Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Asthma
- Related Pathways
- Asthma, Inpatient
- Asthma, PICU
- Asthma, Primary Care
Triage
RN Standing order for dexamethasone ESI 2-3
RN Standing order for dexamethasone ESI 2-3
- Impending Respiratory Failure
- To Resuscitation Room
Mild
ESI Triage 4
ESI Triage 4
Moderate
ESI Triage 3
ESI Triage 3
Severe
ESI Triage1-2
ESI Triage1-2
- Consider
- Dexamethasone tablet, all ages
- Albuterol MDI 2-4 puffs
- MDI spacer teaching
- Discharge and Assess Asthma Control
- Dexamethasone tablet, all ages
- Albuterol MDI weight-based q20min x 3 PRN
- Dexamethasone tablet
- Alternative: IM dex/ IV methylpred
- UniNeb: albuterol + ipratropium
- Unable to tolerate mask:
- MDI with albuterol + ipratropium
- Consider IV magnesium
- Consider SubQ terbutaline
Assess after completion of β-agonist
Considerations for Further Diagnostic Testing
Supplemental oxygen for persistent SpO2 < 90%
Considerations for Further Diagnostic Testing
Supplemental oxygen for persistent SpO2 < 90%
Critical/Impending Respiratory Failure
- Critical
- Escalation medications
- Initiate NIPPV at 10/5 cmH2O, titrate with RT
- No Improvement, Impending Respiratory Failure
- To Resuscitation Room
- Preparation for intubation
- Tier 1 PICU Alert
- PICU Asthma Pathway
Severe
Attending eval at bedside
Attending eval at bedside
- Hold treatment
- Observe
- Initial moderate: 1 hr
- Initial severe: 2 hrs
- 2nd albuterol neb x1 hr
- Consider IV magnesium
Reassess
Allow ≥ 2 hrs for steroid effect before disposition
Allow ≥ 2 hrs for steroid effect before disposition
- Discharge with additional dose of dexamethasone
- Assess Asthma Control
- Q2hr albuterol
- Admit EDECU if available
- Continuous albuterol
- Admit
Albuterol Weight-Based Dosing | |||
---|---|---|---|
Kg | Unit Dose (0.5%) | MDI Puffs | Continuous (1 hr unineb) |
5-10 | 2.5 mg (0.5 mL) | 4 | 7.5 mg/hr |
> 10-20 | 3.75 mg (0.75 mL) | 6 | 11.25 mg/hr |
> 20 | 5 mg (1 mL) | 8 | 15 mg/hr |
Ipratropium Weight-Based Dosing | ||
---|---|---|
Kg | Unit Dose (0.02%) | MDI Puffs |
5-10 | 500 mcg over 1 hr in UniNeb or 250 mcg q20 min x 2 | 4 |
> 10-20 | 1000 mcg over 1 hr in UniNeb or 500 mcg q20 min x 2 | 6 |
> 20 | 1000 mcg over 1 hr in UniNeb or 500 mcg q20 min x 2 | 8 |
Steroids | |
---|---|
Dexamethasone |
|
Prednisone/ Methylprednisolone | 2 mg/kg PO/IV, Max 60 mg |
Escalation Medications | |
---|---|
Magnesium Sulfate |
|
Terbutaline |
|
Evidence
- Early Emergency Department Treatment of Acute Asthma with Systemic Corticosteroids
- Improving Efficiency of Pediatric Emergency Asthma Treatment By Using Metered Dose Inhaler
- Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial
- Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-Analysis
CHOP Programs
Educational Media
Related Links