This is a CONTROLLED document for internal use only.

Any documents appearing in paper form are not controlled and should be checked against the
electronic SharePoint version prior to use.

Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
Approved on 2017-09-29
Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

1.0 Introduction

Asthma is a chronic inflammatory disorder characterized by variable and recurring symptoms of airflow obstruction that
manifest secondary to bronchoconstriction, airway hyper-responsiveness, and airway edema, which tend to occur in
response to a variety of stimuli. Asthma exacerbations are a leading cause of hospitalization in children.

The hallmark of asthma exacerbation management involves optimizing bronchodilation and decreasing airway
inflammation. While these elements are generally well-practiced, there continues to be significant variability in practice
which can hinder optimal management and increase the duration of acute symptoms. Furthermore, inconsistencies in
asthma teaching and associated preventative recommendations that are given to families have been reported, which lead
to confusion, patient and caregiver dissatisfaction, and poor asthma control. It is therefore essential that consistent and
thorough asthma education be provided and prevention strategies initiated while in hospital with appropriate post
discharge follow up in the community.

The recommendations presented in this guideline and the associated pathway have been created using an
interdisciplinary panel of experts and key users following extensive review of the literature, existing guidelines, and
benchmarking with other reputable institutions.

Objectives

In the target population, the objectives of this guideline are to:

 Streamline the medical management of inpatients admitted to Paediatric Medicine with an acute asthma
exacerbation;
 Improve appropriate diagnostic testing;
 Provide optimal pharmacotherapy to prevent or minimize adverse effects of therapy;
 Achieve appropriate length of stay by establishing a standard salbutamol-weaning protocol;
 Standardize and promote effective asthma teaching using an asthma checklist;
 Ensure appropriate ongoing asthma management through initiating and adhering to an asthma action plan;
 Prevent recurrent asthma exacerbations and minimize the need for Emergency Department visits and/or
hospitalizations secondary to poor asthma control by ensuring appropriate follow-up;
 Ensure appropriate targets are met for discharge to minimize readmission rates (i.e., spirometry);
 Ensure access to medications to prevent readmissions; and
 Enhance appropriate utilization of community resources and ensure appropriate follow up.

© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the
electronic SharePoint version prior to use.

Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
Approved on 2017-09-29
Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

Target Users

Include, but are not limited to:

 Inpatient physicians, nurses, nurse practitioners, and trainees

 Respiratory Therapists
 Pharmacists
 Patients and families

2.0 Clinical Recommendations

Target Population:
 Inclusion: This management pathway is intended primarily for use in children age > 12 months of age being
admitted to hospital with an acute asthma exacerbation.
 Exclusion: This pathway is not intended for use in children with:
 Congenital or acquired cardiovascular disease
 Cystic fibrosis
 Chronic lung disease or bronchopulmonary dysplasia
 Immunodeficiency syndromes
 Sickle Cell Disease
 Multiple co-morbidities
 Severe symptoms requiring management in an ICU setting
 A condition requiring treatment with a beta-blocker

Diagnosis:
 Asthma can be diagnosed in children > 1 year old
 In school-aged children > 6 years old and adolescents, prior diagnosis of asthma using pulmonary function tests
is ideal
 In children 1 to 5 years of age, the diagnosis of asthma should be considered in children with ≥ 2 wheezing
episodes or frequent (≥ 8 days/month) wheeze symptoms
o Diagnosis requires documentation of or convincing parent report of signs or symptoms of airflow
obstruction and improvement or reversibility of obstruction with asthma therapy and no suspicion of an
alternative diagnosis

Assessment:
 Thorough clinical history should include:
o Time of onset of exacerbation
© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
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Inpatient Management of Acute Asthma Version: 2

Exacerbation

o All current medications and time of last dose and use of aerochamber
o Estimated number of asthma-related visits and severity (office, ED, hospitalizations, and ICU
admissions/need for intubation)
o Severity of symptoms compared to previous exacerbations
o Response to treatments prior to admission
o Last course of systemic steroids
o Ability to access medications (drug plan)
o Assessment of persistent symptoms: use of salbutamol, nighttime symptoms, and exercise intolerance
o Presence of complicating illnesses (pulmonary, cardiac)
o Diseases aggravated by steroid therapy (diabetes, hypertension, ulcers, psychosis)
o Potential triggers for exacerbation
o History of food allergy or allergy
o Cigarette smoke exposure - maternal, paternal, caregiver
o Social and environment history-crowding in home, exposure to irritants

