Asthma Exacerbation Management
CLINICAL PATHWAYASTHMA EXACERBATION MANAGEMENTTABLE OF CONTENTSFigure 1. Algorithm for Asthma Exacerbation Management – Outpatient ClinicFigure 2. Algorithm for Asthma Management – Emergency DepartmentFigure 3. Algorithm for Asthma Management – InpatientFigure 4. Progression through the Bronchodilator Weaning ProtocolTable 1. Pediatric Asthma Severity (PAS) ScoreTable 2. Bronchodilator Weaning ProtocolTarget PopulationClinical ManagementClinical AssessmentTreatmentClinical Care Guidelines for Treatment of Asthma ExacerbationsChildren’s Hospital Colorado High Risk Asthma ProgramTable 3. Dosage of Daily Controller Medication for Asthma ControlTable 4. Dosage of Medications for Asthma ExacerbationsTable 5. Dexamethasone Dosing Guide for AsthmaFigure 5. Algorithm for Dexamethasone Dosing – Inpatient AsthmaPatient Caregiver Education MaterialsAppendix A. Asthma Management – OutpatientAppendix B. Asthma Stepwise Approach (aka STEPs)Appendix C. Asthma Education HandoutAppendix D. Asthma Action Plan Epic ScreenshotsReferencesClinical Improvement TeamPage 1 of 27
CLINICAL PATHWAYFIGURE 1. ALGORITHM FOR ASTHMA EXACERBATION MANAGEMENT –OUTPATIENT CLINICTriage RN/MA: Check HR, RR, temp, pulse ox. Triage level as appropriate Notify attending physician if patient in severe distress (RR greater than 35, oxygen saturation less than 90%,speaks in single words/trouble breathing at rest)Primary RN: Give oxygen to keep pulse oximetry greater than 90%TreatmentInclusion Criteria1. Give nebulized or MDI3 albuterol up to 3 doses. Albuterol dosing is 0.15 to 0.3mg/kg per 2007NHLBI guidelines. Less than 20 kg: 2.5 mg neb x 3 or 2 to 4 puffs MDI albuterol x 3 20 kg or greater: 5 mg neb x 3 or 4 to 8 puffs MDI albuterol x 3Note: For moderate (dyspnea interferes with activities)/severe (dyspnea at rest) exacerbations youcan add atrovent to nebulized albuterol at 0.5mg/neb x 3.2. Repeat vital signs every 30 minutes3. Prednisone 2 mg/kg orally with a maximum dose of 80 mg should be given if there is not completeresponse** after one treatment dose (Please see dexamethasone dosing guide if usingdexamethasone instead of prednisone)(Contraindications: varicella, varicella exposure, tuberculosis, severe respiratory distress, recent[within 2 weeks] steroids) 2 years or older Treated for asthma or asthmaexacerbation First time wheeze with history consistentwith asthmaExclusion Criteria Patients treated for bronchiolitis, viralpneumonia, aspiration pneumonia,croup, chronic lung disease,bronchopulmonary dysplasia, cysticfibrosis, airway anomalies, cardiacdisease, neurologicdisordersDexamethasone Dosing Guide for AsthmaYesDischarge Discharge home if stable for 1 to 2 hoursafter last bronchodilator therapy Intensify home albuterol therapy to every4 hours as needed Oral Steroids for 5 days if needed Follow-up scheduled Asthma Education and MDI teaching Re-label medications for home ifCompleteResponse?**NoED Transfer Criteria No response or incomplete response to3 back to back treatments OR Oxygen saturations below 90% on roomair OR Requiring nebulizer treatments moreoften than every 2 hourspossible** Complete response is defined as oxygen saturations over 90%, no significant increased work of breathing,(PAS less than 7)**Page 2 of 27
