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Asthma Diagnosis and Management - Adult/Pediatric - Inpatient/Ambulatory/Emergency Department

Asthma Diagnosis and Management - Adult/Pediatric - Inpatient/Ambulatory/Emergency Department - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Respiratory


1
Asthma: Diagnosis and Management –
Adult/Pediatric –
Inpatient/Ambulatory/Emergency
Department-Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 3
METHODOLOGY ..................................................................................................................................................... 4
INTRODUCTION ..................................................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................................................ 5
FIGURE 1. SUMMARY OF DIAGNOSTIC STEPS ....................................................................................................................... 6
UW HEALTH IMPLEMENTATION ............................................................................................................................. 9
APPENDIX A. EVIDENCE GRADING SCHEME(S) ..................................................................................................... 12
STEPWISE APPROACH TO ASTHMA SYMPTOM CONTROL .................................................................................... 13
ASTHMA MEDICATIONS- LOW, MEDIUM AND HIGH DOSES OF INHALED CORTICOSTEROIDS .............................. 14
TABLE 1. ASTHMA RESCUE MEDICATIONS IN AMBULATORY CARE .......................................................................................... 15
TABLE 2. ASTHMA CONTROLLER MEDICATIONS .................................................................................................................. 16
TABLE 3. IMMUNOMODULATORS FOR ASTHMA .................................................................................................................. 18
BRONCHIAL THERMOPLASTY SUMMARY FOR PRIMARY CARE PROVIDERS .......................................................... 19
ASTHMA EXACERBATION TREATMENT ALGORITHMS .......................................................................................... 20
MANAGEMENT OF ASTHMA EXACERBATION IN PRIMARY CARE (AGES 2 YEARS OR OLDER) ......................................................... 20
ADULT EMERGENCY DEPT ASTHMA EXACERBATION ALGORITHM (18 YEARS OR OLDER) ............................................................. 21
PEDIATRIC EMERGENCY DEPT ASTHMA EXACERBATION ALGORITHM (12 MONTHS-17 YEARS)..................................................... 22
ADULT INPATIENT ASTHMA EXACERBATION ALGORITHM (18 YEARS OR OLDER) ........................................................................ 23
PEDIATRIC INPATIENT ASTHMA EXACERBATION ALGORITHM (12 MONTHS-17 YEARS) ............................................................... 24
REFERENCES ......................................................................................................................................................... 25
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

2


Contact for Content:
Name: William Busse, MD – Allergy Medicine
Phone Number: (608) 263-6183
Email Address: wwb@medicine.wisc.edu

Name: Daniel Jackson, MD – Pediatric Allergy
Phone Number: (608) 263-7686
Email Address: djj@medicine.wisc.edu


Contact for Changes:
Name: Katherine Le, PharmD – Center for Clinical Knowledge Management
Phone Number: (608) 890-5898
Email Address: kle@uwhealth.org

Coordinating Team Members:
Vivek Balasubramaniam, MD – Pediatrics Pulmonary
Tim Ballweg, RT – Group Health Cooperative (GHC)
Karen Briggs - Quartz
Victoria Cheung, MD – Internal Medicine
Jared Darveaux, MD – Gundersen Health
Loren Denlinger, MD – Pulmonary
Christine Hellenbrand, RT – Respiratory Therapy
Daniel Jackson, MD – Pediatrics Allergy Medicine
Paula Jacobson – Quartz
Jennifer Kuroda – Swedish American
Mary Anne Long, RN – Health Services
Kelly Mommaerts – Physicians Plus
Jennifer Passini, MD – Hospital Medicine
Karen Pletta, MD – General Pediatrics
Elaine Rosenblatt, MSN, FNP-BC – Health Services
Jennifer Schauer – Unity Pharmacy Program
Kristin Shadman, MD – Pediatric Hospital Medicine
Sara Shull, PharmD – Drug Policy Program
Kate Swenson, NP – Pediatrics Pulmonary
Josh Vanderloo, PharmD- Drug Policy Program
Laurel White, RT – Pediatric Respiratory Therapy
Rhonda Yngsdal-Krenz, RT – Pediatric Respiratory Therapy

Review Individuals/Bodies:
Russel Lemmon, DO – Family Medicine

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (08/24/17)


Release Date: September 2017 | Next Review Date: May 2019




Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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3


Executive Summary
Guideline Overview
UW Health has agreed to endorse the 2017 Global Initiative for Asthma (GINA) Global Strategy
for Asthma Management and Prevention Guideline (accessed 5/30/17).

Summary of Key Revisions (2017)
1. New recommendation that clinicians prescribe treatment to target the mechanism behind a
patient’s asthma or the “treatable trait” versus escalating use of inhaled and/or systemic
corticosteroids, especially in patients who do not respond to initial treatment
recommendations.
2. New recommendation that patients ≥ 6 years old with persistent disease, lung function test
should be completed at least once and annually thereafter.
3. New recommendation that children’s height measured and recorded at least yearly given
growth velocity may be lower in first 1-2 years on inhale corticosteroid (ICS) treatment.
4. Re-organized medication tables to reflect select asthma rescue and controller medications
in ambulatory care, updated inhaled corticosteroid comparative dosing table, and also
created separate table for biologic medications.
5. Included statement in medication table that long acting beta-agonists (LABA) should not be
used as monotherapy.
6. Added intermittent inhaled corticosteroid as treatment option and added recommendation of
baseline low dose ICS for patients with exacerbation in last year requiring prednisone to
Step 1 of Stepwise Approach to Asthma Symptom Control table.
7. Revised Step 5 of Stepwise Approach to Asthma Symptom Control table with “biologic
agent” as alternative option versus listing medication examples.
8. Added tiotropium to Step 4 of Stepwise Approach to Asthma Symptom Control table for
ages 6-11 years.
9. Added recommendation to “Consider immunotherapy as add-on in stepwise management
with allergic asthma” to Stepwise Approach to Asthma Symptom Control table.
10. Removed “Omalizumab Clinical considerations, Administration and Monitoring” section of
guideline.
11. Updated “Bronchial Thermoplasty Summary for Primary Care Providers” to indicate therapy
now available at UW Health.

Key Practice Recommendations
UW Health supports the following key recommendations summarized from GINA, in addition to
those recommendations found within the 2017 GINA quick-reference pocket guides available
online (accessed on 5/30/17):
• 2017 Pocket Guide for Asthma Management and Prevention (age 5 and older)
• 2017 At-A-Glance Asthma Management Reference (Age 6 and older)

Companion Documents
1. 2017 Pocket Guide for Asthma Management and Prevention (age 5 and older)
2. 2017 At-A-Glance Asthma Management Reference (Age 6 and older)
3. 2017 Appendix to GINA Report
Scope
Disease/Condition(s): Asthma

Clinical Specialty: Pulmonary, Allergy, Family Medicine, Internal Medicine, Pediatrics,
Hospitalists, Respiratory Therapy, Emergency Medicine
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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09/2017CCKM@uwhealth.org

4



Intended Users: Physicians, Advanced Practice Providers, Respiratory Therapists, Registered
Nurses, Pharmacists, Asthma Educators

Objective(s): To provide evidence-based recommendations for the management of asthma
across age groups and clinical settings.

