PICU Clinical Pathway for Children with
Acute Asthma Exacerbation
- Related Pathways
- Asthma, Emergent Care
- Asthma, Inpatient Care
- Asthma Escalation Pathway
- History and Physical Exam
- Ensure Standard Medications
- Review previous/current Escalation Medications
Additional Considerations
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 |
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
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
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De-escalation | Maintenance | Escalation | |||||
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Criteria |
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Therapies |
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Continue current therapy |
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Next Step |
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Reassess in 1 hour | Follow Impending Respiratory Arrest |
Posted: March 2019
Revised: May 2024
Revised: May 2024
Evidence
- Noninvasive Ventilation in Status Asthmaticus in Children: Levels of Evidence
- Implementation of a Critical Asthma Protocol in a Pediatric ICU
- Effects of a PICU Status Asthmaticus De-escalation Pathway on Length of Stay and Albuterol Use
- Mechanical ventilation for severe asthma
Educational Media