Text Description: Pediatric Emergency Medicine EvidenceBased Pathway

Text Description: Pediatric Emergency Medicine Evidence?Based Pathway

Management of Acute Asthma Exacerbations

BCH Emergency Department – UCSF Benioff Children’s Hospital (San Francisco)

Purpose of This Pathway

This pathway outlines the emergency department management of acute asthma exacerbations in pediatric patients older than 24 months, using the MPASS (Modified Pulmonary Index Score) to guide treatment and disposition.

Inclusion Criteria

Patients meeting all of the following:

• Age greater than 24 months
• History of asthma or reactive airway disease, with or without wheezing
• May include a family history of asthma

Exclusion Criteria

Patients are excluded if they have:

• Contraindication or allergy to medications used in this guideline
• A different primary diagnosis, such as:
• Pneumonia
• Bronchiolitis
• Croup
• Complicated medical history, including:
• Congenital or acquired heart disease
• Chronic lung disease, bronchopulmonary dysplasia, or cystic fibrosis
• Immune?mediated disorders
• Tracheostomy

Initial Assessment and Monitoring

1. Patient presents with respiratory distress and concern for asthma exacerbation
2. Place patient on:
• Cardiorespiratory monitor
• Continuous vital sign monitoring
3. Provide supplemental oxygen as needed to maintain:
• Oxygen saturation (SpO?) greater than 92 percent
4. A nurse performs and documents an MPASS score

Impending Respiratory Failure Check

• If there is concern for impending respiratory failure, the patient is removed from this algorithm and managed separately.

Severity Classification by MPASS Score

Mild Asthma Exacerbation

MPASS score: 1 to 5

Initial Treatment:

• One albuterol nebulizer treatment
  OR
• Albuterol via metered dose inhaler with spacer, 4–8 puffs once

Next Step:

• Reassess using MPASS

If discharge criteria are met, the patient is discharged home.

Moderate Asthma Exacerbation

MPASS score: 6 to 10

Initial Treatment:

• Albuterol and ipratropium nebulizer treatments every 20 minutes for 3 doses
• Dexamethasone 0.6 mg per kilogram, maximum 12–16 mg, given orally or intramuscularly once

Reassessment:

• Reassess with MPASS

If improved:

• Observe for 90 to 120 minutes
• Repeat MPASS
• Assess for discharge readiness

Decision Point:

• If no further therapy is required, discharge home
• If further therapy is required, consider hospital admission

Severe Asthma Exacerbation

MPASS score: 11 to 15

Immediate Actions:

• Start albuterol and ipratropium nebulizer treatments every 20 minutes for 3 doses
• Call respiratory therapy (RT)
• Consider intravenous access

Medications:

• Dexamethasone 0.6 mg per kilogram (maximum 12–16 mg), oral, intramuscular, or intravenous once
  OR
• Methylprednisolone 2 mg per kilogram intravenously, maximum 60 mg, once

Adjunctive Therapies to Consider:

• Magnesium sulfate 50 mg per kilogram intravenously, maximum 2 grams, once
• Epinephrine 1:1,000 intramuscular injection at 0.01 mg per kilogram, maximum 0.3–0.5 mg
• Terbutaline:
• Loading dose 10 micrograms per kilogram IV or IM once
• Then continuous infusion at 0.08 micrograms per kilogram per minute, titrated to effect

Reassessment:

• Reassess with MPASS

If worse or stable:

• Admit to hospital, with possible PICU admission
• Call respiratory therapy
• Start continuous albuterol

Discharge Criteria

Patients may be discharged if all of the following are met:

• MPASS score of 7 or less
• Patient can maintain hydration orally
• Caregivers are able to recognize and manage asthma symptoms at home

Discharge Instructions

• Albuterol: 4 puffs every 4 hours for 48 hours, then as directed by the attending physician
• Consider a repeat dose of dexamethasone in 24 hours if given initially
• Follow up with primary care provider in 1 to 2 days

Imaging and Laboratory Guidance

• No routine imaging or labs are required
• Consider chest imaging if:
• Fever above 39°C
• Hypoxia
• Abnormal lung exam
• No family history of asthma
• Poor response to bronchodilators
• Imaging may also be considered if there is concern for:
• Foreign body
• Pneumomediastinum
• Pneumothorax
• Consider blood gas testing if there is clinical worsening of:
• Mental status
• Neurologic condition
• Respiratory examination

Medication Dosing Reference

• Albuterol (nebulized):
• Less than 20 kg: 2.5 mg
• 20 kg or more: 5 mg
• Ipratropium (nebulized):
• Less than 20 kg: 250 micrograms
• 20 kg or more: 500 micrograms
• Doses listed apply to single nebulized treatments
• Use EZ?Flow device when available for MDI delivery
• Continuous Albuterol:
• Less than 20 kg: 7.5 mg per hour
• 20 kg or more: 10 to 20 mg per hour