Acute Asthma Exacerbation Clinical Pathway — PICU

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 Medications
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 Medications
Magnesium Sulfate
50 mg/kg, max 2,000 mg
Terbutaline IV Loading Dose
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
    • 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, vital signs, 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 = 6 or
  • Any PASS with rising CO2
Therapies Continue current therapy
Next Step Reassess in 1 hour Follow Impending Respiratory Arrest
Posted: March 2019
Last Revised: March 2025