Pediatric Asthma Exacerbation Pathway in the Urgent Care

The following information is intended as a guideline for the acute management of children with asthma.
Management of your patient may require a more individualized approach

Inclusion Criteria: 2 yo or greater with hx of asthma or recurrent wheezing presenting with acute onset
Revised: CJ, wheezing, cough, shortness of breath, hypoxemia, tachypnea, or other signs of increased work of breathing
KP 1/10/24
Exclusion Criteria: < 2 yo, diagnosed with viral bronchiolitis or croup, history of Cystic Fibrosis,
Chronic Lung Disease, Cardiac Disease, or known Airway Anomalies

1. Obtain oxygen saturation and perform vital signs

2. Identify risk factors: Previous intubation or ICU admission, 2+ admissions in past year, 3+ ED visits in past year,
Prior ED/ admission in last month, >2 inhalers of albuterol per month, poor perception of symptoms

1. Room patient in Room 2, 3, 4, 5, or 6

2. Nurse to calculate Pediatric Asthma Score (PAS)

Severe Distress = PAS 6-10

Mild Distress = PAS 1-2 Moderate Distress = PAS 3-5
- Initiate continuous pulse oximetry with 1:1 staff
monitoring
- ( < 20 kg ) Albuterol MDI 4 puffs - Obtain q15 minute SpO2 - Give oral or IM steroids
1st Hour of Treatment

- (> 20 kg) Albuterol MDI 4-8 puffs - ( < 20 kg ) Albuterol MDI 4 puffs - ( < 20 kg) Albuterol 10 mg/hr continuously for 1
Alternative: - (> 20 kg) Albuterol MDI 4-8 puffs hour
- ( < 20 kg) Albuterol neb 2.5 mg Alternative: - (> 20 kg) Albuterol 20 mg/hr continuously for 1 hour
- (> 20 kg) Albuterol neb 5 mg - ( < 20 kg) Albuterol neb 2.5 mg Alternative:
- Consider oral steroids - (> 20 kg) Albuterol neb 5 mg - ( < 20 kg) Albuterol neb 2.5 mg with ipratropium
- Repeat PAS 15 min after treatment - Give oral steroids 0.5 mg Aerogen neb **
(preferably by same provider) - Repeat PAS 15 min after treatment - (> 20 kg) Albuterol neb 5 mg with ipratropium 0.5
- May repeat at provider's discretion (preferably by same provider) mg Aerogen neb **
** May repeat up to 3 total doses in first hr**
- Repeat PAS 15 min after each treatment (preferably
by same provider)

Reassess PAS 1 hour post initial treatment

Mild Distress = PAS 1-2 Moderate Distress = PAS 3-5 Severe Distress = PAS 6-10

- ( < 20 kg ) Albuterol MDI 4 puffs - Ensure corticosteroids were delivered - Call EMS for transport to Emergency
- (> 20 kg) Albuterol MDI 4-8 puffs - ( < 20 kg ) Albuterol MDI 4 puffs Department
Alternative: - (> 20 kg) Albuterol MDI 4-8 puffs - Ensure corticosteroids were delivered
Alternative: - ( < 20 kg) Albuterol 10 mg/hr
- ( < 20 kg) Albuterol neb 2.5 mg
- (> 20 kg) Albuterol neb 5 mg continuously for 1 hour
- ( < 20 kg) Albuterol neb 2.5 mg
- (> 20 kg) Albuterol 20 mg/hr
- Consider oral steroids - (> 20 kg) Albuterol neb 5 mg
continuously for 1 hour
- Repeat PAS 15 min after treatment - Consider transport by EMS to Emergency
- Perform & document PAS every 15 min
(preferably by same provider) Department

Calculate PAS hourly. Plan disposition at 2 hrs of presentation.

Symptoms Resolve / Patient Stable - DISCHARGE Symptoms Persist / Patient Unstable - ADMISSION
DISPOSITION

DISPOSITION

- Education regarding proper medication administration - Transport via EMS to Emergency Department for unstable or worsening
(asthma education videos) patients, patients requiring > 1 hour of continuous albuterol, patients
- Rx for albuterol Q4 hours while awake with history of requiring PICU admission or intubation
- Consider Rx for oral or inhaled corticosteroids - Notify accepting hospital provider and nursing staff and complete
- Provide patient with Asthma Action Plan documentation with .PATIENTDISPOSITION
- Encourage PCP follow-up within 48 hours

PEDIATRIC ASTHMA SCORE (PAS)

1. PAS should be done prior to treatment and repeated 15 minutes afterward (preferably by the same provider)
2. Add elements into a single score
3. Document score in Epic flowsheet and/or other areas of clinical documentation

ELEMENT POINTS
0 1 2
1. Respiratory Rate 2 - 3 yrs < 34 35-39 > 40
Obtain over 30 sec and multiply by 2 4 - 5 yrs < 30 31-25 > 36
6 - 11 yrs < 26 27-30 > 31
> 12 yrs < 23 24-27 > 28
2. Ausculatation Inspiratory &
Auscultate anterior and posterior lung fields expiratory wheezes
No Wheezes Expiratory Wheezes
Assess air entry and presence of wheezing OR diminished
breath sounds

3. Work of Breathing
Assess for nasal flaring or retractions < 1 sign 2 signs > 3 signs
(suprasternal, intercostal, subcostal)

4. Dyspnea * Speaks short

As developmentally appropriate. Speaks full Speaks partial
phrases, grunting,
* If sleeping AND not showing physical signs of sentences, playful, sentences, short cry
OR unable to take
respiratory distress, sscore the patient zero for AND takes PO well OR poor PO
PO
this category
Supplemental
5. O2 Requirement ** oxygen required to
** Do not take patients off supplemental oxygen to maintain
> 92% on RA
obtain score saturations above
92%