Asthma Clinical Pathway — Inpatient | Children's Hospital of Philadelphia

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Sample Patient Progression

Pathway Documentation

Child with Acute Asthma Exacerbation

History & Physical
Steroid Management
- Prednisone/Prednisolone Q12 hrs. Start 24 hrs after ED dose if dexamethasone given in ED
- Discontinue inhaled corticosteroid
Management of FiO2 and SpO2
Further Diagnostic Testing
Determine severity level of exacerbation based on respiratory assessment

Initiate Discharge Planning:

Case Management
Asthma Education Plan
Asthma Care Plan
PCP Contact

Mild, Moderate, or Severe?

Severe

Continuous Albuterol Dosages

> 20 kg	3 ml/hr (15mg/hr)
> 10-20 kg	2.25 ml/hr (11.25 mg/hr)
5-10 kg	1.5 ml/hr (7.5 mg/hr)

Additional Medications
Consider Ipratropium Bromide
Prednisone / Prednisolone / Methylpred

Assessment
Respiratory q 1 hour
HR, RR q 1 hour, PRN
Continuous pulse oximetry, CRM
Hydration status IV & PO

Progression
Moderate assessment for 2 hours
Then advance to moderate

No Improvement on Continuous or
Adverse Effects

Hypoxemia without Worsening Respiratory Distress

Moderate

Albuterol Dosages

> 20 kg	8 puffs q 2 hours
10-20 kg	6 puffs q 2 hours
5-10 kg	4 puffs q 2 hours

Additional Medications
Discontinue Ipratropium Bromide
Continue Prednisone / Prednisolone

Assessment
Respiratory q 2 hours
HR, RR q 2 hours
Discontinue CRN
Pulse oximetry per protocol
Hydration Status IV & PO

Progression
Must be on RA (no oxygen requirement)
At 1st mild/moderate assessments (treat)
Assess in 2 hours then hourly x2 hours. Hold treatment if mild at 2 and 3 hours.

Mild

Albuterol Dosages

First q 4 hours		Second q 4 hours (Home Dose)
> 20 kg	8 puffs	2 puffs
10-20 kg	6 puffs	2 puffs
5-10 kg	4 puffs	2 puffs

Additional Medications
Continue home dose every 4 hours
until discharge
Continue Prednisone
Restart / initiate ICS as needed

Assessment
Respiratory q 4 hours
HR, RR q 4 hours
Pulse oximetry PRN
Oral intake, hydration status

Progression
Discharge after home dose

Worsening respiratory distress or symptoms/signs of tiring
Asthma Escalation Pathway

After any change in status
(moderate, severe) reassessment every hour until tolerating new interval

Discharge Criteria

Posted: June 2011
Revised: September 2013, November 2013, September 2015, November 2016, February 2018
Authors: C. Kenyon, MD; J. Zorc, MD; M. Dunn, MD; M. McCloskey, RN; J. Coyne, RT; E. Shelov, MD

Resources

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.