Asthma, PICU — Medications — Clinical Pathway: Inpatient and ICU

Acute Asthma Exacerbation Clinical Pathway — PICU

Medications

Standard Medical Therapies

Medication Dosing  
Continuous Albuterol   Weight (kg) Dose (0.5% solution) Maximum Dose
5 - 10 7.5 mg/hr (1.5 mL/hr) 20 mg/hour
> 10 - 20 11.25 mg/hr (2.25 mL/hr) 20 mg/hour
> 20 15 mg/hr (3 mL/hr) 20 mg/hour
Ipratropium   Weight (kg) Dose Maximum Dose
5 - 10 250 mcg/dose nebulized q6h 250 mcg/dose
≥ 10 500 mcg/dose nebulized q6h 500 mcg/dose
Methylprednisolone  

Methylprednisolone Dosing based on Pre-ICU Steroid Exposure

Pre ICU Steroid Exposure Recommended ICU Dosing Timing of ICU Administration
Dexamethasone Methylprednisolone 1 mg/kg/dose IV q6h
(max 30 mg/dose)		 Start 6 hours after last dose of dexamethasone
Methylprednisolone
or
Prednisone		 Methylprednisolone 1 mg/kg/dose IV q6h
(max 30 mg/dose)		 Start 6 hours after last dose of methylprednisolone or prednisone
No steroids Methylprednisolone 2 mg/kg IV once (max 60 mg),
then 1 mg/kg/dose IV q6h (max 30 mg/dose)		 Start immediately
*Hold inhaled steroids at the time of systemic steroid exposure

Escalation Therapies

Begin with magnesium sulfate.

Order of initiation Medication Timing of Initiation Dosing
1 Magnesium Sulfate   On maximum dose albuterol and ipratropium with persistent poor air entry 50 mg/kg/dose IV over 20 minutes (max 2,000 mg/dose)
2 Terbutaline   On maximum dose albuterol and ipratropium with persistent poor air entry and inadequate response to magnesium sulfate
  • Loading dose: 2-10 mcg/kg IV (maximum 400 mcg)
  • Continuous infusion 0.1-0.4 mcg/kg/minute; titrate by clinical response up to 3 mcg/kg/minute
3 Heliox
  • If all criteria are present:
    • FiO2 ≤ 30%
    • Inadequate air entry with maximum dose albuterol and ipratropium
  • Note:
    • Requires removal from NIPPV
    • Use as a trial prior to mechanical ventilation
 Heliox Therapy