Consensus Guidelines for Inpatient Management of Asthma

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents

• Executive Summary
• Introduction
• Evaluation
• ER/Acute Management
• Inpatient Management
• Hospital Discharge
• References
• APPENDIX 1: UCSF BCH PEDIATRIC EMERGENCY MEDICINE (PEM) ACUTE ASTHMA ALGORITHM
• APPENDIX 2: MODIFIED PEDIATRIC ASTHMA SEVERITY SCORE (MPASS)
• APPENDIX 3: ASTHMA MEDICATIONS
• APPENDIX 4: UCSF BCH-SF INPATIENT ASTHMA PATHWAY AND UCSF BCH-OAKLAND PATHWAY
• APPENDIX 5: ICS DOSING TABLE
• APPENDIX 6: STEPWISE APPROACH FOR MANAGEMENT OF ASTHMA 
• Appendix 7: CLASSIFYING ASTHMA SEVERITY
• APPENDIX 8: ASSESSING ASTHMA CONTROL

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Executive summary

Objectives

• Standardize and improve the quality of care of pediatric patients with acute asthma exacerbation being evaluated and treated in the acute care, ER, and inpatient settings.
• Use best available evidence to guide the inpatient management of an asthma exacerbation.

Recommendations

• Implement an inpatient clinical pathway for asthma
• Discontinue use of continuous pulse oximetry monitoring in hospitalized patients who are clinically stable and not requiring supplemental oxygen
• Initiate early transition from nebulized albuterol to albuterol delivered via Metered Dose Inhaler (MDI) and spacer
• Prescribe an inhaled corticosteroid (ICS) for all patients discharged from the inpatient setting with the diagnosis of asthma (including those with first-time wheeze)
• Screen for second hand smoke exposure
• Family Education prior to discharge – including education on how to manage asthma and how to prevent an exacerbation
• All patients who are seen as an outpatient by Pulmonology, Asthma/Allergy, or other asthma specialist should have a follow up appointment with that specialist within 90 days of discharge after hospitalization for asthma.

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

This work is licensed under a Creative Commons Attribution-Noncommerical 4.0 International License https://creativecommons.org/licenses/by-nc/4.0/

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Introduction

Criteria for use of guideline

• The following recommendations are intended for use in otherwise healthy children greater than or equal to 2 years old without chronic lung disease, immunodeficiency, or congenital anomaly.

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Evaluation

Labs

• NO routine lab studies recommended for most patients with acute exacerbation
• Viral testing:
• Consider testing for influenza if high degree of suspicion for influenza
• Consider RSV or viral panel testing if there is a potential alternate diagnosis of bronchiolitis or other viral respiratory syndrome
• Default testing is NOT helpful for management or isolation purposes
• Blood gas (ABG/VBG/CBG): in patients with severe distress, hypoventilation, or inadequate response to initial treatment
• CBC + Blood Culture: not recommended for otherwise healthy children
• Metabolic panel: not recommended for initial assessment

Imaging

• CXR: Not recommended for routine assessment of acute exacerbation
• NOTE: bacterial super-infection is rare; apparent infiltrates are often atelectasis
• Appropriate indications for CXR:
• Focal exam
• Concern for foreign body
• Failure to improve with typical treatments
• NOTE on first-time wheeze: children presenting with first-time wheeze and history suggestive of alternative diagnosis, or who do not demonstrate improvement with albuterol, should have an expanded differential considered and further work-up

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ER/Acute Management

Early treatment of acute exacerbation is best strategy for management

• Example of acute management/ Emergency Medicine pathway -See APPENDIX 1: UCSF BCH Pediatric Emergency Medicine (PEM) Acute Asthma Algorithm
• For the most up to date UCSF BCH (PEM) pathway please check here:
• https://www.ucsfbenioffchildrens.org/medical-professionals/pediatricemergency-medicine-clinical-pathways

Severity Assessment:

• Use objective measures to categorize exacerbation as mild, moderate, severe, or impending respiratory failure based on oxygenation, RR, auscultation (wheezing), retractions, dyspnea
• For example of a score see APPENDIX 2: Modified Pediatric Asthma Severity Score (MPASS)
• NOTE: this score was developed at UCSF and not validated.

