Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Asthma

Goals and Metrics
Patient Education
Child with Asthma and Respiratory Complaint
Triage (Critical/Acute/Urgent)
MD/CRNP/RN Brief Rapid Assessment
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%
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%
None/Mild
Severe
Concern for Resp Failure
Terbutaline
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:
  • Start rate 0.4 mcg/kg/min
  • Loading dose 10 mcg/kg
  • Max 400 mcg
Titrate to 3 mcg/kg/min max
BiPAP Initiate if worsening distress after maximal medical treatment
Start at 10/5 cm H20 and titrate upwards with RT support
PICU Asthma Pathway
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
Discharge
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:

  • 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 400 mcg
  • If infusion clinically indicated
    • Start at 0.4 mcg/kg/min
    • Titrate prn to MAX 3mcg/kg/min
Posted: October 2005
Revised: May 2023
Editors: Clinical Pathways Team