Target Population: Any pediatric (0-11 years), adolescent (12-17 years), or adult (18 years or
older) patient diagnosed with asthma.

Interventions and Practices Considered: oxygen, immunomodulator therapy, bronchial
thermoplasty

Major Outcomes Considered: lung function improvement, asthma action plan to patient and
documentation of action in medical record, decrease in acute asthma exacerbation visits,
decrease in hospital admissions
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 3 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Cost Analysis: An analysis was completed by the UW Health Drug Policy Program to compare
the inpatient and emergency department cost for an inhaler vs. nebulized treatment.
• Inhaler (Ventolin): 60 actuations, 90mcg per puff = $16.50
Neb: 2.5mg/3mL = $0.20 per neb

Recognition of Potential Health Care Disparities: Poverty is associated with restrictive
spirometry.
1
Refer to page 23 of 2017 GINA guideline for more information.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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5


Introduction
Asthma is a chronic inflammatory disorder of the airways which causes symptoms of wheezing,
shortness of breath, tightness in the chest, and cough that may vary in frequency and over time.
In susceptible individuals, this inflammation causes recurrent episodes of coughing (particularly
at night or early in the morning), wheezing, breathlessness, and chest tightness. These
episodes are usually associated with widespread but variable airflow obstruction that is often
reversible either spontaneously or with treatment. The goals of asthma therapy are to prevent
chronic asthma symptoms and asthma exacerbations, maintain normal activity levels, have
normal or near normal lung function, experience no or minimal side effects and have patient
satisfaction with asthma care.
Recommendations
UW Health endorses the recommendations outlined within the 2017 GINA Guideline located
online at 2017 GINA Report, Global Strategy for Asthma Management and Prevention
(accessed 5/30/17).
1


The full guideline document references appendices, located here: 2017 Appendix to GINA
Report (accessed on 5/30/17).
1


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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6


ESTABLISHING A DIAGNOSIS
It is recommended to complete a medical history to establish respiratory symptoms, as well as
lung function testing using spirometry or peak expiratory flow (PEF) (see Figure 1). A diagnosis
of asthma may be made after consideration of a patient’s history and whether the patient
exhibits variable expiratory airflow limitations (i.e., difficulty exhaling due to bronchoconstriction,
airway wall thickening, and increased mucus).


Figure 1. Summary of Diagnostic Steps
Common Characteristics of Asthma:
• Symptoms of wheezing, shortness of
breath, chest tightness, or cough
• Symptoms occur or worsen at night
• Symptoms may be triggered by exercise,
infection, allergens, changes in weather,
or emotions/hormonal changes

Patient presents with
respiratory symptoms
Perform detailed medical
history/examination
Symptoms
consistent with
asthma?
Perform lung
function testing
(spirometry or PEF)
Yes
Results
support diagnosis of
asthma?
Asthma
diagnosis
Yes
Consider alternative diagnosis
(outside guideline scope)
No
No
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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7


PROVIDING TREATMENT AND ASSESSMENT
The goals of asthma treatment include:
• Prevention of chronic asthma symptoms and asthma exacerbations;
• Maintenance of normal activity levels;
• Patient satisfaction with asthma care and quality of life (i.e., having normal or near
normal lung function, experiencing no or minimal side effects).

Asthma treatment should follow a repeating pattern of assessment of control, adjustment of
treatment, and review of response to the treatment.














Assessment
An age-appropriate questionnaire should be used to help determine asthma control and efficacy
of the treatment plan. It is recommended to assess asthma control at least annually.
• Asthma Control Test (ACT) for patients age 12 years or older.
• Childhood Asthma Control Test (cACT) for patients age 4-11 years.
• Test for Respiratory and Asthma Control in Kids (TRACK) for patients age 5 years or
younger.

The ACT questionnaire may be used for telephone outreach follow-up. (UW Health Low Quality of
Evidence, weak/conditional recommendation.) In the clinic setting, the most age-appropriate,
validated tool is recommended for asthma control assessment. (UW Health Moderate Quality of
Evidence, strong recommendation.)

Treatment
The age-differentiated Stepwise Approach to Control should be used to guide the prescription of
asthma medication (controllers and rescue). Medications most likely to be prescribed for asthma
in the ambulatory care setting are listed in the Rescue Medications and Controller Medications
table. Dosing options for inhaled corticosteroids are available in the Asthma Medications- Low,
Medium and High Doses of Inhaled Corticosteroids (ICS) table and Immunomodulators tables
lists biologic agents for asthma treatment.

Clinicians are recommended to prescribe treatment to target the mechanism behind a patient’s
asthma or the “treatable trait” versus escalating use of inhaled and/or systemic corticosteroids,
especially in patients who do not respond to initial treatment recommendations.
2
(UW Health
Moderate Quality of Evidence, weak/conditional recommendation.) For example, a clinician may
consider omalizumab in a patient with uncontrolled allergic asthma currently taking a medium
ASSESS
•Diagnosis
•Symptom control + risk factors
•Inhaler technique + adherence
•Parent or patient preferences
ADJUST TREATMENT
•Asthma medications
•Non-pharmacological interventions
•Treat modifiable risk factors
REVIEW RESPONSE
•Symptoms and side effects
•Exacerbations
•Parent or patient preferences
•Lung function
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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09/2017CCKM@uwhealth.org

8


dose ICS and long acting beta agonists (LABA) versus escalating prescribed therapy to include
a high dose ICS.

Patients age 18 years or older with uncontrolled severe-persistent asthma, despite use of
recommended therapeutic regimens and referral to an asthma specialist (Step 5) may be
candidates for a non-pharmacological intervention of Bronchial Thermoplasty.

All patients should have a written asthma action plan, which should include:
• A list of medications and a description of how to use them
• Environmental triggers

Review Response
It is recommended that patients be seen every 1-3 months after initiating treatment and every 3-
12 months thereafter. For patients who are ≥ 6 years old with persistent disease, a lung function
test should be completed at least once and annually thereafter. (UW Health Moderate quality of
evidence/ strong recommendation.) For patients who appear to have adequate asthma symptom
control, periodic lung function assessment is recommended as well.

