Acute Asthma Exacerbation Clinical Pathway — PICU | Children's Hospital of Philadelphia

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Child admitted to PICU for Acute Asthma Exacerbation

History and Physical Exam
Ensure Standard Medications
Review previous/current Escalation Medications

Conserving IVF During Shortage

Additional Considerations

**Standard Medications**
Albuterol Weight-based Dosing
Kg	Continuous
5-10	7.5 mg/hr
> 10-20	11.25 mg/hr
> 20	15 mg/hr
Ipratropium Weight-based Dosing
5-10	250 mcg nebulized q6h
> 10	500 mcg nebulized q6h
Methylprednisolone
	1 mg/kg IV q6, max 30 mg/dose

**Escalation Medications**
Magnesium Sulfate
50 mg/kg, max 2,000 mg
Terbutaline IV Loading Dose
10 mcg/kg, max 250 mcg

Determine Severity Level of Asthma Exacerbation
- PASS (Pediatric Asthma Severity Score)
- Respiratory distress
- Mental Status (MS)
- Hypoxemia and Hypercarbia

Moderate/Severe

Critical

Impending Respiratory Arrest

MS reassuring with:
- PASS ≤ 3 and
- FiO₂ ≤ 50%

MS reassuring with:
- PASS ≥ 4 or
- FiO2 > 50%
or MS agitated or drowsy

MS combative or obtunded with:
- PASS = 6 and
- Rising CO₂

Inpatient Asthma Pathway
Consider transfer to inpatient unit after stable for 4 hours

Consider NIPPV

Consider Mechanical Ventilation

Rapid titration of NIPPV step to reduce work of breathing

High risk of cardiac arrest
Consider NIPPV as a temporizing measure
Consider ECMO consult
Consider isoflurane

NIPPV: Noninvasive positive pressure ventilation
IPAP: Inspiratory positive airway pressure
EPAP: Expiratory positive airway pressure

Step	IPAP	EPAP
1	10	5
2	14	6
3	16	8
4 (max)	20	10

Obtain initial venous blood gas
Consider transcutaneous CO₂ monitor
if FiO2 > 30%
Anxiolysis only if needed
NPO

De-escalation of Mechanical Ventilation

Monitor hourly	MS, PASS, vital signs, transcutaneous CO₂ if applicable
Additional monitoring	Intravascular volume status every 1-4 hr BMP, Mg, PO4 every 12-24 hours Blood gas as indicated

De-escalation

Maintenance

Escalation

Criteria

MS Reassuring
and
2 consecutive PASS ≤ 3

MS Reassuring
and
PASS = 4-5

Combative or obtunded MS
PASS = 6 or
Any PASS with rising CO₂

Therapies

Remove escalation medications first.
Then, decrease NIPPV by step.

Continue current therapy

Escalate NIPPV step.
Reconsider escalation medications.

Next Step

When stable on NIPPV step 1
- Discontinue NIPPV
- Follow Inpatient Asthma Pathway
- Consider subspecialty consult

Reassess in 1 hour

Follow Impending Respiratory Arrest

Posted: March 2019
Last Revised: October 2024

Authors:
- B. Bruins, MD;
- L. Salomone, RRT-NPS;
- A. Oxenreiter, RN;
- H. Wolfe, MD;
- B. Blowey, PharmD

Evidence

Educational Media

PEM Podcast: Severe Asthma

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

PICU Clinical Pathway for Children with Acute Asthma Exacerbation

Evidence

Educational Media

PICU Clinical Pathway for Children with
Acute Asthma Exacerbation