Asthma Clinical Pathway

February 2021

Outcomes/Goals 1. Early identification, classification and treatment of asthma using Asthma Severity Tool
2. Standardize best practices for asthma treatment in the Emergency Department
Inclusion Criteria Pediatric patients 2-19 years of age with a history of asthma
Exclusion Criteria • Patients presenting with chief complaint of first-time wheezing, respiratory distress
without history of asthma, and/or wheezing in children
• Patients with chronic lung disease (e.g. CF)
• Cardiac disease
NURSE Chief complaint. Onset of symptoms. Asthma history, including use of peak flow, medications,
Documentation last steroid use, recent illness, hospitalizations, PICU stays, intubation. General appearance, lung
sounds, work of breathing, retractions, pulses, skin temperature/fever. Initial room air Asthma
Severity Score. (See page 4 for Pediatric AST Severity Scale)
INTERVENTIONS Determine severity of exacerbation (initial and rescoring is on room air)
Initiate on arrival ESI Triage level II, III, or IV, depending on severity
Evaluate need for isolation and initiate immediately if applicable
Full set of vitals per standard of care
Continuous pulse oximetry if SaO2 ≤ 95%
Oxygen to maintain SaO2 > 90%
Initiate Duo nebs for audible wheezing, retractions, or distress, and considering asthma history
(consider initially using continuous albuterol for severe exacerbations)
Administer continuous nebs with air, using oxygen as needed to maintain SaO2 levels
PHYSICIAN (LIP)
Medication Mild: Albuterol inhaler with spacer 4-8 puffs, repeat x 1 within first 30-60 minutes if needed
Moderate/Severe: 3 stacked Duo nebs. Do not delay time between nebs > 5 minutes, continue
Bronchodilators albuterol nebs Q 2-4 hours as needed
Continuous Albuterol:
Weight Continuous Neb Dose
5-10 kg 10 mg/hr.
10-20 kg 15 mg/hr.
>20 kg 20 mg/hr.
*Younger children may be dosed at 0.3-0.5 mg/kg/hr.
Steroids Dexamethasone 0.6 mg/kg up to 16 mg max; PO x 1 (Use IV version orally to minimize volume)
If unable to tolerate PO: Dexamethasone 0. 6 mg/kg up to 16 mg max IM/IV (second dose of
dexamethasone 24 hours after first dose)
Additional Additional medication considerations for severe exacerbation:
Medications • Magnesium 25-50 mg/kg (maximum 150 mg/min) x 1 over 15-30 minutes, may repeat x 2
doses up to 2 g total
• Terbutaline 10 mcg/kg IV (loading dose) over 10 minutes, then infusion 0.1- 10 mcg/kg/min IV
pending PICU admission
**Can be given SQ/IM 0.005-0.01 mg/kg/dose – max 0.4 mg/dose every 15-20 minutes x 3
doses
• Epinephrine SQ/IM 0.01 mg/kg 1:1000 maximum 0.5 mg every 20 minutes x 3 doses if
refractory to all other methods
• Heliox (80/20%) with albuterol via mask
Rehydration Evaluate/encourage oral rehydration as appropriate
Consider IV rehydration if unable to tolerate PO fluids or significantly increased WOB
Non-Invasive • CPAP/BiPAP: Use EPAP 5 cm H2O; IPAP 15 cm H20 as initial order
Ventilation • High-Flow Nasal Cannula: 21-100% humidified warmed oxygen. Flow based upon cannula size
and work of breathing, though 1-2L/kg initiation recommended.
Rescue • Consider Ketamine Loading dose 0.3 to 0.5 mg/kg IV over 1-2 minutes followed by infusion of
Medication 0.3-0.5 mg/kg/hr IV
 Asthma Clinical Pathway
February 2021

Initial Assessment & Immediate Action

Vitals/pulse oximetry/monitor
Consider isolation
Oxygen to maintain SaO2 >90% (Notify MD immediately if hypoxia)
Initial Asthma Severity Tool room air score to determine severity
TRIAGE- ASSESS & SCORE

Moderate Severe
Mild
AST 6-11 (ESI III) AST 12-18 (ESI II)
AST < 6 (ESI IV)
Moderate accessory muscle use Severe accessory muscle use
No distress (may have end
expiratory wheezing) Inspiratory/expiratory wheezing Inspiratory/expiratory
with good aeration wheezing with poor aeration
Mild accessory use
Tachypnea and/or tachycardia Abnormal HR and RR
Room air SaO2 ≥93%
Room air SaO2 ≥ 90 Room air SaO2 ≤90%
1ST HR RE-SCORE