A lung function test is important not only for diagnostic purposes but also because monitoring
asthma symptoms alone may not indicate the extent of lung function compromise or disease
severity. For example, if a patient who reports minimal to no asthma symptoms has significant
decrease in lung function from the previous year’s assessment, the clinician may consider
adjusting the patient’s asthma controller medication regimen.

It is recommended that any patient with a recent asthma exacerbation be seen by the provider
managing his or her asthma within 1 week following the exacerbation to re-evaluate patient
compliance and treatment plan efficacy.

ICS and Growth in children
Clinicians are strongly encouraged to avoid the risk of harm due to excessive inhaled or
systemic corticosteroid use. This can be done by ensuring the appropriate treatment is
prescribed and reduced to the lowest dose that maintains symptom control and minimizes
exacerbations. It is also recommended that the child’s health should be measured and
recorded at least yearly, as growth velocity may be lower in the first 1-2 years of ICS treatment.
If decreased growth is noticed, other factors should be considered including poor nutrition and
asthma control and referral is advised.

MANAGING ASTHMA EXACERBATIONS
Asthma exacerbations are acute or subacute episodes of progressively worsening asthma
symptoms (i.e., shortness of breath, coughing, wheezing, chest tightness).

Treatment algorithms should be followed to guide exacerbation management within the
outpatient, emergency department, and inpatient settings:
• Asthma Exacerbation- Primary Care Algorithm
• Asthma Exacerbation- Emergency Department (Adult) Algorithm
• Asthma Exacerbation- Emergency Department (Pediatric) Algorithm
• Asthma Exacerbation- Inpatient (Adult) Algorithm
• Asthma Exacerbation- Inpatient (Pediatric) Algorithm

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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9


The severity of an asthma exacerbation in pediatric patients (age 12 months to 17 years)
presenting in the ED or inpatient setting should be assessed using the modified Pediatric
Asthma Severity Score (mPASS) (Figure 2). The mPASS is an internally developed
assessment tool based upon the Pediatric Asthma Severity Score (PASS).
4


Figure 2. Modified Pediatric Asthma Severity Score (mPASS)
POINTS 0 1 2 Points
Respiratory Rate
Infant (0-1 yr.) < 50
Child (2-9 yrs.) < 40
Adolescent (10-17 yrs.) < 20
Normal Above tachypnea threshold N/A
Accessory Muscle Use None
Suprasternal/sub-
costal/intercostal retractions
or nasal flaring
Neck or abdominal
muscles (belly
breathing)

Air Exchange Normal
Decreased in single lung
field
Decreased in multiple
lung fields

Wheezing
None or
end
expiratory
only
Entire expiration
Expiration & inspiration
or if no wheezing heard
due to poor air entry

Expiration
Normal
( < 1:2)
Prolonged ( > 1:3) N/A
Coughing None Infrequent (Occasional) Frequent (Consistent)
TOTAL POINTS
UW Health Implementation
Potential Benefits:
• Decrease in hospital admissions
• Decrease in practice variation

Potential Harms:
• Adverse effects of long term corticosteroid exposure

Pertinent UW Health Policies & Procedures
1. UWHC Policy 1.53: Respiratory Care Protocol
2. UWHC Policy 2.25: Inhaler Medication Treatment
3. UWHC 6.1.5 UW Health Formulary Restricted Clinic Administered Medication Pharmacy
Department Review and Use of Non-UW Health Supplied Medications
4. UWHC 6.1.9: Restricted Primarily Ambulatory Administered Medications in Hospitalized
Patients

Patient Resources
1. HFFY #3028: About Asthma
2. HFFY #3171: Severe Asthma Packet
3. HFFY #6129: Adult and Pediatric Asthma Treatment Plan
4. HFFY #4815: Asthma- How to Use Your Spacer
5. HFFY #5122: Asthma and Pregnancy
6. HFFY #6844: Asthma Controller Medicine (Combined Medicines)
7. HFFY #6657: Asthma Controller Medicine Inhaled Corticosteroids
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10


8. HFFY #6843: Asthma Controller Medicine Inhaled Corticosteroids: Respiratory
9. HFFY #6662: Asthma Controller Medicine Leukotriene Modifiers
10. HFFY #6661: Asthma Medicine Oral Corticosteroids
11. HFFY #6660: Asthma Rescue Medicine
12. HFFY #4506: Exercise-Induced Asthma or Bronchospasm in Children
13. HFFY #5125: How to Manage an Asthma Flare or Attack
14. HFFY #6659: Internet Websites for Allergy/Asthma Information
15. HFFY #4300: What is Asthma?
16. HFFY #5121: What is Asthma?
17. HFFY #5040: Corticosteroids (Inhalation) (with or without Long Acting Beta-Agonist)
18. HFFY #5020: Your Peak Flow Meter
19. Healthwise: Asthma: Adult
20. Healthwise: Asthma: General Info
21. Healthwise: Asthma: Pediatric
22. Healthwise: Asthma: Pediatric: 0 to 4 Years
23. Healthwise: Asthma: Pediatric 5 to 11 Years
24. Healthwise: Asthma: Pediatric: 12 Years and Older
25. Healthwise: Asthma: Teen
26. Healthwise: Asthma Attack
27. Healthwise: Asthma Attack: Pediatric
28. Healthwise: Asthma Triggers: General Info
29. Healthwise: Asthma Triggers: Pediatric: General Info
30. Healthwise: Asthma: Action Plan
31. Healthwise: Asthma: Action Plan: Pediatric
32. Healthwise: Asthma: Asthma Control
33. Healthwise: Asthma: Asthma Control: Pediatric
34. Healthwise: Asthma: Metered-Dose Inhaler With A Mask Spacer: Pediatric
35. Healthwise: Asthma: Peak Flow Meters: Teen: General Info
36. Healthwise: Asthma: Using a Dry Powder Inhaler
37. Healthwise: Asthma: Using a Metered-Dose Inhaler
38. Healthwise: Asthma: Using a Metered-Dose Inhaler: Teen
39. Healthwise: Wheezing or Bronchoconstriction
40. Health Information: Asthma
41. Health Information: Asthma Action Plan
42. Health Information: Asthma Action Plan: Green Zone
43. Health Information: Asthma Action Plan: Yellow Zone
44. Health Information: Asthma Action Plan: Red Zone
45. Health Information: Asthma and GERD
46. Health Information: Asthma and Vocal Cord Problems
47. Health Information: Asthma and Wheezing
48. Health Information: Asthma Attack
49. Health Information: Asthma Diary
50. Health Information: Asthma During Pregnancy
51. Health Information: Asthma in Children
52. Health Information: Asthma in Children: Helping a Child Use A Metered-Dose Inhaler and
Mask Spacer
53. Health Information: Asthma in Children: Knowing How Bad an Attack Is

Guideline Metrics
Inpatient Quality Reporting
CAC-1 Use of Relievers for Inpatient Asthma
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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11


CAC-2 Use of Systemic Corticosteroids for Inpatient Asthma
CAC-3 Home Management Plan of Care Given to Patient/Caregiver

CPG-derived
1. Percentage of asthma patients with a completed asthma action plan
2. Percentage of asthma patients with a measurement of control (i.e., ACT score, outpatient
use of systemic corticosteroids)
3. Percentage of adult patients with asthma and a lung function test within the last year
4. Attendance rates to follow-up appointments following discharge from the hospital or
emergency department.