Initial Treatment:

• See APPENDIX 3: Asthma Medications for recommended medication dosing
• Oxygen: Humidified oxygen to keep O2 sats greater than or equal to 90% on RA
• Bronchodilators: (typically not dosed based on weight, dose based on severity of presentation)
• MILD: Albuterol single neb or MDI w/spacer treatment x 1
• MODERATE: Albuterol/Ipratropium neb (i.e. “Duoneb”) back-to-back x 3 or continuous Albuterol x 1hr + ipratropium
• SEVERE: Albuterol/Ipratropium (i.e. “Duoneb”) x 3 or continuous Albuterol + ipratropium
• Systemic Corticosteroids:
• Indication: MODERATE and SEVERE exacerbations
• Timing: should be administered within 1hr of presentation
• Choice of medication:
• Dexamethasone PO/IM
• PO route is preferred but may be administered IM if unable to tolerate PO
• Maximum dosing subject to local protocols, see APPENDIX 3: Asthma Medications for recommended dosing
• Prednisone/Prednisolone PO
• Methylprednisolone IV
• Consider for SEVERE exacerbation who cannot tolerate PO
• NOTE: Ensure patient receives adequate steroid dose (i.e., consider repeating dose if emesis < 30min after PO steroid)

Reassessment:

• MILD: reevaluate after bronchodilator therapy
• MODERATE: reevaluate midway through back-to-back bronchodilator therapies (or within first 1hr of continuous treatment) and after bronchodilators x 3 complete (or after 1hr of continuous treatment)
• SEVERE: reevaluate q15min or more frequently based on clinical status
• IMPENDING RESPIRATORY FAILURE: continuous evaluation

Respiratory Support:

• Maximize noninvasive respiratory support for children with SEVERE asthma exacerbation or IMPENDING RESPIRATORY FAILURE
• Pursue PICU consultation prior to intubation of any patient with asthma exacerbation

Observation & Disposition from ER:

• Disposition based on asthma exacerbation category following therapies
• MILD: discharge
• MODERATE: consider admission
• SEVERE: admission; consider PICU
• NOTE: Consider observation of MODERATE asthmatics x 2hrs after systemic corticosteroid administration to determine disposition

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Inpatient Management

Admission Criteria

• Hypoxemia (SpO2 < 90% on room air)
• Need for bronchodilator more frequently than q4hr
• Significant increased work of breathing (MODERATE/SEVERE scoring)
• Inability to tolerate PO intake
• Social concerns:
• Inability to administer medications or concerns regarding medication adherence at home
• Teaching needs

Clinical Management

• Consider implementing a clinical pathway to standardize inpatient asthma management.
• Clinical pathways have been shown to decrease variation in care, increase adherence to evidence based guidelines and could help decrease length of stay
• Components of a pathway should include recommended monitoring, assessments and medications including how to wean albuterol.
• Frequency of assessments and albuterol weaning will be dependent on local resources, protocols and staffing
• For examples of pathways see APPENDIX 4: UCSF BCH-SF Inpatient asthma pathway and UCSF BCH-Oakland pathway

Monitoring

• Pulse Oximetry:
• Indications for continuous pulse oximetry monitoring:
• First 2-4 hours of any asthma admission
• Supplemental oxygen requirement + 2-4hrs following discontinuation of supplemental oxygen
• SEVERE asthma exacerbations
• Patients requiring continuous Albuterol
• Intermittent oxygen saturation checks q4hrs with vital signs for all other cases
• Labs:
• Consider metabolic studies if patient is on prolonged high-dose continuous albuterol or NPO on prolonged IV fluids as inpatient (> 24hrs)
• Consider blood gas (ABG/VBG/CBG) if significant worsening of clinical status

Assessments

• Use objective measures to categorize exacerbation as mild, moderate, severe, or impending respiratory failure based on RR, prolonged expiration, auscultation, retractions, dyspnea
• Implement a Respiratory Score
• A standardized asthma or respiratory score is helpful in standardizing assessments and informing when to titrate therapies
• no specific asthma score is universally recommended; select a score that is easy to implement in your setting (will be dependent on local resources including who is scoring (RN vs MD vs RT)
• For an example of a respiratory score see APPENDIX 2: - Modified Pediatric Asthma Severity Score (MPASS)
• NOTE: this score was developed at UCSF and not validated.
• Assess a score prior to bronchodilator treatment and use score to determine if therapy needs to be titrated up or down.

