Clinical Pathway for Child Admitted to PICU for Acute Asthma Exacerbation

Albuterol Weight-based Dosing
Kg Continuous
5-10 7.5 mg/hr
> 10-20 11.25 mg/hr
> 20 15 mg/hr
Ipratropium Weight-based Dosing
5-10 250 mcg nebulized q6h
> 10 500 mcg nebulized q6h
Methylprednisolone
  1 mg/kg IV q6, MAX 30 mg/dose
Magnesium Sulfate
  50 mg/kg, MAX 2000 mg
Terbutaline IV
  10 mcg/kg, MAX 400 mcg
Moderate/Severe
Critical
Impending Respiratory Arrest
  • MS reassuring with:
    • PASS ≤ 3 and
    • FiO2 ≤ 50%
  • MS reassuring with:
    • PASS ≥ 4 or
    • FiO2 > 50%
  • or MS agitated or drowsy
  • MS combative or obtunded with:
    • PASS = 6 and/or
    • Rising CO2
Consider NIPPV
Rapid titration of NIPPV step to reduce work of breathing
  • High risk of cardiac arrest
  • Consider NIPPV as a temporizing measure
  • Consider ECMO consult
  • Consider isoflurane
  • NIPPV: Noninvasive positive pressure ventilation
  • IPAP: Inspiratory positive airway pressure
  • EPAP: Expiratory positive airway pressure
Step IPAP EPAP
1 10 5
2 14 6
3 16 8
4 (Max) 20 10
  • Obtain initial venous blood gas
  • Consider Transcutaneous CO2 monitor
    if FiO2 > 30%
  • Anxiolysis only if needed
  • NPO
Monitor hourly MS, PASS, VS, Transcutaneous CO2 if applicable
Additional monitoring Intravascular volume status every 1-4 hr
BMP, Mg, PO4 every 12-24 hours
Blood gas as indicated
  De-escalation Maintenance Escalation
Criteria
  • MS Reassuring
  • and
  • 2 consecutive PASS ≤ 3
  • MS Reassuring
  • and
  • PASS = 4-5
  • Combative or obtunded MS
  • PASS Score = 6 or
  • Any PASS score with rising CO2
Therapies Continue current therapy
Next step Reassess in 1 hour Follow Impending Respiratory Arrest
Posted: March 2019
Authors: B. Bruins, MD; L. Salomone, RRT-NPS; A. Oxenreiter, RN; H. Wolfe, MD; J. Coyne, RRT-AEC; G. Stitt, PharmD; N. Craig, RRT-NPS; B. Blowey, PharmD