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Delegation Protocols
Asthma or Recurrent Wheezing – Pediatric – Inpatient [3]
Respiratory Therapy Treatment – Adult/Pediatric – Inpatient [70]
Spirometry Ordering – Adult/Pediatric – Allergy [104]
Medication Therapeutic Interchange – Adult – Inpatient [13]

e-Consults
Asthma [5655]
Shortness of Breath [5664]

Order Sets & Smart Sets
Allergic Rhinitis/Asthma/Conjunctivitis [72]
Allergy Asthma [3199]
Asthma ACHC [147]
Asthma/Wheezing [99]
Injection- Acute Allergic Reaction/Steroids/Asthma [173]
Ped Allergy Asthma [3284]
Ped Pulmonary Asthma [2534]
IP – Asthma Exacerbation – Pediatric – Admission [997]
IP – Asthma Exacerbation – Adult – Intensive/Intermediate Care [1524]
IP - Asthma Exacerbation – Adult – General Care – Admission [1525]
IP – Status Asthmaticus – Intensive Care – Pediatric – Admission [5592]
Respiratory Therapy- Asthma Exacerbation – Pediatric [2594]

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

12
Appendix A. Evidence Grading Scheme(s)
Figure 3. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Stepwise Approach to Asthma Symptom Control







STEP 5
C
O
N
T
R
O
L
L
E
R


STEP 4
Age 0-5 yrs.
Preferred?
Refer to asthma
specialist

STEP 3
Age 0-5 yrs.
Preferred?
Refer to asthma specialist
Alternatives:
Add LTRA or increase ICS
frequency or add
intermittent ICS

STEP 2
Age 0-5 yrs.
Preferred?
Dou?le low dose ICS
Alternative:
Add LTRA
Age ? -11 yrs.
Preferred?
Refer to asthma
specialist
Alternative:
Biologic agent
STEP 1
Age 0-5 yrs.
Preferred?
Low dose ICS
Alternatives:
LTRA or
intermittent ICS
Age ? -11 yrs.
Preferred?
Medium dose ICS or
Low dose ICS ? LABA
Alternative:
Low dose ICS + LTRA
Age ? -11 yrs.
Preferred?
Refer to asthma specialist
Alternatives:
Medium dose ICS + LABA or
High dose ICS + LABA
or add tiotropium
All Ages
Alternative:
Intermittent
or Low dose
ICS

Consider baseline
low dose ICS for
patients with
exacerbation in
last year
requiring
prednisone
Age ? -11 yrs.
Preferred?
Low dose ICS
Alternatives:
LTRA

Age ? 12 yrs.
Preferred?
Low dose ICS ⬠ LABA
Alternatives:
Medium dose ICS or
Low dose ICS + LTRA +
theophyline

Age ? 12 yrs.
Preferred?
Medium dose ICS ? LABA
Alternatives:
High dose ICS + LABA and/or
LTRA (+ theophylline)
or add tiotropium

Age ? 12 yrs.
Preferred?
Refer to asthma
specialist
Alternatives:
Add tiotropium or
biologic agent, or
bronchial
thermoplasty*
Age ? 12 yrs.
Preferred?
Low dose ICS
Alternatives:
LTRA or
theophyline
* For adult patients only. Not indicated or recommended for patients younger than 18 years.
R
E
S
C
U
E

All Ages
Preferred? PRN Short -acting Beta
2
-agonist (SABA)
Consider stepping down if symptoms controlled for 3 months and low risk for exacerbations.
Ceasing ICS is not advised.


Reference.㨠 Asthma ? Adult?Pediatric ?
Inpatient?Ambulatory?Emergency Dept Guideline
ASSESS
•Diagnosis
•Symptom control + risk factors
•Inhaler technique + adherence
•Parent or patient preferences
ADJUST TREATMENT
•Asthma medications
•Non-pharmacological
interventions
•Treat modifiable risk factors
REVIEW RESPONSE
•Symptoms and side effects
•Exacerbations
•Parent or patient preferences
•Lung function
Consider immunotherapy as add-on in stepwise management of patients with allergic asthma. Consider stepping up if
uncontrolled symptoms? exacerbations or risks. Always evaluate diagnosis? inhaler technique? and adherence before therapy
changes.

14
Asthma Medications- Low, Medium and High Doses of Inhaled
Corticosteroids
The following tables provide an estimate of comparative daily doses for inhaled corticosteroids
administered to children and adults with asthma. It may be used in conjunction with the
Stepwise Approach to Asthma Symptom Control found within guideline.
Children 5 years and younger - Low, medium and High doses of ICS
Low
(mcg)
Medium
(mcg)
High
(mcg)
Beclomethasone HFA 100 - -
Budesonide DPI 200 - -
Budesonide (nebules) 500 - -
Ciclesonide HFA 160 - -
Fluticasone HFA 100 - -
Mometasone furoate Not studied < 4 years - -
Triamcinolone acetonide Not studied in age group - -
Children 6-11 years - Low, medium and High doses of ICS
Low
(mcg)
Medium
(mcg)
High
(mcg)
Beclomethasone
dipropionate HFA
50-100 >100-200 >200
Budesonide DPI 100-200 >200-400 >400
Budesonide (nebules) 250-500 >500-1000 >1000
Ciclesonide HFA 80 >80-160 >160
Fluticasone furoate (DPI) N/A N/A N/A
Fluticasone propionate (DPI) 100-200 >200-400 >400
Fluticasone propionate
(HFA)
100-200 >200-500 >500
Mometasone furoate 110 ≥220-<440 ≥440
Triamcinolone acetonide 400-800 >800-1200 >1200
Adult (≥ 12 years) - Low, medium and High doses of ICS
Low
(mcg)
Medium
(mcg)
High
(mcg)
Beclomethasone
dipropionate HFA
100-200 >200-400 >400
Budesonide DPI 200-400 >400-800 >800
Budesonide (nebules) N/A N/A N/A
Ciclesonide HFA 80-160 >160-320 >320
Fluticasone furoate (DPI) 100 N/A 200
Fluticasone propionate (DPI) 100-250 >250-500 >500
Fluticasone propionate
(HFA)
100-250 >250-500 >500
Mometasone furoate 110-220 >220-440 >440
Triamcinolone acetonide 400-1000 >1000-2000 >2000
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