Treatment

See APPENDIX 3: Asthma Medications for recommended medication dosing

• Bronchodilators:
• Albuterol
• typically not dosed based on weight, dose based on severity of presentation
• Severe exacerbations - high dose continuous nebulization
• can start at 20 mg/hr for all ages
• studies have shown that continuous albuterol can be given safely on pediatric wards
• Moderate to mild exacerbations
• intermittent Albuterol via Meter-Dosed Inhaler (MDI) with spacer
• Evidence supports early transition to MDI with spacer once no longer needing continuous albuterol and has been shown to be as effective as intermittent albuterol delivered by nebulization:
• can transition from continuous to every 2 hours treatment when moderate severity and then to every 4 hours once mild severity.
• Systemic corticosteroids:

NOTE: Evidence for benefit is comparable for all forms of systemic corticosteroids; dexamethasone and prednisone have equivalent efficacy in outpatient management of MODERATE asthma exacerbation

• Dexamethasone (i.e., Dex)
• BENEFITS (vs. Prednisolone or Prednisone): improved PO tolerance when IV formulation given orally (4 mg/mL concentration), shorter duration of therapy, ability to give IM if not tolerated PO
• Use for MODERATE asthma exacerbation requiring hospital admission especially if there is concern for poor PO tolerance or family medication adherence
• Recent studies have shown Dexamethasone has similar outcomes to Prednisone/Prednisolone in children hospitalized for an asthma exacerbation.
• Dosing: see APPENDIX 3: Asthma Medications 
• NOTE: it is not recommended to give a 3rd dose of dexamethasone due to the larger total cumulative dose. If a patient is not improving (unable to wean albuterol), transition to Prednisone/Prednisolone (Pred) to complete a 5-day steroid course. For inpatient setting, begin Pred 24hrs after last Dexamethasone dose)
• Prednisone / Prednisolone (i.e., Pred)
• BENEFITS (vs. Dexamethasone): longer duration of therapy, greater experience/body of evidence to support use particularly in inpatient setting
• Use for MODERATE or SEVERE asthma exacerbation who can take POs
• Dosing: see APPENDIX 3: Asthma Medications
• NOTE: Use prednisolone preferentially over prednisone due to smaller volume dosing (more concentrated solution = 3 mg/ml versus 1 mg/ml)
• NOTE: Children who receive Dexamethasone in outpatient/ER setting may be transitioned to Prednisolone/Prednisone to complete a 5-day steroid course (beginning 24 hrs after Dexamethasone dose) for inpatient setting
• Methylprednisolone
• should use for patients with a severe exacerbation who:
• are unable to tolerate PO meds due to vomiting
• are NPO due to respiratory compromise
• Dosing: see APPENDIX 3: Asthma Medications
• NOTE: Transition to oral Pred when the patient’s respiratory status improves and child is able to tolerate PO intake to complete a total steroid course of 5-10 days depending on severity
• Timing to initiate inpatient systemic corticosteroid dosing after initial dose given as outpatient:
• Dexamethasone – 24 hours after initial dose
• Prednisone / Prednisolone – 12 hours after initial dose
• Methylprednisolone – 6 – 12 hours after initial dose
• NOTE: taper may be considered if steroid course >10 days
• Adjunct pharmacologic therapies:
• Magnesium Sulfate (IV)
• Use for Moderate and SEVERE acute exacerbation or SEVERE exacerbation resistant to initial albuterol and systemic corticosteroid therapy
• Studies show that this reduces hospital admissions in some patients
• Dosing: see APPENDIX 3: Asthma Medications
• NOTE: May be administered in ER, pediatric ward, or PICU setting; availability of protocols for administration on pediatric ward may vary between institutions.
• Requires close BP monitoring for hypotension during infusion.
• Consider IV fluid bolus when administering
• NOTE: May consider repeat dosing spaced at least 12 hours apart in SEVERE / resistant exacerbation, not evidence-based
• Intramuscular Epinephrine
• Use in ER, PICU, ward, or urgent care setting for SEVERE acute exacerbation not responsive to IV Magnesium, when no IV access, or impending respiratory arrest
• Dosing: see APPENDIX 3: Asthma Medications
• Terbutaline
• Use for SEVERE acute exacerbation or SEVERE exacerbation resistant to initial albuterol, systemic corticosteroid, and magnesium therapy
• NOTE: may be administered in ER or PICU setting, or while awaiting transport to higher level of care
• Dosing: see APPENDIX 3: Asthma Medications
• Mucolytics – not recommended
• Ipratropium – not recommended in the inpatient setting
• Inhaled corticosteroids (ICS):
• Inhaled corticosteroids are “controller” medications meant to control symptoms and prevent an asthma exacerbation. They are not primary management during an exacerbation
• Indication: Initiate / continue / escalate ICS for all patients with asthma exacerbation requiring admission including patients with first time wheeze
• NOTE: Start/restart ICS as inpatient at least 24hrs prior to discharge in order to perform asthma education for family
• See Discharge Planning section and Discharge medication section for more details of how to initiate or escalate an ICS
• see APPENDIX 5: ICS Dosing Table dosing specifics
• see APPENDIX 6: STEPWISE APPROACH FOR MANAGEMENT OF ASTHMA from the National Asthma Education and Prevention Program (NAEPP)/National Heart, Lung and Blood Institute (NHLBI) 2020 Focused Updates to the Asthma Management Guidelines (i.e., NAEPP/NHLBI 2020 Updates to Asthma)