CLINICAL PATHWAYFIGURE 2. ALGORITHM FOR ASTHMA MANAGEMENT – EMERGENCYDEPARTMENTIntended for: Children 2 years or older with acute wheeze or cough AND A HISTORY OF: Asthma OR Episodic symptoms of airflow obstruction (recurrent cough and/or wheeze)—including anaphylaxis—that are atleast partially reversible with bronchodilator treatmentNOT Intended for: Children less than 2 years old; co-morbid conditions, including: chronic lung disease, cystic fibrosis,cardiac disease, bronchiolitis, stridor, aspiration or neuromuscular disordersTriage RN/Primary RN:Routine vital signs and check saturation, blood pressure Perform Pediatric Asthma Score (PAS) If PAS score is 8 or above and the patient has a history of asthma, reactive airway disease, recurrent albuteroluse or recurrent wheezing, initiate the ED asthma nurse standing order including oral steroids (dexamethasone) Oxygen to keep SpO2 greater than 90% Notify respiratory therapyRT or RN: Give up to three initial inhaled albuterol or combination ipratropium - albuterol treatments, either nebulized or viaMDIs.8,9 See weigh specific dosing below. Refer to standing order. Repeat PAS pre and post nebulizer. Dexamethasone (or equivalent) 0.6mg/kg orally with a maximum dose of 16 mg to any child with a PAS scoreover 7 if not contraindicated. Goal is administration within 60 min of arrival. Initiate asthma bundle (RT assess and treat flowsheet).*See algorithm on next pagePage 3 of 27
CLINICAL PATHWAYFIGURE 2. ALGORITHM FOR ASTHMA MANAGEMENT – EMERGENCYDEPARTMENT (CONTINUED)Perform Pediatric Asthma Score(PAS)Inclusion Criteria 2 years or older Treated for asthma or asthmaexacerbation First time wheeze with history consistentwith asthmaExclusion CriteriaYes Patients treated for bronchiolitis, viralpneumonia, aspiration pneumonia,croup, chronic lung disease,bronchopulmonary dysplasia, cysticfibrosis, airway anomalies, cardiacdisease, neurologicdisordersNoGood response?Good ResponseIncomplete ResponsePAS 5 to 7 within 30 minutes ofcompleting nebs AND SpO2 greaterthan 90% on room air (RA) 30minutes after albuterol dosePAS 8 to 11 or Poor Response(PAS 12 to 15) with saturation lessthan 90% Observe for at least 60 minutesVS (HR, RR, SpO2), PAS in 1hourIf PAS 8 or if hypoxic, treat as“Incomplete Response” Home bronchodilator therapyevery 4 hours as needed forcough, wheezing or troublebreathingPrescribe single dose of oraldexamethasone to be given24-36 hours after initial dosefor patients receiving 2 ormore albuterol treatments andconsider if patient has ahistory of severe asthmaexacerbationsPrescribe fluticasonepropionate (Flovent) 44 mcg 2puffs twice a day if the patienthas albuterol use 3 or moredays/week (excludingpretreatment) or 2 or moresteroids bursts in the last 12months (including this EDvisit)Complete asthma bundleAsthma Education and AsthmaAction PlanIf needed, provide phonenumber(s) for potential PCPRe-label beta agonist andcontroller for home useFrequencytimes 3times 3 Place on cardio-respiratory monitor with VS (HR,RR,SpO 2) every hourAlbuterol continuous neb with oxygen as needed to keep saturations 90%WeightDoseLess than 20 kg7.5mg/hr20 kg or more10mg/hrRecheck in one hour: If PAS less than 8, go off continuous If PAS is 8 or more put the child back on continuous If PAS is 12 or greater, go to “Poor Response” below.Discharge Criteria: PAS less than7 and SpO2 90% Discharge Plan WeightAlbuterol DoseLess than 20 kg2.5 mg20 kg or more5 mgPAS 8-11, For patients still oncontinuous nebs:PAS 8, Once patient is offcontinuous: Observe for 2 hours If PAS is 8 or more, put back oncontinuous nebs and monitor hourly. If PAS is less than 8 at 2 hours give 2-8puffs Albuterol MDI and wean as toleratedand consider discharge Repeat PAS every hour Consider a 30 minute trail off continuousneb. Go to “POOR RESPONSE” if PAS is 12or greaterPAS 12, Poor Response: Consider ABG and CXR Increase albuterol per ED attending andadjunct therapies such as IV magnesium,noninvasive ventilation, or subcutaneousterbutaline Consult ICU!PAS 8 or more?Consider admitPAS less than 8?Consider dischargeAdmit Criteria:Unable to weanalbuterol to every 2hours or SpO2 less than90% on room