15
Table 1. Asthma Rescue Medications in Ambulatory Care
NOTE: This table outlines select rescue medications that are most likely used in the ambulatory care setting to treat
an asthma exacerbation. Additional drug and UW Health formulary information may be found internally on Lexicomp.
Medication How Supplied Purpose Consideration
R
E
S
C
U
E

M
e
d
i
c
a
t
i
o
n
s

Short-acting beta agonists
Albuterol Sulfate
Branded products:
- ProAir
®
MDI
- Proventil
®
MDI
- Ventolin
®
MDI
- AccuNeb
®
nebulization
- VoSpire
®
ERT
- Metered dose inhaler
- Nebulizer solution
Bronchodilation
through smooth
muscle relaxation
Although available, oral
albuterol is not recommended
Levalbuterol
Branded products:
- Xopenex
®
MDI
- Xopenex
®
nebulization
- Metered dose inhaler
- Nebulizer solution
Has UW Health inpatient
formulary restricted uses)
Short-acting anticholinergics
Ipratropium Bromide
- Tablets
- Injection
Bronchodilation
through inhibition of
muscarinic receptors
to reduce intrinsic
vagal tone of the
airway
May be an alternative to short-
acting beta agonists in
patients who cannot tolerate
short-acting beta agonists
Combination short-acting beta agonist and short-acting anticholinergic
Albuterol
Sulfate/Ipratropium Bromide
Branded products:
- Combivent Respimat
®
MDI
- DuoNeb
®
nebulization
- Metered Dose
inhaler
- Nebulizer solution
See individual agents
Respimat inhaler not on UW
Health formulary
Systemic corticosteroids
Prednisone
Branded products:
- Rayos
®
delayed-release
tablet
- Intensol
®
concentrated
solution
- Tablets
- Solution
Bronchodilation via
anti-inflammatory
effect
May be used for asthma
exacerbation treatment
Methylprednisolone
Branded products:
- Medrol
®
tablet
- Solu-Medrol
®
injection
-Tablets
- Dosepak
- Solution
Dexamethasone
Branded products:
- Intensol
®
concentrated
solution
- Tablets
- Solution
- Elixir
- Injection
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

16
Table 2. Asthma Controller Medications
NOTE: This table outlines select asthma control medications and formulations most likely used in an ambulatory
setting. Additional drug and UW Health formulary information may be found internally on Lexicomp.
Medication How Supplied Purpose Consideration
C
O
N
T
R
O
L
L
E
R

M
e
d
i
c
a
t
i
o
n
s

Inhaled corticosteroids
Beclomethasone
Dipropionate
Branded product:
- QVAR
®
MDI
- Metered dose inhaler
Reduce airway
hyper-
responsiveness,
inhibit
inflammatory cell
migration and
activation, and
block late phase
reaction to allergen
Certain formulations of
the medication(s) are UW
Health non-formulary and
subject to therapeutic
interchange; for more
information refer
internally to Lexicomp
Budesonide
Branded products:
- Pulmicort Flexhaler
®
DPI
- Pulmicort
®
nebulization
- Dry powder inhaler
- Inhalation
suspension
Ciclesonide
Branded product:
- Alvesco
®
MDI
- Inhaler
Flunisolide
Branded product

- Aerospan
®
MDI
- Inhaler
Fluticasone Furoate
Branded product:
- Arnuity Ellipta
®
DPI
- Dry powder inhaler
Fluticasone Propionate
Branded product:
- Flovent Diskus
®
DPI
- Flovent
®
MDI
- Dry powder inhaler
- Metered dose inhaler
Mometasone Furoate
Branded product:
- Asmanex
®
DPI
- Asmanex
®
MDI
- Dry powder inhaler
- Metered dose inhaler
Long-acting beta agonists
Formoterol Fumarate
- Foradil Aerolizer
®
DPI
- Perforomist
®
nebulization
- Dry powder inhaler
- Nebulizer solution
Bronchodilation
Should not be used as
monotherapy for asthma
Salmeterol Xinafoate
- Serevent Diskus
®
DPI
-Dry powder inhaler
Mast cell stabilizers
Cromolyn
- nebulizer solution
- Nebulizer solution
Stabilize mast cells
Combination long-acting beta agonists and corticosteroid
Budesonide/Formoterol
Fumarate
Branded product:
- Symbicort
®
MDI
- Metered dose inhaler
See individual
agents
Mometasone Furoate
/Formoterol Fumarate
Branded product:
- Dulera
®
MDI
- Metered dose inhaler
Fluticasone Propionate/
Salmeterol Xinafoate
- Advair Diskus
®
DPI
- Advair
®
MDI
- Dry powder inhaler
- Metered dose inhaler
Fluticasone Furoate/
Vilanterol
- Breo Ellipta
- Metered dose inhaler
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

17
Medication How Supplied Purpose Consideration
C
O
N
T
R
O
L
L
E
R

M
e
d
i
c
a
t
i
o
n
s
Long-acting anticholinergics
Tiotropium
- Spiriva
®
Handihaler DPI
- Spiriva
®
Respimat MDI
- Dry powder inhaler
- Metered dose inhaler
Bronchodilation
through inhibition
of muscarinic
receptors to
reduce intrinsic
vagal tone of the
airway
Respimat is indicated for
asthma
Leukotriene Modifiers
Montelukast
- Singulair
®
- Tablet
- Chewable tablets
- Packet
Interferes with the
pathway of
leukotriene
mediators, which
are released from
mast cells,
eosinophils, and
basophils
Zafirlukast
- Accolate
® - Tablet
Zileuton
- Zyflo
®
- Zyflo ER
®
- Immediate release
tablet
- Extended release
tablet
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

18
Table 3. Immunomodulators for Asthma
5,6

Medication Mechanism of
Action
Dosing Indication(s)* Considerations
C
O
N
T
R
O
L
L
E
R