Supportive care

• Supplemental Oxygen:
• Criteria for starting supplemental O2: SpO2 < 90%
• Criteria for discontinuing supplemental O2: SpO2 consistently > 90%, no or minimal respiratory distress
• IV fluids:
• Consider for patients with SEVERE asthma exacerbation requiring high dose or prolonged continuous albuterol, those unable to tolerate PO, or those who are NPO due to respiratory compromise
• Chest physiotherapy - Not recommended

PICU Consultation / Transfer Considerations

• Need for escalation of respiratory support (e.g., HFNC, CPAP/BIPAP)
• Failure to respond to high-dose continuous albuterol therapy; Failure to improve following escalation of therapy (e.g., magnesium administration and not improving)
• NOTE: Initiate transfer to PICU by most rapid means possible for the following conditions:
• Impending respiratory failure (e.g., hypercarbia on blood gas)
• Requirement for epinephrine or terbutaline

Additional assessment

• Peak flow:
• Not helpful for inpatient assessment / acute management
• May be considered for patient/family education and discharge planning if patient will be discharged with peak flow meter
• Spirometry:
• Not helpful for inpatient assessment / acute management
• May be considered for patient/family education and outpatient follow-up purposes in children >5yrs who are approaching discharge if available
• Allergy testing:
• Not indicated in the inpatient setting
• Consider referral for outpatient RAST or skin testing if strong/clear history of allergic triggers (pulmonology or asthma clinic)
• Pulmonology consultation:
• Goal: facilitate transition to outpatient care and follow-up
• Indications for inpatient consult (if available onsite):
• Severe asthma exacerbation requiring PICU admission
• Patients with > 2 asthma-related ED/urgent care visits that require systemic corticosteroids or > 3 unscheduled asthma-related visits within the past 1 year
• Patients with > 2 asthma-related admissions within the past 5 years
• Indications for outpatient referral to pulmonology (or asthma clinic):
• Severe asthma exacerbation:
• Patients requiring inpatient pulmonology consultation
• Patients with PICU admission
• Patients with prolonged hospitalization (>72hrs)
• Poorly controlled asthma:
• Patients with > 2 asthma-related ED/urgent care visits that require systemic corticosteroids or >3 unscheduled asthma-related visits within the past 1 year
• Patients with > 2 asthma-related admissions in the past 5 years
• Patients unresponsive to therapy (e.g., not meeting goals of asthma therapy after 3-6 months of treatment) or those requiring advanced medication regimens
• Need for further education: Patients with poor medication adherence or those needing reinforcement of asthma education, guidance on complications of therapy, or allergen avoidance
• Complicated diagnoses:
• Presence of other medical conditions which complicate asthma diagnosis
• Atypical signs/symptoms or need for diagnostic clarification

