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 Bolus
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
Revised: July 2023
Editors: Clinical Pathways Team