Pediatric Acute Asthma Pathway - Emergent and Urgent Care
JUNE 2008
At Initial Assessment
Mild
(Score 0-4)
Moderate (Score 5-8)
Severe (Score 9-12)
Impending
Respiratory
Failure
See Reverse Side for:
See Reverse Side for:
See Reverse Side for:
See Reverse Side for:
description of score
initial dosing and at discharge
description of score
initial dosing and at discharge
list of drugs and dosing
description of score
initial dosing and at
discharge
ABBREVIATIONS:
ACH-Alberta Childrens Hospital; ED-Emergency Department; ICU-Intensive Care Unit; MDI-Metered Dose Inhaler; ICS-Inhaled Corticosteroid; DPI-Dry Powder Inhaler; CBG/ABG-Capillary or Arterial Blood Gas; IM-Intramuscular; IV-Intravenous
DRUGS:
Fluticasone (Flovent); Beclomethasone (QVAR); Budesonide (Pulmicort); Ciclesonide (Alvesco); Budesonide + Formoterol (Symbicort); Fluticasone + Salmeterol (Advair)
JUNE 2008
Asthma Clinical Score (PRAM)*
Medication Dosing
Discharge Medications
Rapid Sequence Intubation
Mild, Moderate, Severe or Impending Respiratory Failure
Mild, Moderate or Severe
Mild, Moderate or Severe
Impending Respiratory
Failure
Acute Care Medications
Chalut D, Ducharme F, Davis G
Journal of Pediatrics 2000;137:762-768
Aerosolized 2 Agonist
*modified to adjust for higher altitude
Signs
Suprasternal
Indrawing
absent
present
Scalene
retractions
absent
present
Wheezing
absent
Air entry
Oxygen saturation
on room air
normal
> 93%
expiratory
only
inspiratory and
expiratory
decreased
at bases
widespread
decrease
90% - 93%
< 90%
Salbutamol
Via MDI/Spacer: 5 puffs if < 20kg or
10 puffs if 20kg per aerosol
MDI/Spacer is preferred over
Nebulizer
Via Nebulizer: 2.5mg if < 20kgs or
5mg if 20kgs per aerosol
Aerosolized Anticholinergic
audible without
stethoscope/
silent chest
with minimal
air entry
Ipratropium
Via MDI/Spacer: 5 puffs per aerosol
MDI/Spacer is preferred over
Nebulizer
Via Nebulizer: 250mcg per aerosol
Can mix with salbutamol
Oral Corticosteroids
absent/minimal
Dexamethasone
Use parenteral solution
0.15-0.30mg/kg per dose, max dose 10mg
Causes less vomiting than
prednisone/prednisolone
Prednisone/Prednisolone
1-2mg/kg per dose, max dose 60mg
Intravenous Corticosteroids
PRAM CLINICAL Score
Mild
0-4
Moderate
5-8
Severe
9 - 12
Severity Classification
Impending Respiratory Failure
12+ following
lethargy, cyanosis, decreasing respiratory effort,
and/or rising pC02
Use oral corticosteroids unless patient is
vomiting or is in impending respiratory
failure
Methylprednisolone 1-2mg/kg, max dose
80mg
Hydrocortisone 4-8 mg/kg, max dose 400mg
Magnesium
Administer MgSO4 25mg/kg IV bolus over
20 minutes (max dose 2 grams)
Use only in severe asthma unresponsive
to aerosolized bronchodilators
Aerosolized 2 Agonist
Frequency
Administer q4 hours for 24 hours then
PRN
Salbutamol
Via MDI/Spacer 2 puffs per aerosol
treatment
Via DPI 1-2 puffs per aerosol treatment
Terbutaline (Bricanyl Turbuhalers)
Via DPI 1-2 puffs per aerosol treatment
Dry Powdered Inhalers (DPI) are preferred
over MDI/Spacer in children > 6 years of age
Normal Saline bolus
20ml/kg IV
If < 8 years, Atropine
0.02mg/kg IV,
minimum dose 0.1mg
Oral Corticosteroids
Prednisone/Prednisolone 1-2mg/kg,
max dose 60mg po qday for 5 days
Dexamethasone 0.15-0.30mg/kg,
max dose 10mg po qday for 5 days
Some pharmacies do not stock
dexamethasone
Aerosolized Corticosteroids
Inhaled corticosteroids for 14 days.
The following minimum doses are suggested:
Beclomethasone MDI/Spacer (Qvar):
100mcg/puff, 2 puffs BID
Budesonide DPI (Pulmicort):
200mcg/puff, 2 puffs BID
Fluticasone DPI (Flovent):
100mcg/puff, 2 puffs BID
Fluticasone MDI/Spacer (Flovent):
125mcg/puff, 2 puffs BID
Ciclesonide MDI/Spacer (Alvesco):
200 mcg/puff, 1 puff BID
Dry Powdered Inhalers (DPI) are preferred
over MDI/Spacer in children > 6 years of age
Midazolam 0.1mg/kg IV
Ketamine 3.0mg/kg IV
Succinylcholine
1.5mg/kg IV
DEVICE RECOMMENDATIONS:
Intravenous Salbutamol
Mix 5ml of 1mg/ml solution diluted in 500ml
of D5W (10mcg/ml)
Infusion: Start at 1mcg/kg/minute
(6ml/kg/hour) & titrate upwards in
1mcg/kg/minute increments as necessary
Use only in severe asthma unresponsive to
aerosolized bronchodilators or impending
respiratory failure
MDI/Spacer with mask 0-4 years
MDI/Spacer with mouthpiece 4-6 years
DPI >6 years
Epinephrine
IV 0.1ml/kg of 1/10,000
IM 0.01ml/kg of 1/1,000
Use only in impending respiratory failure
ABBREVIATIONS:
ACH-Alberta Childrens Hospital; ED-Emergency Department; ICU-Intensive Care Unit; MDI-Metered Dose Inhaler; ICS-Inhaled Corticosteroid; DPI-Dry Powder Inhaler; CBG/ABG-Capillary or Arterial Blood Gas; IM-Intramuscular; IV-Intravenous
DRUGS:
Fluticasone (Flovent); Beclomethasone (QVAR); Budesonide (Pulmicort); Ciclesonide (Alvesco); Budesonide + Formoterol (Symbicort); Fluticasone + Salmeterol (Advair)
