Acute Asthma Exacerbation Clinical Pathway – PICU

PICU Clinical Pathway for Children with
Acute Asthma Exacerbation

Goals and Metrics
Patient Education

Additional Considerations

Standard Medications
Continuous Albuterol
5–10 kg 7.5 mg/hr
> 10–20 kg 11.25 mg/hr
> 20 kg 15 mg/hr
Ipratropium
5–10 kg 250 mcg nebulized q6hr
> 10 kg 500 mcg nebulized q6hr
Methylprednisolone
  1 mg/kg IV q6hr
Max 30 mg/dose
Escalation Medications
Magnesium Sulfate
50 mg/kg, Max 2,000 mg
Terbutaline IV Loading Dose
10 mcg/kg, Max 400 mcg
Child admitted to PICU for acute asthma
 
 
  • Exclusions
    • Complex congenital heart disease
    • Current tracheostomy
    • History of cardiac arrest in the preceding 48 hrs
    • Respiratory distress due primarily to non-bronchospastic disease
 
 
 
 
 
 
 
 
Moderate/Severe
 
 
 
Critical
 
 
 
Impending Respiratory Failure
  • Alert and conversant with
    • PASS ≤ 3
      and
      FiO2 ≤ 50%
  • Changes in alertness or speech pattern
    • PASS ≥ 4
      FiO2 > 50%
  • Combative, obtunded, inability to speak
    • PASS = 6
      Rising CO2
 
 
 
 
 
 
Consider NIPPV
Consider Mechanical Ventilation
  • Rapid titration of NIPPV step to reduce work of breathing
    • SpO2 goal > 92%
  • 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%
  • NPO
 
 
De-escalation of Mechanical Ventilation
 
 
Monitor
Severity score q1hr
Symptoms of Critical Asthma and Associated Therapies
  De-escalation Maintenance Escalation
Criteria
  • Improving alertness and speech pattern
  • and
  • 2 consecutive PASS ≤ 3
  • Reassuring alertness and speech pattern
  • and
  • PASS = 4–5
  • Worsening alertness and speech pattern
  • PASS = 6
  • or
  • Any PASS with rising CO2
Therapies Continue current therapy
Next Step Continue q1hr assessments Follow impending respiratory failure