air.Admit to Floor or ICU?Colorado Springs Hospital- Admit toPICU** RT and floor RN must be notified beforetransfer to the inpatient unit** FloorAlbuterol every 2 hours or stable on continuousalbuterol neb for at least 1 hourContinuous neb requirements belowNormal mental statusWeightLess than 20 kg20 kg or moreDoseMore than 7.5 mg/hrMore than 10 mg/hr Intensive Care UnitRequires more than one dose of IV magnesium,terbutaline infusion, or subcutaneous epinephrineContinuous neb requirements belowChange in mental statusImpending respiratory failureWeightDoseLess than 20 kgMore than 7.5 mg/hr20 kg or moreMore than 10 mg/hrPage 4 of 27
CLINICAL PATHWAYFIGURE 3. ALGORITHM FOR ASTHMA MANAGEMENT – INPATIENT AND NOC Inclusion CriteriaInitial assessment: 2 years or older Treated for asthma or asthmaexacerbation First time wheeze with history consistentwith asthmaVital signs, SP02, PAS scoreChronic asthma severityContinuous monitoring only if on continuousnebulizerGuideline andbronchodilator weaneligible?Exclusion Criteria Patients treated for bronchiolitis, viralpneumonia, aspiration pneumonia,croup, chronic lung disease,bronchopulmonary dysplasia, cysticfibrosis, airway anomalies, cardiacdisease, neurologicdisorders Clinically indicatedNocare Can still use asthmaorder set Yes Initiate asthma clinical care guideline with PULM IP asthma order set for treatment including: Oxygen as needed, systemic corticosteroids*,inhaled beta agonist using weaning protocol (see Table 4), and AAPand education If appropriate, initiate controller medication* See page 18 for oral steroid dosing recommendationsIs Child Improving?NoYes Does child meet discharge criteria?Patient on room airBeta agonist required every four hoursFamily able to manage care (if not, consider consulting social work)Discharge PlanController for persistent asthmaOral steroidsHome bronchodilator therapy every 4 hours for 72 hours or untilcompleting oral steroidsMonitoring:Routine vital signs per protocol including PASscore per Asthma Clinical Care Guideline asappropriateContinuous pulse oximeter and CVR monitoringonly while on continuous nebulizerIV access is only needed in a child who is beingadmitted to the Intensive Care Unit or who is nottolerating liquids or oral corticosteroid therapy orotherwise clinically indicatedThere is no mandatory RRT associated withbronchodilator weaning no matter how long thechild has been on continuous albuterol. If thetreating team is concerned about deterioration,then, an RRT can be called. Continue inpatientmanagement and consider consulting pulmonaryin children needing continuous for more than 12hours.For acute deterioration or escalation of the PEWS to 5or more*, consider RRT Work up including blood gas and x-rayIncrease SABA dosingSubcutaneous Terbutaline or EpinephrineRRT and PICU transfer is required for Magnesiumand theophylline and when giving terb drip or epion the floor.RRT and PICU transfer is required for Noninvasive ventilation (CPAP, BiPAP etc)*the child may already have a PEWS of 5 oncontinuous. The RRT would only be for escalatingPEWS scoresFinalize and document Asthma Action Plan and Asthma educationduring Phase 3Place orders for re-label of asthma medications for home use andsend to pharmacy during within 24 hours of dischargeIf needed, provide phone number(s) for potential PCP. Assist inarranging follow up care.Page 5 of 27
