Asthma care in the emergency department

Approved 11/08 Division of Pediatric Emergency Medicine Asthma Care in the Emergency Department
Clinical Practice Guideline
Inclusion: 1) Children 2 years of age or older with a prior history of wheezing, and 2)
Children less than 2 years of age with likely Asthma rather than Acute Bronchiolitis
Exclusion: History of unstable heart disease or suspicion of other reason for wheezing
(laryngomalacia, tracheomalacia, foreign body, etc.)
Time 0: Obtain vital signs, pulse oximetry and height in children older than 6 years, then
determine initial asthma score:
Modified CAS (Woods and Downes) Asthma Score:
Initial Asthma Score 
CAS 0­2 
CAS 3­
CAS 5­10 
Continuous Albuterol with Atroventneb over  Approved 11/08 Division of Pediatric Emergency Medicine Repeat Asthma Score at 1 hour 
CAS 1­2 
CAS 3­
CAS 5­10 
Continuous Albuterolneb over 1 hour.
Repeat Asthma Score at 2 hours 
CAS 1­2 
CAS 3­
CAS 5­10 
Continuous Albuterol neb over 1 hour.
Repeat Asthma Score at 3 hour 
CAS 1­2 
CAS 3 
CAS 4­10 
Admit to Floor 
Admit to TCU
Admit PICU. 
q 2 hour nebs. May have q 1hour x 1‐2  Approved 11/08 Division of Pediatric Emergency Medicine Nebulization Dosing
Wt > 20 kg
Wt < 20 kg
Score
0 – 2
Oral steroids 2mg/kg 2 mg/kg up to 60 mg Approved 11/08 Division of Pediatric Emergency Medicine Cardinal Glennon Children’s Medical Center
Asthma Care in the Emergency Department
Asthma is a major public health problem of increasing concern in the United States. From 1980 to 1996, asthma prevalence among children increased by an average of 4.3% per year, from 3.6% to 6.2%. Low-income populations, minorities, and children living in inner cities experience disproportionately higher morbidity and mortality due to asthma. Asthma’s effects on children and adolescents include the following: • Asthma accounts for 14 million lost days of school missed annually. • Asthma is the third-ranking cause of hospitalization among those younger than • The number of children dying from asthma increased almost threefold from 93 in • The estimated cost of treating asthma in those younger than 18 years of age is The pathophysiology of asthma is composed of:
‐ Bronchoconstriction by bronchial smooth muscle contraction Emergency department management of asthma includes:
‐ Oxygen to maintain pulse oximetry>90% ‐ Short acting beta agonist therapy in the form of repetitive or continuous administration: three treatments spaced every 20-30 minutes or continuous administration ‐ Inhaled ipratropium bromide particularly for patients with severe airflow ‐ Corticosteroids by the parenteral or oral routes ‐ Intravenous magnesium sulfate and beta agonists (terbutaline) Approved 11/08 Division of Pediatric Emergency Medicine Unproven Therapy:
(theophylline/amiophylline) is not recommended though it may be utilized as an aggressive measure to stave off intubation Emergency Department Asthma Care Pathway
Who Qualifies:
1) Children older than 2 years of age with a prior history of wheezing, and 2) Children less than 2 years of age with likely asthma rather than acute bronchiolitis Who Does NOT Qualify:
Children with unstable heart disease or suspicion of other reasons for wheezing, such as a laryngomalacia, tracheomalacia, or foreign body Step 1: Obtain vital signs, pulse oximetry and height in children older than 6 years.
Step 2: Determine asthma score: Modified CAS (Woods and Downes) Asthma Score.
Asthma score < 3
1 - Order a single albuterol nebulizer treatment of 5 mg for children weighing 20 kg. and above, or 2.5 mg for children less than 20 kg. 3 – The RN should initiate the treatment if respiratory therapy has not arrived Approved 11/08 Division of Pediatric Emergency Medicine Asthma score 3 to 5
1 - Place the child on continuous pulse oximetry 2 - Order a continuous nebulization treatment with albuterol and atrovent to Run over 1 hour: 10 mg and 250 micrograms in children less than 20 kg. 20 mg and 500 micrograms in children 20 kg and above. The RN should initiate the treatment if respiratory therapy has not 3 – Request the respiratory therapy check post treatment peak flows in 4 – Order and administer 2 mg/kg of oral steroid (form at the discretion of the RN) with a maximum of 60 mg. Notify MD if unable to tolerate PO 5 – Place the chart in the door, notify the attending or fellow of patient’s enrollment in the pathway and when the nebulization treatment is Asthma score > 5
1 – Place the child on continuous pulse oximetry 2 – The RN initiates a continuous nebulization treatment if respiratory 3 – Notify the attending or fellow of patient’s enrollment and need for their 4 - The timing and route of administration of steroids as well as any supplemental medications (Magnesium, terbutaline, etc.) should be determined by the attending or fellow at the time of their evaluation. Magnesium: 25 - 75 mg/kg IV up to 2 grams
Therbutaline: 2 – 10 mcg/kg IV load followed by 0.1 – 0.4 mcg/kg/min.
(May titrate in incements of 0.1 – 0.2 mcg/kg/min Q 30 min) Approved 11/08 Division of Pediatric Emergency Medicine Admission of asthma patients:
The pathway for admission of patients to the appropriate unit in the hospital is outlined in the ED to Inpatient Admission Pathway. Discharge from the emergency department requires that:
‐ If the patient is able to perform an appropriate peak flow it should be greater than or equal to 70% of predicted (available in table format with peak flow meters) ‐ The patient is comfortable and is able to tolerate oral meds and fluids as well as ‐ The above conditions remain stable 30 to 60 minutes after the last nebulized Discharge medications:
‐ Inhaled bronchodilator (albuterol via a home nebulizer or MDI) including education in the use of an MDI as indicated. Albuterol: MDI: 2 – 4 puffs, Nebulizer: 2.5 mg. ‐ Oral corticosteroids (2 mg/kg/day, max. of 60 to 80 mg) for 4 to 5 days ‐ Continuation of any current asthma medications (long term bronchodilators, ‐ Consider adding an inhaled corticosteroid for patients with persistent disease ‐ Follow-up with a health care provider in 1 week Approved 11/08 Division of Pediatric Emergency Medicine

Source: http://illinoisaap.org/wp-content/uploads/AsthmaGuidelinesER.pdf