Asthma — Critical/Impending Respiratory Failure — Clinical Pathway: Emergency Department

Asthma Clinical Pathway — Emergency Department

Critical/Impending Respiratory Failure

Critical

Escalation Medications

  • STAT terbutaline bolus SQ, IV if in place:
    • Can use IM epinephrine via EPIPEN instead if not immediately available
  • Continuous neb albuterol + ipratropium
  • IV solumedrol
  • IV fluid bolus for volume support if impending intubation
  • IV Magnesium: Hold if concern for immediate intubation due to hypotension

Initiate NIPPV

  • Rapid titration of NIPPV step to reduce work of breathing
  • Obtain Istat or venous blood gas

NIPPV Steps

  Step 1 (starting)
Any level of CPAP
 Step 2 Step 3 Step 4 (Maximal) Additional Considerations
IPAP: Inspiratory positive airway pressure 10 14 16 20 Application of IPAP allows for driving pressure (Delta P) which may improve inspiratory airflow and decrease work of breathing.
EPAP: Expiratory positive airway pressure 5 6 8 10 Inadequate EPAP results in inefficient INSPIRATORY effort. Inspiratory flow will not occur until sufficient negative pleural pressure is created to reopen obstructed airways, increasing work of breathing.

No Improvement, Impending Respiratory Failure

  • Move to resuscitation room
  • Attach CPR pads
  • Draw up resuscitation dose of epinephrine
  • Repeat IV terbutaline bolus q15 min x 3
  • Obtain Istat or VBG as indicated

Preparation for Intubation/Mechanical Ventilation

  • Tier 1 PICU Alert
  • IV fluid bolus for volume loading
  • Medications
    • Ketamine: 2 mg/kg IV, max 100 mg
    • Rocuronium: 1 mg/kg
  • Slow resp rate: 10-12/min, allow expiration
  • Transition to ventilator with ICU Consult
  • If CPR arrest, consider ECMO with PICU