CLINICAL PATHWAYFIGURE 4. PROGRESSION THROUGH THE BRONCHODILATOR WEANINGPROTOCOLIntended for: patients 2 years or older who are being treated for asthma or an asthma exacerbation, including firsttime wheezeNOT Intended for: patients less than 2 years old; co-morbid conditions, including but not limited to: chronic lungdisease, cystic fibrosis, cardiac disease, bronchiolitis, croup/stridor, aspiration, neurological disorderNORMAL PROGRESSIONABERRANT COURSEAdvance PhaseEscalationIf PAS improved by 2 or moreORPAS 7 or lessORIf PAS has not improved by at least 2But is NOT getting worseANDIn phase 12 hours or moreIf at any time PAS is more than 7 ANDworsens by 2 or moreORPAS is 12 or moreORPAS worsens by more than 2 within 1hour after advancing*RT to notify RN and MD whenever patientchanges phasesORESCALATE AND NOTIFY BedsideRN and MDContinue Current PhaseIf PAS is less than 12ANDHas not improved by at least 2ANDIn phase less than 12 hoursIf in phase 1 for 12 hours, attempt 1530 minute trial off of continuous nebsIf PAS improves by 2 ormoreANDPAS 11 or lessIf PAS has not improved byat least 2ORPAS is 12 or moreORThe patient is worseningContinueCurrent PhaseNOTIFY MDIf tolerated: AdvanceIf fails: Place back on continuous neb,discontinue the protocol and NOTIFYMDRE-EVALUATEIn less than 1HOURRRT is NOT requiredPage 6 of 27
CLINICAL PATHWAYTABLE 1. PEDIATRIC ASTHMA SEVERITY (PAS) SCORENOTE: Use PAS Score to guide intervention and response to treatment. Older pediatric asthma patients may exhibitlower PAS scoring during an exacerbation.ScoreRespiratory rate2 to 3 years4 to 5 years6 to12 yearsolder than 12 years12334 or less30 or less26 or less23 or less35 to 3931 to 3527 to 3024 to 2740 or greater36 or greater31 or greater28 or greaterOxygen requirementsGreater than 90% onroom air85% to 90% on roomairLess than 85% on room airAuscultationNormal breathsounds to endexpiratory wheezeonlyExpiratory wheezingInspiratory and expiratorywheezing to diminishedbreath sounds or pooraerationRetractionsZero to one siteTwo sitesThree or more sitesDyspneaSpeaks insentences, coos andbabblesSpeaks in partialsentences, short crySpeaks in singlewords/shortphrases/gruntingPage 7 of 27
CLINICAL PATHWAYTABLE 2. BRONCHODILATOR WEANING PROTOCOLFor patients 2 years or older, who are being treated for asthma or an asthma exacerbation. Any patient with asthmaon the floor (including PICU transfers) can be placed on this protocol. Children should be taken off of the protocol ifthey require more than one intensification per phase, fail a trial off of continuous, or by provider discretion. Once takenoff the protocol, the Provider will determine/order timing of bronchodilator wean.PHASE 1PHASE 2PHASE 3Continuous Nebulizer:AlbuterolWeight: DoseMore than 20 kg: 10mg/hourLess than 20 kg: 7.5mg/hourAlbuterol every 2hours via MDI/VHCWeight: DoseMore than 20 kg: 8puffsLess than 20 kg: 4 puffsAlbuterol every 3hours via MDI/VHCWeight: DoseMore than 20 kg: 8puffsLess than 20 kg: 4 puffsPHASE 4Albuterol every 4hours via MDI/VHCWeight: DoseMore than 20 kg: 4puffsLess than 20 kg: 2puffs-OR**Anschutz- Patientsrequiring higher dosesof continuous albuterolmust be transferred tothe PICU**Colorado SpringsHospital- Patientsrequiring continuousalbuterol must betransferred to thePICU**-ORAlbuterol every 2hours via nebWeight: DoseMore than 20 kg: 5 mgLess than 20 kg: 2.5mgAlbuterol every 3hours via nebWeight: DoseMore than 20 kg: 5 mgLess than 20 kg: 2.5mg-ORAlbuterol 2.5 mgevery 4 hours via nebINTENSIFICATIONAlbuterol via nebulizertimes oneWeight: DoseMore than 20 kg: 10 mgLess than 20 kg: 7.5 mg –ORAlbuterol via MDI/VHCWeight: DoseMore than 20 kg: 10 puffsLess than 20 kg: 6 puffs**Consider subcutaneousterbutaline if intensifyingwhile on continuousnebulizer.(See Table 4 for dosingand requirements.)