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Hospital Discharge

Discharge Criteria

• No oxygen requirement (SpO2 >90% on room air)
• Improved work of breathing
• Transitioned to albuterol MDI
• Requiring bronchodilators greater than or equal to every 4 hours
• Asthma education performed (see “Discharge Planning” below)

Discharge Planning

• Start discharge planning and family education early in the hospitalization
• Asthma education: Give to all patients with a diagnosis of asthma or wheeze responsive to bronchodilators
• Asthma Action Plan (AAP):
• Give written copy of AAP prior to discharge
• Give verbal explanation of AAP, including detailed instructions on the difference between control and rescue medications (if applicable)
• MDI and spacer teaching: verbal teaching by nursing, respiratory therapists, or educator (if available) and have child/family demonstrate use prior to discharge
• Education on environmental controls including reduction of second-hand smoke exposure
• Nebulizer teaching (if applicable)
• Peak flow teaching (if applicable)
• Inhaled Corticosteroids (ICS): Initiate, continue, or escalate a controller medication in the form of an ICS for all admitted patients with asthma exacerbations including patients with first time wheeze.
• Educate families to continue ICS daily until PMD tells them to stop

Discharge Medications

• Albuterol: Discharge patient home when on albuterol 2-4 puffs via MDI and spacer q4hrs with a plan for spacing albuterol treatments at home
• Example of appropriate spacing plan: 2 puffs q4hrs ATC x 24-48 hours, then q6hrs ATC x 24 hours, then q4hrs PRN; administer treatments at night only if symptomatic 
• Inhaled Corticosteroids (ICS): Initiate, continue, or escalate a controller medication in the form of an ICS for all admitted patients with asthma exacerbations including patients with first time wheeze.
• see APPENDIX 5: ICS Dosing Table for dosing specifics
• NOTE re: appropriate dosing of ICS for discharge:
• For patients < 4 years old with recurrent wheezing (i.e., viral- induced wheezing) +/- on intermittent ICS prior - START a low dose daily ICS prior to discharge
• Advise family and PMD to continue ICS for at least 6-8 weeks after discharge and should have PMD have follow-up to reassess diagnosis, control, and reassess therapy.
• Diagnosis of recurrent wheezing with URI is best made by PMD
  o If assessment is recurrent wheezing with URI, then they may benefit from intermittent ICS with colds
• For patients without known asthma greater than or equal to 5 years old who are not currently on an inhaled corticosteroid - start a low dose ICS prior to discharge
• Advise family and PMD to continue ICS for at least 6-8 weeks after discharge and should have PMD follow up to reassess diagnosis, control and therapy
• For patients with known asthma who are not currently on an inhaled corticosteroid - start a moderate dose ICS prior to discharge
• Advise family and PMD to continue ICS for at least 6-8 weeks after discharge and should have PMD follow up to reassess diagnosis, control and therapy
• PMD to stepped up therapy if not well controlled
• asthma should be well controlled for at least 3 months before stepping down on therapy
• For patients with known asthma who are already on a daily dose ICS and PRN SABA (with good adherence) - continue/modify/escalate medication regimen based on the National Asthma Education and Prevention Program (NAEPP)/National Heart, Lung and Blood Institute (NHLBI) 2020 Focused Updates to the Asthma Management Guidelines (i.e., NAEPP/NHLBI 2020 Updates to Asthma) Stepwise Approach For Management Of Asthma. See APPENDIX 6: STEPWISE APPROACH FOR MANAGEMENT OF ASTHMA. Options:
• If on low dose ICS, can step up to moderate dose ICS on discharge
• If on moderate dose ICS
• Can continue moderate dose ICS and PRN SABA with follow up with PMD. PMD to reassess control and if needed step up therapy
  OR
• Can step up to moderate dose ICS-LABA with prn SABA with PMD follow up to reassess control.
