Asthma Pathway

Very Severe/Severe - PICU / Moderate / Mild
Continuous Albuterol Dosages
>20 kg / 15 mg/hr
10-20 kg / 10 mg/hr
<10 kg / 7.5 mg/hr
/ Albuterol Dosages (with VHC)
> 20 kg / 8 puff Q2 hours
10-20 kg / 6 puffs Q2 hours
<10 kg / 4 puffs Q2 hours
/ Albuterol Dosages (with VHC)
First Q4 hours / Second Q4 hours
(Home Dose)
> 20 kg / 8 puffs / 2 puffs
10-20 kg / 6 puffs / 2 puffs
<10 kg / 4 puffs / 2 puffs
Additional Medications
Prednisone/Prednisolone/Methylprednisone0.5 mg/kg/dose Q6h (max 80 mg/day)
Supplemental oxygen as needed
Consider Ipratropium Bromide 500 mcg or 250 mcg nebulized Q6h
If worsening or not improving, consider:
Magnesium sulfate 50 mg/kg/dose (max 2g) with NS bolus
Terbutaline (SQ) 0.01mg/kg Q15 min (max 0.25 mg/dose)
Terbutaline (IV) 0.01 mg/kg over 10 min (max 0.75 mg/dose) or continuous infusion at 1 mcg/kg/min
Epinephrine (IM) (1mg/ml) (1:1000) 0.01 mg/kg Q20 min x 3 doses (max 0.5 mg/dose)
May also consider initiating noninvasive ventilation (BLPAP) / Additional Medications
Prednisone/Prednisolone/Methylprednisone
1 mg/kg/dose Q12 hours (Max 80 mg/day if ≥ 12 yrs; Max 60 mg/day if < 12 yrs)
Discontinue Ipratropium Bromide
Supplemental oxygen at needed / Additional Medications
Continue Prednisone/Prednisolone
Continue Home Dose albuterol every 4 hours until discharge
Restart/initiate ICS on discharge as needed
Assessment
Respiratory assessment/score Q1 hour
HR & RR Q1 hour and PRN
Continuous Pulse oximetry
Cardiopulmonary monitoring
Hydration status / Assessment
Respiratory assessment/score Q2 hours
HR &RR Q2 hours
Continuous pulse if on supplemental oxygen, if not spot check with respiratory assessments
Discontinue Cardiopulmonary monitoring
Hydration status / Assessment
Respiratory assessment/score Q4 hours
HR & RR Q 4 hours
Pulse oximetry PRN
Hydration status – oral intake
Progression
Moderate assessment for 2 hours then advance to moderate arm of pathway / Progression
Mild assessment for 4 hours with treatment
Off supplemental O2 / Progression
Discharge after home dosed
Educations
Initiate educations on “What is asthma.” Signs and symptoms, triggers / Education
Initiate education on meter-dose inhalers (MDI) and valve-holding chambers (VHC) use / Education
Finalize discharge training. Check understanding of key concepts, device technique, review medications and asthma action plan

Note:If a patient will progress outside of these guidelines, please have provider enter a variance order/note to support/explain the reason for change. All variance orders/note should be discussed with senior resident and/or attending if necessary.

Discharge Criteria

Respiratory Assessment

  • Mild
  • No supplemental oxygen required

Hydration status

  • Adequately hydrated
  • Tolerating oral

Education

  • Asthma education in class or at bedside completed with appropriate documentation
  • An asthma action plan was filled out and reviewed with the family
  • Family educated about asthma action plan

Other

  • Case management consulted for asthma needs including spacer and/or nebulizer for home
  • Consider referral to Keeping Families Healthy Program and/or home nursing
  • Referral should be made through social work for any patient with 2 or more emergency department visits or hospitalizations within the last 12 months
  • Referrals should be made through social work for other patients with identifiable concerns.
  • Consider flu vaccine during influenza season

Education

  • Asthma education should be provided throughout the episode of treatment.
  • An asthma action plan will be completed for all children discharged from the hospital with a primary diagnosis of asthma or treated for asthma during the admission. Any child diagnosed with “reactive airway disease (RAD)” is considered to have the same diagnosis of asthma
  • Any child who is receiving scheduled albuterol treatments should be considered as being treated for asthma
  • The asthma action plan should include controller medications (or no controller indicated), triggers, and follow up provider and phone number. The asthma action plan should be reviewed with the patient and caregiver.
  • The primary caregiver and/or patient need to demonstrate understanding of signs and symptoms, medications and device use, patient specific asthma triggers, and the asthma action plan.
  • Smoking avoidance and cessation counseling referral will be provided to patients and primary caregivers as indicated.
  • Materials: (asthma class would satisfy)
  • “What is asthma?”
  • Common Triggers
  • Asthma and the environment
  • Asthma action plan
  • Metered dose inhaler
  • Dry powder inhaler – Diskus, Twisthaler, Flexhaler, RespiClick
  • Home nebulizer treatments