**Systemic CorticosteroidsRT evaluate everyhour HR, RR, SpO2, RA. Pediatric AsthmaSeverity Score (PAS) Initiate education on“what is asthma”, signsand symptoms, andtriggersRT evaluate every 2hours HR, RR, SpO2, RA. Pediatric AsthmaSeverity Score (PAS) Initiate education onMDI with VHC use(handout)RN evaluate everyhour Continuous SpO2,HR, RR, with fullcardiorespiratoryassessment. Temp &BP Q4hrRN evaluate every 2hours Spot check SpO2, HR,RR, with fullcardiorespiratoryassessment. Temp &BP Q4hrProvider Add controllermedications. Verify orders forAAP/EducationRT evaluate every 3hours HR, RR, SpO2, RA. Pediatric AsthmaSeverity Score (PAS) Peak flow Education( 6 yrs.) BPA triggers for AAPand asthma teaching. Finalize AAP andAsthma education.Check understandingof key concepts,device technique,review meds, and AAPwith patient/family.RN evaluate every 4hours Spot check SpO2,HR, RR, with fullcardiorespiratoryassessment. Temp &BP Q4hrRT evaluate every 4hours HR, RR, SpO2, RA, Pediatric AsthmaSeverity Score (PAS) Peak flowEducation ( 6 yrs.) BPA triggers for RTto re-label meds forhome use.RT evaluate in 1 hour HR, RR, SpO2, RA. Pediatric AsthmaSeverity Score (PAS) Peak flow Education ( 6yrs.)RN evaluate every 4hours Spot check SpO2,full set of VS , with fullcardiorespiratoryassessment. Review AAP iscomplete andreconciled with DCorders. EnsureAsthma educationdocumented.Provider Review AAPRN evaluate in 1 hour Continuous SpO2 HR,RR, check BP, fullcardiorespiratoryassessmentPage 8 of 27
CLINICAL PATHWAYTARGET POPULATIONInclusion Criteria 2 years and older Being treated for asthma or an asthma exacerbation First time wheeze with a history consistent with asthmaExclusion Criteria Patients being treated primarily for bronchiolitis, viral pneumonia, aspiration pneumonia, or croup. (Patients withan asthma exacerbation who also have a viral illness will benefit from the clinical care guidelines.) Chronic lung disease, bronchopulmonary dysplasia (BPD), cystic fibrosis, airway anomalies (e.g.tracheomalacia), cardiac disease, or neurologic disordersCLINICAL MANAGEMENTDiagnosing Asthma Suspect asthma in any child with episodic symptoms of airflow obstruction (cough, wheeze, shortness ofbreath) that is at least partially reversible with a bronchodilator Rule out other causes of airway obstruction such as cystic fibrosis, recurrent aspiration, airway anomalies(such as tracheomalacia), GERD, sinusitis, and foreign body aspirationAsthma Severity AssessmentIntermittent vs. Persistent asthma: Persistent asthma is diagnosed if the child has any of the following:oSymptoms more than twice per week during the dayoSymptoms twice per month at nightoAny exercise limitationoFEV1 less than 80% predicted (for children over 5 years)oTwo or more steroid bursts for asthma in 12 monthsTreat persistent asthma with a daily controller medication such as inhaled corticosteroids See Appendix A. Asthma Management-Outpatient See Table 3. Dosage of Daily Controller Medication for Asthma ControlKeys to Managing Any Asthma ExacerbationsTelephone Triage1,2 Mild (dyspnea with activities and/or peak flow greater than 80% of personal best) Primary Care Provider(PCP) contact AND short acting bronchodilator every 4 hours. Moderate (Dyspnea interfering with activities and peak flow 50 to 80% of personal best) Same day clinic visitAND short acting bronchodilator every 4 hours AND consider home prednisone/dexamethasone. . Severe (Dyspnea interfering with speech and peak flow 50 to 80% of personal best) Emergency Department(ED) visit AND repeat short acting bronchodilator every 20 minutes up to 3 doses. Life Threatening (Severe difficulty breathing, not able to speak, cyanosis, combative, agitated or difficult toarouse) Activate EMS.Page 9 of 27