• The details of up-titration to a SMART (single maintenance and reliever therapy) i.e., daily and PRN combination medium-dose ICS-formoterol on discharge and to manage exacerbation after hospitalization is beyond the scope of this guideline. Consult the National Asthma Education and Prevention Program (NAEPP)/National Heart, Lung and Blood Institute (NHLBI) 2020 Focused Updates to the Asthma Management Guidelines and/or refer/consult Pediatric Pulmonology or Pediatric Asthma clinic for specific recommendations or complex cases.
• Starting SMART requires close PMD involvement including knowledge of patient’s formulary, being able to provide prior authorization if needed, intensive family education (including education on risk of adrenal suppression if too many prn doses are taken per day) and close PMD follow up
• Requires checking insurance coverage prior to prescribing to check that insurance would cover more than 1 inhaler a month, if they do not, patient may run out of inhaler prior to refill and this therapy may not be the best option
• SMART therapy considerations- PMD could consider initiating on those > 5 years old AND severity of asthma moderate-persistent or above AND
• Not well controlled on current therapy OR not doing well with 2 inhalers AND
• Patient likes the idea/would prefer having 1 inhaler for both control and rescue
• Initial choice of ICS should take into account safety profile, available dosing recommendations for age, insurance/formulary coverage and provider experience/preference
• A good initial choice for all ages is fluticasone (Flovent MDI), which has recommended dosing available for all age groups and available as MDI that can be used with spacer
• Another ICS may be chosen based on response to fluticasone, provider preference, insurance coverage, concern for growth suppression, or other considerations (see APPENDIX 5: ICS Dosing Table and consult pulmonology for additional recommendations)
• ICS via MDI and spacer is the preferred route for all ages (including infants and toddlers).
• Even infants can use a MDI and properly fitted spacer with mask 
• If difficult for patient to tolerate, then use of less puffs to achieve dose (e.g., 1 puff higher dose ICS BID vs 2 puffs lower dose ICS BID is an option. Still should divide dose BID.
• Use a nebulized steroid (budesonide) if a hand-held administration device (e.g., MDI/spacer) cannot be used (e.g., cooperation, comorbidities, etc). If prescribed, nebulized medications should be given via mask/mouthpiece and not “blow by”
• Reference the National Asthma Education and Prevention Program (NAEPP)/National Heart, Lung and Blood Institute (NHLBI) 2020 Focused Updates to the Asthma Management Guidelines step therapy for escalating therapy if poorly controlled. See APPENDIX 6: STEPWISE APPROACH FOR MANAGEMENT OF ASTHMA
• Educate patients regarding use of ICS medications and to use daily until reassessed by PMD (also see above section on education)

Discharge Follow-Up

• Schedule evaluation by PMD within 2-3 days of discharge
• Consider earlier follow-up for patients/families might benefit from reenforcement of asthma education or those with concern for medication adherence
• Follow-Up Goals:
• Ensure continued clinical improvement and adjust bronchodilator spacing plan as needed
• Reinforce asthma education – confirm understanding of medications and spacer/MDI usage
• Answer questions regarding diagnosis, long-term plan for asthma management, and follow-up
• Specialist Referral:
• All patients who are seen as an outpatient by Pulmonology, Allergy, or other asthma specialist should have a follow up appointment with that specialist within 90 days of discharge after hospitalization for asthma.
• Indications for pulmonology or asthma clinic referral:
• See referral criteria in “pulmonology consultation” section above
• Indications for Allergy Referral:
• Consider for patients with suspected allergic triggers or need for RAST testing

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References

Ball, S., Glover, B.T., Rechler, W., Wetzel, M., Hames, N., Jenkins, E., Lantis, P., Varghese, S., & Hemani, S.A. (2020). “Comparing outcomes of Dexamethasone versus Prednisone in children hospitalized with acute asthma exacerbations”. Pediatrics, 146, 232-232.

