing House October 2007 Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of Nebulized Ipratropium on the Hospitalization Rates of Children with Asthma N Eng J Med 1998; 339 (15):1030-1035 Methods of Calculating the Asthma Score and the Severity of Asthma From: Qureshi: N Eng J Med, Volume 339(15).