M
e
d
i
c
a
t
i
o
n
s
Omalizumab Recombinant DNA
monoclonal
antibody that
selectively binds
to human
immunoglobulin E
(IgE) preventing
crosslinking on
mast cells and
basophils
Dose for severe
allergenic asthma
is determined by
patient’s pre-
treatment serum
IgE level and
actual patient
weight
Medication is
administered
every 2-4 weeks
Indicated as adjunctive
therapy in patients age
≥ 6 years with moderate
or severe allergic
asthma whose
symptoms are
uncontrolled with a
combination of medium-
to high-dose inhaled
corticosteroid and a
long-acting beta2-
agonist
• Injection site reaction of
any severity may occur in
patients
• UW Health formulary
restricted
• Administration restricted
to outpatient setting per
UWHC Policies 6.1.5 and
6.1.9
Mepolizumab Humanized
monoclonal
antibody that
inhibits interleukin-
5 (IL-5)
100mg
subcutaneously
every 4 weeks
Patients age ≥ 12 years
with severe eosinophilic
asthma that is
uncontrolled on Step 4
treatment
• Reduces likelihood of
severe exacerbation
requiring hospitalization
• May improve forced
expire volume in 1
second (FEV1)
• UW Health formulary
restricted
• Administration restricted
to outpatient setting per
UWHC Policies 6.1.5 and
6.1.9
Reslizumab Humanized
monoclonal
antibody
neutralizes
circulating
interleukin-5
IV 3mg/kg once
every 4 weeks
Patients age ≥ 18 years
with severe eosinophilic
asthma that is
uncontrolled on Step 4
treatment
• Reduces blood and
sputum eosinophil counts
• Reduces likelihood of
clinical asthma
exacerbation and
improves lung function in
patients with
inadequately controlled
eosinophilic asthma
• Generally well tolerated
• Consider in patients with
nasal polyposis
• UW Health formulary
restricted
* Additional drug information such as UW Health medication initiation and formulary
restricted criteria can be found internally on Lexicomp.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

19
Reference: Asthma – Adult/Pediatric – Inpatient/Ambulatory/Emergency Dept Clinical Practice Guideline
Bronchial Thermoplasty Summary for Primary Care Providers
Overview: Bronchial Thermoplasty (BT) is an innovative procedure for the treatment of severe
persistent asthma. This procedure is performed in an outpatient setting under moderate
sedation, and is accomplished in three separate bronchoscopic sessions scheduled
approximately 3 weeks apart. In the first procedure, airways under direct vision and reachable
by the bronchoscope in the right lower lobe are treated. During the second procedure, targeted
airways in the left lower lobe are treated, and in the third and final procedure, targeted airways
in both upper lobes are treated.
1-2

Target Population: A potential treatment option for highly-selected patients aged 18 years and
older with uncontrolled asthma, despite use of recommended therapeutic regimens and referral
to an asthma specialist (Step 5).
3
(GINA Evidence B)
Technology Assessment Review: Alair™ BT was reviewed by the UW Health Technology
Assessment Committee. In January 2015, the committee recommended adoption of Alair
Thermoplasty for use at UW Health and the program became live at UW Health in Spring 2017.
Outcomes: Bronchial thermoplasty has been studied in four clinical studies in patients with
asthma; three of which were randomized controlled clinical trials and the results for which have
been published in peer-reviewed journals. Most notably, published data from the Asthma
Intervention Research 2 (AIR2) clinical trial demonstrates that bronchial thermoplasty continues
to show benefits in adult patients with severe uncontrolled asthma out to at least five
years.
4
Bronchial thermoplasty was shown to provide long term asthma control, demonstrated
by a sustained reduction in the rate of severe exacerbations (asthma attacks) and emergency
room (ER) visits over a five year period after treatment.
5