Cloutier, M., Baptist, A., Blake, K., Brooks, E., Bryant-Stephens, T., DiMango, E., Dixon, A., Elward, K., Hartert, T., Krishnan, J., Lemanske, R., Ouellette, D., Pace, W., Schatz, M., Skolnik, N., Stout, J., Teach, S., Umscheid, C., Walsh, C. “2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group”. Journal of Allergy and Clinical Immunology, Vol.146, Issue 6, 2020,1217-1270, https://doi.org/10.1016/j.jaci.2020.10.003.

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma– Summary Report 2007. Journal of Allergy and Clinical Immunology, Volume 120, Issue 5, S94 - S138

Hemani SA, Glover B, Ball S, Rechler W, Wetzel M, Hames N, Jenkins E, Lantis P, Fitzpatrick A, Varghese S. “Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations”. Hosp Pediatr. 2021 Nov;11(11):1263-1272. doi: 10.1542/hpeds.2020-004788. Epub 2021 Oct 5. PMID: 34610967.

Kenyon CC, Fieldston ES, Luan X, Keren R, Zorc JJ. “Safety and effectiveness of continuous aerosolized albuterol in the non-intensive care setting”. Pediatrics. 2014 Oct;134(4):e976- 82. doi: 10.1542/peds.2014-0907. PMID: 25266428.

Kulalert P, Phinyo P, Patumanond J, Smathakanee C, Chuenjit W, Nanthapisal S. “Continuous versus intermittent short-acting B2-agonists nebulization as first-line therapy in hospitalized children with severe asthma exacerbation: a propensity score matching analysis” Asthma Res Pract. 2020 Jul 2;6:6. doi: 10.1186/s40733-020-00059-5. PMID: 32632352; PMCID: PMC7329360.

National Heart, Lung, and Blood Institute. “Asthma Care Quick Reference: Diagnosing and Managing Asthma.” Guidelines from the National Asthma Education and Prevention Program Expert Panel Report 3. NIH Publication No. 12-5075; Revised Sept 2012 https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

Appendix 1: UCSF BCH Pediatric Emergency Medicine (PEM) Acute Asthma Algorithm

For most current pathway please visit: https://www.ucsfbenioffchildrens.org/medical-professionals/pediatric-emergency-medicine-clinical-pathways

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Appendix 2: Modified Pediatric Asthma Severity Score (MPASS)

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Appendix 3: Asthma Medications

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Appendix 4: UCSF BCH-SF Inpatient asthma pathway and UCSF BCH-Oakland pathway

UCSF BCH-SF Inpatient asthma pathway

Asthma Inpatient Management

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Appendix 5: ICS Dosing Table (check local formulary for availability)

NOTE: Advair may not be covered by some insurance plans; use the table below to switch to covered formulations

USE THE TABLE TO SWITCH PATIENTS GREATER THAN OR EQUAL TO 5 YEARS WHO ARE ALREADY ON ADVAIR TO SYMBICORT OR DULERA:
For children < 5 years: consult with pulmonologist / asthma specialist for recommendations

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Appendix 6: STEPWISE APPROACH FOR MANAGEMENT OF ASTHMA

Reference: Figure 2: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group

Reference: Figure 3: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group

Reference: Figure 3: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group

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Appendix 7: Classifying Asthma Severity

Reference: National Heart, Lung, and Blood Institute. Asthma Care Quick Reference: Diagnosing and Managing Asthma. NIH Publication No. 12-5075; Revised Sept 2012

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APPENDIX 8: ASSESSING ASTHMA CONTROL

Reference: National Heart, Lung, and Blood Institute. Asthma Care Quick Reference: Diagnosing and Managing Asthma. NIH Publication No. 12-5075; Revised Sept 2012 

Disclaimer

These clinical practice guidelines are based upon the evidence-based consensus opinions of consortium members affiliated with UCSF Benioff Children's Hospitals. They are intended to guide pediatric/neonatal providers, but do not substitute for individual clinical judgment. Evaluation and treatment of specific patients should be adapted based upon the unique conditions of each patient, family and clinical environment.

Northern California Pediatric Hospital Medicine Consortium. Originated 12/2014, Revised 12/2021

Approved by UCSF BCH Medication Committee: 1/19/2022

Approved by UCSF Pharmacy and Therapeutics Committee: 2/9/2022

Approved by UCSF QI Executive Committee: ____

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International License