Asthma, PICU — Clinical Red Flags — Clinical Pathway: Inpatient and ICU

Acute Asthma Exacerbation Clinical Pathway — PICU

Clinical Red Flags

Look out for potential side effects for all pathway patients.

Symptoms of Critical Asthma and Associated Therapies

Symptom Evaluation Differential Diagnosis Treatment
Chest pain EKG, Troponin, Chest X-ray Myocardial ischemia (MI), pneumothorax MI: decrease β-agonist as able, Pneumothorax: place chest tube
Worsening shortness of breath Chest X-ray, auscultation Pneumothorax, superinfection Place chest tube, treat with antibiotics if indicated on CXR or exam
Tachycardia Assess volume status Hypovolemia, β-agonist side effect Fluid bolus as needed
ST segment changes EKG and Troponin Myocardial ischemia hypotension Decrease β-agonist as able, epinephrine if hypotensive
Hypotension
  • Assess volume status
  • Assess jugular venous distension
 Hypovolemia, myocardial ischemia
  • Fluid bolus
  • Decrease β-agonist
Hypoxemia VQ mismatch Decrease β-agonist as able

Complications of Critical Asthma

Condition Presentation Diagnosis Treatment
Air Leak Syndrome (Pneumothorax)
  • Chest pain
  • Shortness of breath
  • Crepitus
  • Asymmetric breath sounds
  • Distended Neck veins
  • Shock
  • POC US
  • CXR
  • If obstructive shock: needle thoracostomy
  • Otherwise: confirm with POC ultrasound or chest radiograph; then consider tube thoracostomy
Myocardial Ischemia
  • Chest pain
  • Shortness of breath
  • ST segment changes
  • Dysrhythmias (PVCs)
  • Shock
  • Troponin
  • ECG
  • Ensure that clinical scenario not consistent with myocarditis
  • If clinical status allows: limit beta agonists
  • Ensure euvolemia
  • Correct hypotension with alpha agonists if needed
Pneumonia
  • Fever
  • Chest pain
  • Shortness of breath
  • Crackles on auscultation
 CXR Antibiotics as per pathway
Relative Hypovolemia
  • Poor oral intake
  • Severe bronchospasm
  • Vasoplegia from beta agonists
  • Dry mucous membranes
  • No signs of fluid overload
  • Shock
  • Intravascular volume expansion with crystalloid
  • Minimize intrathoracic pressure (improve bronchospasm)
  • Minimize beta agonists as able