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Pediatric ED Asthma Exacerbation Algorithm

Pediatric ED Asthma Exacerbation Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Respiratory, Related


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