ED Pathway for Evaluation/Treatment
of Children with Asthma
Respiratory Arrest
Imminent
To resuscitation room
Moderate: ESI Triage 3
  • Consider Dexamethasone tablet (alternative prednisone/olone)
  • If needed:
    Albuterol MDI -2-4 puffs
  • MDI spacer teaching
  • Discharge
  • Dexamethasone tablet (preferred for all ages)
    (alternative prednisone/olone)
  • Albuterol MDI q20min x 3, prn RT assess
  • Dexamethasone tablet (if can take po)
    Alternative: IM dex/ IV solumedrol
  • Unineb: Albuterol x3 + ipratropium
  • Critical: consider terbutaline SQ/IV
  • Consider IV Mg
Reassess
ASSESS after completion of β-agonist
Considerations for further diagnostic testing
Oxygen: Initiate only for persistent 02 sat < 90%
Mild-Moderate
(PASS 0-3)
Severe (PASS > 3)
Attending Eval at bedside
Hold Treatment Reassess after 1 hr
Repeat albuterol via Unineb
Consider IV Mg
Admission
Wait for steroid effect (> 2 hrs)
Oxygen: Initiate only for persistent 02 sat < 90%
Severe
Concern for Resp Failure
Terbutaline
Subcutaneous: Initial treatment prior to IV placement
10 mcg/kg, maximum of 250 mcg

Intravenous bolus
10 mcg/kg (Range 2-10 mcg/kg) maximum 750 mcg

IV infusion (not recommended, use repeat boluses prn)
Starting dose 0.4 mcg/kg/minute
(Titrate prn to 3 mcg/kg/min maximum)

Admit to ICU
Mod / Severe
Needs continuous albuterol
Continuous albuterol
Consider IV mg bolus + NS
Admit to inpatient floor
RT assess O2 requirement with blender if sat < 88%
Oxygen management
Moderate
Needs q2h treatment
If awake O2sat > 90%
EDECU admit preferred if available
Albuterol Weight-based Dosing
Kg Unit Dose (0.5%) MDI Puffs Continuous
5-10 2.5 mg (0.5 mL) 4 7.5 mg/hr
> 10-20 3.75 mg (0.75mL) 6 11.25 mg/hr
> 20 5 mg (1.0 mL) 8 15 mg/hr
Ipratropium Weight-based Dosing
5-10 500 mcg over 1 hr in unineb or
250 mcg q20 min x 2
   
> 10 1000 mcg over 1 hr in unineb or
500 mcg q20 min x 2
   
Prednisone/Methylprednisolone
  2 mg/kg p.o./IV, MAX 60 mg    
Dexamethasone: Mild-moderate flare, repeat in 24-48 hours, crush tablet with cherry syrup, juice, or yogurt
5-8 4 mg    
> 8-12 6 mg    
> 12 8 mg    
Magnesium Sulfate
  50 mg/kg, MAX 2 g
Give with Normal saline bolus, 20ml/kg (max 1 liter)
q15 min VS, observe in ED 60 min prior to transfer to inpatient floor
   
Terbutaline
 

Intermittent dose: Repeat as needed every 15-30 minutes for a maximum of 3 doses total:

  • Subcutaneous: (If IV unavailable) 10 mcg/kg,
    Maximum 250 mcg
  • Intravenous: (Infuse over 5 minutes) 10 mcg/kg,
    Maximum 250 mcg
IV Infusion
  • Not generally recommended in ED
  • Use loading dose of 10 mcg/kg, MAX 750 mcg
  • If infusion clinically indicated
    • Start at 0.4 mcg/kg/min
    • Titrate prn to MAX 3mcg/kg/min
Posted: October 2005
Revised: November 2011, September 2013, October 2014, April 2015, September 2015, October 2016, October 2017, November 2019
Authors: J. Zorc, MD; R. Scarfone, MD; A. Reardon, CRNP; N. Stroebel, CRNP; W. Frankenberger, RN; L. Tyler, RT;
D. Simpkins, RT; R. Abaya, MD; E. Delgado, MD; E. Brill, RN;