Risk assessment: The most common side effect found in the clinical studies was an expected
transient increase in the frequency and worsening of respiratory-related symptoms, including
asthma (multiple symptoms), respiratory tract infections, wheezing, dyspnea, and chest pain.
Long-term follow-up out to 5 years has been completed in 4 studies: the safety profile for the BT
treated patients has demonstrated consistency over time based on the percent of subjects
reporting respiratory adverse events, the number of respiratory adverse events per subject, and
the number of hospitalizations and emergency room visits due to respiratory symptoms per
subject.
Pre-Approval Needs: While non-coverage policies exist, there is a need to request pre-
approval to the insurer by submitting documentation that supports a severe asthma diagnosis.
This documentation is inclusive of differentiating other respiratory-related disorders (i.e., COPD,
bronchiectasis, vocal cord dysfunction, obstructive sleep apnea), management of comorbidities
(i.e., allergic rhinitis, sinusitis, GERD), and observations of compliance and/or attempts to
manage their asthma with current standard medications (i.e., minimum of ICS+LABA) over at
least a 3 month period yet still demonstrating evidence of exacerbations, activity limitation
and/or risk of future exacerbations. As coverage policies get implemented, a shorter, more
specific pre-authorization form may be required.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Patient presentation with acute or
sub-acute asthma exacerbation
Management of Asthma Exacerbation in Primary Care (Age 2 years or older)
Assess the Patient
-Is it asthma?
- What is the exacerbation severity?
- Does the patient exhibit risk factors
for asthma-related death?*
Mild or Moderate
Exacerbation
Severe
Exacerbation
TRANSFER TO ED
While waiting, give dual therapy
(SABA + ipratropium bromide),
administer O
2
, and/or oral
corticosteroid (OCS)
*Risk Factors for Asthma-
related Death
History of near-fatal
asthma requiring
intubation and
mechanical ventilation
Hospitalization or
emergency care visit
for asthma in the past
year
Currently using or
recently stopped using
oral corticosteroids
Not currently using
inhaled corticosteroids
Over-use of SABAs,
especially use of more
than one canister of
monthly
A history of psychiatric
disease or psychosocial
problems
Poor adherence with
asthma medications
and/or poor adherence
with (or lack of) a
written asthma action
plan
Food allergy in a
patient with asthma
Initiate Treatment
- Short-acting beta
2
-agonist (SABA) by
pMDI with spacer or nebulizer
- Administer O
2
to maintain SpO
2
>90%
Continue Treatment
- Administer Short-acting beta
2
-agonist
(SABA) as needed
- If no resolution after initial treatment, give
dual therapy (SABA + ipratropium bromide)
-Consider oral corticosteroid (OCS)
Assess Response
- Have symptoms improved (not needing SABA)?
-Is O
2
saturation (on room air) > 90%?
- Are resources at home adequate?
Symptoms
Resolved?
Reference: Asthma –Adult/Pediatric – Inpatient/Ambulatory/EmergencyDept Guideline
Yes
Follow-up within 2-7 days to assess stabilization
- Rescue Medication: reduce to as-needed
- Controller Medication: continue higher dose for short term (1-2 weeks) or long
term (3 months), depending on background to exacerbation
-Continue oral corticosteroid (OCS) as needed (5-7 days in adults; 3-5 days in pediatrics)
- Risk factors for exacerbation: provide patient education, including inhaler technique/adherence
- Print and review Asthma Action Plan (Note: If pediatric patient, print 2 copies for home/school)
No
Symptoms
Resolved?
Yes
No
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Adult patient presentation to ED with asthma exacerbation
RT perform spirometry (if patient able)
Does patient
have any of the following?*
- FEV1 or PEF < 40% or unable to perfor m spirometry due to work of breathing?
- Diffuse wheezes or poor air movement without wheezes?
- Breathless at rest/agitated or confused?
- In need of O
2
to keep SpO
2
> 92%?
Moderate or Severe Exacerbation
HIGH DOSE THERAPY
RT order and give albuterol 5 mg Q20 min x3 in 1
st
hour
via nebulizer
RT order and give ipratropium bromide 500 mcg Q20
min x3 via nebulizer
Administer O
2
to maintain SpO
2
>92%
Oral corticosteroids per ED provider
Consider EtCO
2
or arterial blood gas per ED provider
Yes
Mild Exacerbation
STANDARD DOSE THERAPY
RT order and give albuterol 5 mg via nebulizer x1.
RT order and give ipratropium bromide 500 mcg via
nebulizer x1 (if using albuterol at home > q2-4 hours).
Administer O
2
to maintain SpO
2
>92%
Oral corticosteroids per ED provider
No
RT assess response to intervention
(including spirometry)
Good Response
Patient exhibits at least one of the
following:
FEV1 or PEF > 70%
No distress, normal exam
Response sustained for > 60 min.
Incomplete Response
Patient exhibits at least one of the
following:
FEV1 or PEF = 40-69%
Mild or moderate symptoms*
RT order and give albuterol via MDI with
spacer x8 puffs or 5 mg Q20 min. x2 via
nebulizer.
MDI therapy is the preferred delivery
method. If the patient is unable to perform
MDI therapy adequately, give treatments
via nebulizer.
Initiate Discharge
Planning
Administer O
2
to maintain SpO
2
>92%
IVF per ED provider
ED provider to consider possible
intubation and ventilation or adjunctive
therapies: Heliox (if FiO
2
< 50%); BiPAP;
HFNC; Magnesium sulfate 50-75 mg/kg
(max 2 g) over 20 min
Continue Reassessment and Admission Planning
RT notify ED provider
Reference:
Asthma – Adult/Pediatric – Inpatient/
Ambulatory/Emergency Dept Guideline
Admit to Hospital
Adult ED Asthma Exacerbation Algorithm (Age 18 years or older)
Incomplete or Poor Response
Patient exhibits at least one of the
following:
FEV1 or PEF < 70%
PCO2 > 42 mmHg
Mild, moderate, or severe
symptoms*
Significant distress
RT assess response to intervention
(including spirometry)
Poor Response
Patient exhibits at least one of the
following:
FEV1 or PEF < 40%
PCO2 > 42 mmHg
Severe symptoms*
Significant distress
Good Response
Patient exhibits at least one of the
following:
FEV1 or PEF > 70%
No distress, normal exam
Response sustained for > 60 min.
RT notify ED provider
RT notify ED provider
RT notify ED provider
RT notify ED provider RT notify ED provider
RT order and give albuterol
continuous at 0.5 mg/kg over 1 hour
(up to 15 mg/hour) via nebulizer
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Does patient have
any of the following?
* FEV1 < 40% or unable to perform spirometry due to work of breathing?
* mPASS score > 2, breathless at rest, agitated, confusion?
* Diffuse wheezes or poor air movement without wheezes?
* In need of O
2
to keep SpO
2
> 92%?
Moderate or Severe Exacerbation
HIGH DOSE THERAPY
RT order and give albuterol 2.5 mg Q20 min (age < 12 yrs.)
or 5 mg Q20 min (age > 12 yrs.) via nebulizer x3 in 1
st
hour
OR continuous at 10 mg/kg over 1 hour (up to 15 mg/hour)
RT order and give ipratropium bromide 250 mcg Q20 min
(age < 5 yrs.) or 500 mcg Q20 min (age > 5 yrs.) x3 via
nebulizer or add to continuous albuterol nebulizer
Administer O
2
to maintain SpO
2
>90%
Oral or IV corticoste roids per ED provider
IVF per ED provider if dehydration, impending respiratory
failure, or shock
Consider 1:1000 epinephrine 0.01 mg/kg IM (max 0.3 mg)
per ED provider
Consider EtCO
2
or venous blood gas per ED provider
Yes
Mild Exacerbation
STANDARD DOSE THERAPY
RT order and give albuterol 2.5 mg Q20 min (age < 12
yrs.) or 5 mg Q20 min (age > 12 yrs.) via nebulizer x1-3.
RT order and give ipratr opium bromide 250 mcg Q20
min (age < 5 yrs.) of 500 mcg Q20 min (age > 5 yrs.) via
nebulizer x1 (if using albuterol at home > q2-4 hours).
Administer O
2
to maintain SpO
2
>90%
Oral corticosteroids per ED provider
No
RT assess response to intervention (including mPASS and post spirometry)
Good Response
RT notify ED provider
Incomplete Response
RT notify ED provider
RT give albuterol continuous at 10 mg/kg over 1 hour
(up to 15 mg/hour)
Observe for 60 minutes.
RT repeat mPASS.
mPASS
score < 2 and
SpO
2
> 90% on
room air?
No
Initiate Discharge Planning
Yes
Continue albuterol per ED provider.
ED provider to consider adjunctive
therapies:
Magnesium sulfate 50-75 mg/kg IV
(max 2 g) over 20 min
Heliox (if FiO
2
< 50%)
BiPAP, HFNC
Terbutaline 2-10 mcg/kg IV bolus then
0.08-0.4 mcg/kg/min IV titrated to
effect (max 1 mcg/kg/min)
Continue Reassessment and Admission
Planning
Reference:
Asthma – Adult/Pediatric – Inpatient/Ambulatory/Emergency Dept
Guideline
Requiring
albuterol > Q2
hours?
Admit to PICU
Admit to General
Care Floor
No
Pediatric Emergency Dept. Asthma Exacerbati on Algorithm (Age 12 months to 17 years)
Incomplete Response
RT notify ED provider
Good Response
RT notify ED provider
Observe for 60 min.
and RT repeat
mPASS.
RT assess response to intervention
(including mPASS and post spirometry)
mPASS
score < 2 and
SpO
2
> 90% on
room air?
Yes
No
If mPASS score > 5, strongly consider PICU admission.
If mPASS score 3-4, consider PICU consult.
Yes
RT perform mPASS assessment and spirometry (if patient able)
R
T

