Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Asthma
- Related Pathway
- Asthma, Inpatient
- Asthma, PICU
- Asthma, Primary Care
- Critical/Impending Respiratory Failure
- To Resuscitation Room
Mild: ESI Triage 4
Moderate: ESI Triage 3
Severe: ESI Triage1-2
- 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
- Modifications for COVID-19
Reassess
ASSESS after completion of β-agonist
Considerations for further diagnostic testing
Oxygen: Initiate only for persistent 02 sat < 90%
Considerations for further diagnostic testing
Oxygen: Initiate only for persistent 02 sat < 90%
Mild-Moderate
(PASS 0-3)
(PASS 0-3)
Severe (PASS > 3)
Attending Eval at bedside
Attending Eval at bedside
Hold Treatment Reassess after 1 hr
Repeat albuterol via Unineb
Consider IV Mg
Consider IV Mg
Severe
Concern for Resp Failure
Concern for Resp Failure
Subcutaneous | Initial treatment before IV placement |
---|---|
IV Bolus | Intermittent boluses once IV placed is preferred 10 mcg/kg, maximum of 250 mcg, q15-30min x 3 |
IV Infusion | Not recommended, use repeat boluses prn instead If used:
|
BiPAP | Initiate if worsening distress after maximal medical treatment Start at 10/5 cm H20 and titrate upwards with RT support PICU Asthma Pathway |
Continuous albuterol
Consider IV mg bolus + NS
Admit to inpatient floor
RT assess O2 requirement with blender if sat < 88%
Oxygen Management
Consider IV mg bolus + NS
Admit to inpatient floor
RT assess O2 requirement with blender if sat < 88%
Oxygen Management
Moderate
Needs q2h treatment
Needs q2h treatment
If awake O2sat > 90%
EDECU admit preferred if available
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 |
4 | |
> 10-20 | 1000 mcg over 1 hr in unineb or 500 mcg q20 min x 2 |
6 | |
> 20 | 1000 mcg over 1 hr in unineb or 500 mcg q20 min x 2 |
8 | |
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 before transfer to inpatient floor |
|||
Terbutaline | |||
Intermittent dose: Repeat as needed every 15-30 minutes for a maximum of 3 doses total:
|
Posted: October 2005
Revised: May 2023
Revised: May 2023
Evidence
- Efficacy and Time of Action of Oral Steroids in the ED
- Improving Efficiency of Pediatric Emergency Asthma treatment by using metered dose inhaler
- Follow-up Care after an ED visit
- Meta-analysis of Dexamethasone for Acute Asthma
CHOP Programs
- Asthma @CHOP Site and Educational Materials
- Community Asthma Prevention Program (CAPP) Services and Eligibility
Educational Media
Related Links