CLINICAL PATHWAYCLINICAL ASSESSMENTHistory Document recent exposures to asthma triggers including illness. Document recent beta agonist use and anyoral steroid use. Assess the timeline of progression of the exacerbation. Evaluate chronic asthma severity by asking about baseline daytime and nighttime asthma symptom frequency,and bronchodilator use previous to this exacerbation, and history of previous asthma exacerbations and oralsteroid bursts. Document the chronic asthma severity, chronic asthma medications, and reported medicationsadherence in the medical record. (For severity assessment please see appendix B).Physical exam Evaluate for cough, wheeze, tachypnea, increased work of breathing, low oxygen saturation Use Pediatric Asthma Severity (PAS) Score to guide intervention and response to treatment. PAS2,4,5score includes the following elements: Respiratory rate, Oxygen requirements, Auscultation, Retractions,DyspneaLaboratory and radiologic studies Chest X-Ray: Consider if history of choking and/or foreign body aspiration, delayed symptom resolution,persistent asymmetric lung exam. NOTE: A normal chest exam does not exclude asthma. Arterial or venous blood gas: Consider in cases with impending respiratory failure.TREATMENTTherapeutics Oxygen: Start supplemental oxygen for any child whose oxygen saturation is less that 90%. Increase asneeded. Short-acting beta-agonist (SABA): Used for reversal of bronchospasm. SABAs should be used in everychild admitted to the
CLINICAL PATHWAY . Page 1 of 27 . ASTHMA EXACERBATION MANAGEMENT . TABLE OF CONTENTS . Figure 1. Algorithm for Asthma Exacerbation Management –Outpatient Clinic Figure 2. Algorithm for Asthma Management – Emergency Department. Figure 3. Algorithm for Asthma Management – Inpatient Fig
Appendix 5- Summary of management of asthma in adults Appendix 6- Summary of management of asthma in children Appendix 7- Asthma care plan Appendix 8- QOEST Asthma criteria Appendix 9- Sending consultations Appendix 10-Acute asthma 1. Arrival of patient Obtain consent from the patient to access full medical records 2. Clinical system/Accessing
Childhood Asthma is Challenging on Many Levels – Asthma Educators Can Help Asthma is the most common chronic condition among children 55% had at least one asthma attack in the previous ye
Asthma - an interprofessional case study At the end of this presentation students will be able to: Give a definition of asthma Discuss what could cause asthma Identify four triggers of asthma Describe symptoms of an asthma flare-up Explain three asthma treatment strategies Develop an interprofessional plan of care for
Visit(s) to family physician in the last 12 months for asthma symptoms If Yes, indicate the number of primary care visits for asthma in the last 12 months Visit(s) to a specialist for asthma Yes No Unknown Last 12 Months Yes No Unknown Recent 1yr Total # ever ED visits ever for asthma Hospitalized ever for asthma ICU admissions in the last 12 .
The goal of this asthma care quick reference guide is to help clinicians provide quality care to people who have asthma. Quality asthma care involves not only initial diagnosis and treatment to achieve asthma control, but also long-term, regular follow-up care to maintain control. Asthma control focuses on two domains: (1) reducing
and ventilation (consider arterial blood gas measurements) Guideline: Pediatric Asthma Management, Inpatient Admission 4 Asthma Specific Investigations For the general care of asthma exacerbation, no labs or images are necessary. Investigations may be warranted in certain circumstances; common considerations are listed.
Jan 09, 2017 · asthma-related quality of life, asthma control, and treatment adherence. Weak for Reviewed, New-replaced 18. We suggest patients with asthma participate in regular exercise to improve quality of life and asthma control. Weak for Reviewed, Amended 19. We su
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