n
o
t
i
f
y

E
D

p
r
o
v
i
d
e
r

t
o

c
o
n
s
i
d
e
r

P
I
C
U

c
o
n
s
u
l
t
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Adult patient admitted to general care floor
Does patient
have any of the following?*
- FEV1 or PEF < 40% or unable to perform spirometry due to
work of breathing?
- Diffuse wheezes or poor air movement without wheezes?
- Breathless at rest/agitated or confused?
- In need of O
2
to keep SpO
2
> 92%?
Moderate or Severe Exacerbation
RT order and give albuterol 5 mg Q20
min x3 in 1
st
hour via nebulizer
RT order and give ipratropium
bromide 500 mcg Q20 min x3 via
nebulizer
Administer O
2
to maintain SpO
2
>92%
RT contact physician to consider non-
invasive ventilation and moving
patient to ICU/IMC
Mild Exacerbation
RT order and give albuterol 5 mg via
nebulizer x1.
RT order and give ipratropium
bromide 500 mcg via nebulizer x1 (if
using albuterol at home > q2-4 hours)
Administer O
2
to maintain SpO
2
>92%
No
RT assess response to intervention
(including spirometry)
Adult Inpatient Asthma Exacerbation Algorithm (Age 18 years or older)
Does patient
have any of the following?
- Subjective improvement of their shortness of breath?
- Decreased use of accessory muscles?
- Improved breath sounds?
RT order and give albu terol therapy 4- 8 puffs via MDI with spacer or 2.5
mg via nebulizer. Frequency determined by t riage score. * MDI is the
preferred delivery method. If the patient is unable to perform MDI
therapy adequately, give treatments via nebulizer. If the patient ha s an
artificial airway, refer to Bronchodilator via Artificial Airway Algorithm.
RT order and cont inue any long-acting beta agonist (LABA) or inhaled
corticosteroid (ICS) medications as patient receives at home, after
checking the pharmacy medication list. All other asthma medications
should be ordered per the admitting provider.
RT assess patient’s compliance and ability to sel f-administer all inhaled
medications. RT notify provider of patien t compliance via progress note
and verbal communication.
RT init iate peak flow monitoring (CS# 3330773 ) twice daily 10 minutes
after bronchodilator therapy.
Yes
Refer to Bronchodilator
Follow-up Algorithm and
assess patient for self-
administration if indicated
RT contact physician to consider:
Moving patient to an ICU and starting
continuous bronchodilator therapy
Starting adjunct therapies such as
BiPAP, Heliox, or inhaled
corticosteroids
No
Was patient
admitted from
ED?
Yes
Yes
RT perform assessment (including spirometry)No
Reference: Asthma – Adult/Pediatric – Inpatient/Ambulatory/EmergencyDept Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Pediatric Inpatient Asthma Exacerbation Algorithm (Age 12 months to 17 years)
Was
the patient admitted from
the ED, and received 3
treatments?
Maintain pulse oximetry and
administer oxygen to maintain
SPO
2
>90%.
RT performs mPASS Assessment.
RT orders albuterol 2.5 mg Q5
min PRN (age < 12 yrs.) or 5 mg
Q5 min PRN (age > 12 yrs.)
Yes
Reference:
Asthma – Adult/Pediatric – Inpatient/Ambulatory/Emergency Dept Guideline
Maintain pulse oximetry and administer
oxygen to maintain SPO
2
>90%.
RT orders and gives albuterol 2.5 mg Q5 min
PRN (age < 12 yrs.) or 5 mg Q5 min PRN
(age > 12 yrs.) via nebulizer x3 within 1
st
hour.
RT orders and gives ipratropium bromide
250 mcg Q20 min (age < 5 yrs.) or 500 mcg
Q20 min (age > 5 yrs.) via nebulizer x3
within 1
st
hour.
RT performs mPASS Assessment.
No
Is mPASS score > 2,
and/or hypoxia?
Patient admitted to PICU
off of adjunctive therapies
(i.e., BiPAP, continuous
medications, etc.)
Patient admitted to
General Care
Inclusion Criteria:
1. Diagnosis of asthma or
history of recurrent
wheezing
2. Patients with first time
wheezing that have
demonstrated
responsiveness to
albuterol suggesting initial
presentation of reactive
airway disease
3. FiO2 < 50%
4. Exhibits one of the
following symptoms:
Persistent cough
Dyspnea
Chest pain
Wheezing
Exclusion Criteria:
1. Any patient on
adjunctive therapies
2. FiO2 > 50%
3. Concomitant diagnosis
including:
Cystic fibrosis or
other chronic lung
disease
Congenital or
acquired
cardiovascular
disease
Bronchopulmonary
dysplasia
Immunodeficiency
syndromes
RT give 1 Treatment Bundle*
RT may repeat Treatment Bundle up to three times in 1
st
hour based on
mPASS assessment. MDI is preferred delivery method per provider.
Yes
*Treatment Bundle:
1. mPASS Assessment
2. If mPASS score > 2, give initial dose of 4 puffs albuterol**
3. Repeat mPASS Assessment
4. If mPASS score continues to be > 2, repeat 4 puffs albuterol
5. Repeat mPASS Assessment
6. Senior Resident to notify Atte nding MD if mPASS score not improved
May repeat steps 1-5 up to three times in the 1
st
hour (equals 24 puffs).
No albuterol given.
RT reassess in 1 hour.
No
Is mPASS
score > 2?
Is mPASS
score > 2?
Call MD and agree
on a care plan.**
Yes
No albuterol given.
RT reassess in 1 hour.
No
RT give 1 Treatment Bundle* until mPASS score < 2.
RT reassess q1 hour.
Yes
RT reassess q1 hour.
Do not wean albuterol to q3
hours until patient off O
2
.
When mPASS score < 2 and no
albuterol is indicated for 4 hours,
change scheduled assessment
to q2 hours x2.
RT provide asthma education and
prepare for discharge.
No
**Notification of Resident MD by RT
- Initiation of or increasing requirement of supplemental O2
- Worsening or increasing respiratory distress
- Increasing frequency of bronchodilator therapy
- mPASS score > 2 after Treatment Bundle
- Unable to wean from q2 hour bronchodilator therapy after
receiving therapy for 6 hours (exclusion of ED protocol)
Notification of Attending MD by Resident
- Patient requires q2 hour bronchodilator therapy for > 8-12 hours
- Concern for patient condition
RT perform mPASS
Assessment
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

25
References
1. Global Strategy for Asthma Management and Prevention. Global Initiative for
Asthma;2017.
2. Bel EH, Ten Brinke A. New Anti-Eosinophil Drugs for asthma and COPD: targeting the
trait! Chest. 2017.
3. Aaron SD, Vandemheen KL, FitzGerald JM, et al. Reevaluation of Diagnosis in Adults
With Physician-Diagnosed Asthma. Jama. 2017;317(3):269-279.
4. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. Performance of a novel clinical
score, the Pediatric Asthma Severity Score (PASS), in the evaluation of acute asthma.
Acad Emerg Med. 2004;11(1):10-18.
5. Oberle AJ, Mathur P. Precision medicine in asthma: the role of bronchial thermoplasty.
Curr Opin Pulm Med. 2017;23(3):254-260.
6. Deeks ED, Brusselle G. Reslizumab in Eosinophilic Asthma: A Review. Drugs.
2017;77(7):777-784.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org