Albuterol MDI with spacer 4- Call EARLY to setup

Stacked duo nebs (3 within 20 transfer to PICU or a
8 puffs minutes) Children’s Hospital
Repeat x 1 within 30-60 Dexamethasone 0.6 mg/kg up to
minutes if needed Worsening condition,
16 mg maximum; PO x 1 (may give fatigue with
Dexamethasone 0.6 mg/kg IM/IV if unable to tolerate PO) breathing give
up to 16 mg maximum; PO Consider MgSO4 25-50mg/kg up to magnesium or
Oral hydration 2g maximum IV terbutaline prior to
transfer
Oral hydration if improvement
after 3 stacked nebs, otherwise
consider IV hydration
Continuous albuterol 10-20
2ND HR RE-SCORE AND DETERMINE DISPO

Review rescue inhaler and Continue Q2 hr. albuterol nebs

spacer use/technique mg/hr.
with AST assessments pre/post
Discharge +/- second dose nebs Dexamethasone 0.6 mg/kg up
of oral steroid to take in 24 to 16 mg maximum; PO x 1 (may
Consider chest x-ray give IM/IV if unable to tolerate
hours
PO)
Assure follow-up with
primary provider or asthma IV hydration
specialist within 1 week Admission vs. Discharge Consider adjunct medications
prior to transfer (magnesium,
Score >8 after the first hr. of terbutaline, epinephrine,
neb therapy, consider transport ketamine)
to children’s hospital/admission
Consider Heliox
Score 6-8 following 2nd hr. of
neb therapy or continued need VBG
for Q2 hr. nebs, consider Chest x-ray
transfer Children’s hospital
If able to space Q4 hour MDI
puffs, consider discharge
planning
 Asthma Rationale and Data

Goals of Clinical Pathway

1. Early identification, classification and treatment of Asthma using Asthma Severity Tool
2. Standardize best practices for asthma treatment in the Emergency Department
Weaning from continuous Albuterol nebs: Do not stop continuous nebs abruptly unless patient is deteriorating or in
respiratory failure. To wean continuous nebs decrease dose in half for one hour. If tolerated, stop continuous
Albuterol and resume Q2 hour nebs per protocol.
Data Considerations Interventions Rationale
Steroids Dexamethasone Two doses of oral dexamethasone is as effective as 5 days of oral
prednisone in preventing relapse for pediatric asthma exacerbations
and had better compliance

Single dose oral Dexamethasone is as effective as 3-5 days of twice-

daily prednisolone in the management of children with mild to
moderate asthma Dexamethasone is well absorbed orally, has the
same bioavailability as when given parenterally and duration of
action lasting up to 72 hours after a single dose

Inhaled Medications Albuterol & Treatment with combination albuterol ipratropium appears to
Ipratropium reduce hospitalization compared to albuterol alone.
(Duoneb) Patients with severe respiratory distress have decreased rates of
hospitalization and improvement in pulmonary function when
Continuous Albuterol treated with continuous Albuterol nebulizer

Adjunct Medications Magnesium IV magnesium sulfate improves pulmonary function and prevents
hospitalization
Terbutaline A trend toward improvement in clinical asthma severity score is seen
with IV Terbutaline, but adverse effects may include cardiac
dysrhythmias and elevated troponin

Rescue Medication Ketamine Ketamine IV bolus followed by a continuous infusion may have
moderate benefits to standard therapy in children with moderately
to severe asthma exacerbation
 Pediatric Asthma Severity Scoring Tool (AST)

Severity Score
Parameter 0 1 2 3
Room air SPO2 >95% 93-95% 90-92% <90%
Accessory Muscle Use None Mild Moderate Severe
Inspiratory/Expiratory 2:1 1:1 1:2 1:3
Ratio
None End expiratory Inspiratory and Inspiratory and
Wheezing expiratory with expiratory with
good aeration poor aeration
Heart Rate
<3 years old <120 120-140 141-160 >160

3 years old or older <100 100-120 121-140 >140

Respiratory Rate
< 6years old <30 31-45 46-60 >60

6 years old or older <20 21-35 36-50 >50

TOTAL SCORE:
• 0-5 Mild Consider Q4 hour treatment and Assessment after initial treatment and stabilization
• 6-11 Moderate Consider Q2 hour treatment and Assessment after initial treatment and stabilization
and admission/transfer
• 12-18 Severe Consider early transfer, continuous nebs and adjunct medications

Citations:
Griffiths B, Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in
children. Cochrane Database Syst Rev 2013; CD000060.

Keeney GE, Gray MP, Morrison AK, et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics
2014; 133:493

Cronin JJ, McCoy S, Kennedy U, et al. A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for
Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med 2016; 67:593

Zemek R, Plint A, Osmond MH, et al. Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved
emergency department efficiency. Pediatrics 2012; 129:671.

Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium sulphate for treating acute asthma. Arch Dis Child 2005;
90:74

Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane
Database Syst Rev 2003; CD001115.

Kim IK, Phrampus E, Venkataraman S, et al. Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate
to severe asthma exacerbations: a randomized, controlled trial. Pediatrics 2005; 116:1127.

Denmark TK, Crane HA, Brown L. Ketamine to avoid mechanical ventilation in severe pediatric asthma. J Emerg Med 2006; 30:163