PICU Clinical Pathway for Children with
Acute Asthma Exacerbation

Goals and Metrics
Patient Education
Provider Resources
Child admitted to PICU for Acute Asthma Exacerbation
Additional Considerations
Standard Medical Therapies
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
Escalation Medical Therapies
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
Consider Mechanical Ventilation
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
De-escalation of Mechanical Ventilation
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
Revised: June 2022
Authors: B. Bruins, MD; L. Salomone, RRT-NPS; A. Oxenreiter, RN; H. Wolfe, MD; J. Coyne, RRT-AEC; B. Blowey, PharmD