PEDIATRIC EMERGENCY DEPARTMENT ASTHMA GUIDELINE

INCLUSION:

  • Age 2 Y - 18 Y w/ history of Asthma or 2 or more episodes of lifetime wheeze with response to SABA.

EXCLUSION:

  • Age less than 2 years
  • Chronic lung disease (e.g. cystic fibrosis, primary ciliary dyskinesia, non-CF bronchiectasis, restrictive lung disease)
  • Congenital or acquired heart disease
  • Airway issues (e.g. tracheomalacia, laryngomalacia, tracheoesophageal fistula, tracheostomy dependent, vocal cord paralysis)
  • Medically complex children with impaired cough or impaired secretion clearance
  • Immune disorders
  • Alternate diagnosis besides asthma (Bronchiolitis, croup, pneumonia, foreign body)
  • History of bronchopulmonary dysplasia who are on diuretic therapy or supplemental oxygen
  • Neurologic disorders or Neuromuscular diseasewhich may lead to impaired cough and secretion clearance

Upon arrival

Patients will be triaged those meeting inclusion will have a Pediatric Asthma Score (PAS) assigned

Pathways:

Mild (PAS 0-4)

  • Albuterol MDI with Aerochamber x 1 dose
  • Oral DEX or PRED if:

History of intermittent asthma requiring more than one dose of SABA

History of persistent asthma on daily controller medications

Moderate (PAS 5-8)

  • Albuterol
  • MDI with Aerochamber q20 min x 3 doses (preferred)
  • Nebulized q20 min x 3 doses (w/ O2 if SpO2 < 95%)
  • PRED or DEX
  • After 1 hour
  • If PAS 0-4, then re-assess after an additional hour
  • if PAS remains 0-4 then discharge home with appropriate AAP/education, oral corticosteroids, Albuterol, (daily controller medications as indicated)
  • If PAS 5-7
  • Administer an additional dose of albuterol, and re-assess after an additional hour.
  • If PAS 0-4 then discharge home with appropriate AAP/education, oral corticosteroids, Albuterol, (daily controller medications as indicated).
  • If PAS remains 5-8, admitto Gen Peds floor for albuterol q2 h.

Severe (PAS 9-12)

  • Albuterol - nebulized q20 min x 3 doses (w/ O2 if SpO2 < 95%) with Ipratropium
  • q20 min x 3 doses (alternatively Albuterol may be given as continuous w/
  • ipratropium)
  • PRED oral or MethylPREDnisolone IV
  • After 1 hour
  • If not improved (alternative diagnosis?)
  • Continuous albuterol x 1 hour
  • Magnesium Sulfate IV
  • Normal Saline Bolus 20 cc/kg (max 1L)
  • Antipyretics if febrile
  • Admit PICU
  • If PAS 5-8, then administer an additional dose of albuterol
  • Re-evaluate after 1 hour
  • if improving score then re-evaluate at 2 hours for Gen pedsfloor admission
  • if not improving or worsening (alternative diagnosis?)
  • Continuous albuterol x 1 hour
  • Magnesium Sulfate IV
  • Normal Saline Bolus 20 cc/kg (max 1L)
  • Antipyretics if febrile
  • Admit PICU

Very Severe (PAS >12)

  • Albuterol continuous w/ Ipratropium x 3 doses added
  • Methylprednisolone IV
  • Magnesium Sulfate IV
  • Normal Saline Bolus 20 cc/kg (max 1L)
  • Antipyretics if febrile
  • (Consider Terbutaline SC or Epinephrine SC/IM for for poor air movement or RF)
  • (Consider BiPAPwith continuous albuterol for impending RF if alert and maintaining airway)
  • (Consider ETCO2 monitoring)
  • Admit PICU

Respiratory failure

Prior to RSI

  • Contact PICU Attending
  • Normal saline bolus 20cc/kg (pre-load compromised)
  • Pre-oxygenate NRB +/- NC 5-10L or BVM with PEEP valve (if not on BiPAP)

Medications for RSI

  • Ketamine 1.5 mg/kg
  • Succinylcholine 1.5 mg/kg (Rocuronium 1 mg/kg if SCh contraindicated)

Adjuncts

  • Use Cuffed ETT
  • Low I:E ratio
  • Avoid high tidal volumes
  • Permissive hypercapnia

References

Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis

Grant E.Keeney,Matthew P.Gray,Andrea K.Morrison,Michael N.Levas,Elizabeth A.Kessler,Garick D.Hill,Marc H.Gorelick,Jeffrey L.Jackson

PediatricsFeb 2014,peds.2013-2273;DOI:10.1542/peds.2013-2273

Cates CJ,Welsh EJ,Rowe BH.Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma.Cochrane Database of Systematic Reviews2013, Issue9. Art. No.: CD000052. DOI: 10.1002/14651858.CD000052.pub3.

*National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (Summary Report 2007). In: Busse W, ed.J Allergy Immunol. 2007;120(5):S94-138. National Institutes of Health-National Heart Lung, and Blood Institute.

Zorc JJ, Pusic MV, Ogborn CJ, et al. Ipratropium bromide added to asthma treatment in the pediatric emergency department.Pediatrics. 1999;103(4 pt 1):748-752.

Dotson, K; Dallman, M; Bowman, CM, et al. Ipratropium Bromide for Acute Asthma Exacerbations in the Emergency Setting: A Literature Review of the Evidence. Pediatric Emergency Care:2009; 25(10): 687-692

Medication dosing References

*Figure 22, Dosages of Drugs for Asthma Exacerbations, page 56.

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