 Physical examination should include but is not limited to:

o Assess the overall severity of the exacerbation using: (Respiratory Assessment Criteria)
 Vital signs and pulse oximetry
 Level of alertness
 Ability to speak in sentences
 Degree and quality of wheezing/aeration
 Presence of signs suggestive of increased work of breathing
 Presence of cyanosis/pallor
o Assessment of hydration status
o Signs suggestive of complications (pneumothorax, pneumomediastinum, pneumonia) or of upper airway
obstruction (croup, foreign body, etc.)
Diagnostic Tests:
 Blood work, nasopharyngeal swabs, and chest imaging are NOT recommended for routine management of a
patient with an acute asthma exacerbation
o Consider checking serum potassium in patients who are receiving salbutamol q1h (or less) for a
prolonged period of time (x6 hours or longer)
o Consider checking blood gases in patients who are in severe respiratory distress that are not improving
with treatment
o Consider nasopharyngeal swab if high suspicion for influenza with intention to start Tamiflu if positive or
on patients with severe asthma for whom the asthma escalation pathway has been initiated.
o Consider chest imaging in patients who fail to respond to treatment in 48 hours, develop increasing
oxygen requirements, develop a new fever that in is not explained by the physical examination, or have
an atypical asthma exacerbation presentation without a previous chest x-ray
 Spirometry should be ordered for children ≥ 8 years old once stable during admission in order to provide an
objective comparison measure of lung function. If the FEV1 < 40, consult Respiratory Medicine to ensure
adequate follow up with a respirologist
© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the
electronic SharePoint version prior to use.

Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
Approved on 2017-09-29
Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

Alternative treatments:
 The following treatments are NOT routinely recommended for asthma management:
 Methylxanthines
 Antibiotics except as needed for comorbid conditions
 IV hydration unless unable to safely maintain oral hydration
 Chest physical therapy
 Mucolytics
 Sedation

Management
Basic The basic inpatient management of an acute asthma exacerbation involves bronchodilators,
Management decreasing airway inflammation, supportive care to ensure that the patient is clinically stable, well
oxygenated, and well hydrated, and the initiation of interventions (asthma prevention therapy and
asthma teaching) to reduce the risk of future exacerbations.
Assessment of  There are no asthma severity scoring tools that have been validated for use in the inpatient
Asthma Severity setting.
 Using the best available evidence, the consensus of the Guideline Committee was to use
the Respiratory Assessment Criteria adapted from the Children's Hospital of Philadelphia to
assess Asthma Severity and direct pathway interventions accordingly.
Oxygen Therapy  There is a lack of evidence to specify an oxygen saturation (by pulse oximetry) threshold
below which supplemental oxygen is indicated. The consensus of the guideline committee
using best available evidence recommends starting supplemental oxygen when the
saturation is consistently < 88% while breathing room air.
 Intermittent oxygen saturation monitoring should be used for any child not requiring
continuous oxygen therapy.
Bronchodilator  Salbutamol is the bronchodilator of choice and frequency of administration should reflect the
therapy respiratory assessment criteria.
 Administration of salbutamol is recommended using a metered dose inhaler (MDI) with an
appropriate-sized spacer and mask (if under 4 years old).
 Administration via an MDI and spacer is better tolerated, associated with decreased
adverse effects, decreased length of stay, and has been found to be more effective at
medication administration than a nebulizer
 Use of a nebulizer may be considered in managing patients with severe respiratory
distress and impending respiratory failure who may require continuous or passive
medication administration with concurrent high flow oxygen administration

© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the
electronic SharePoint version prior to use.

Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
Approved on 2017-09-29
Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

Steroid Therapy  Systemic corticosteroids are essential in the treatment of the acute asthma exacerbation
 Dexamethasone, Prednisone, Prednisolone, and IV Methylprednisolone are frequently used
medications in the management of patients with an acute asthma exacerbation
 There is a lack of evidence to suggest that the use of any of these medications is
superior to the others. The consensus of the Guideline Committee is to recommend
a 2-day course of dexamethasone for the treatment of the routine acute asthma
exacerbation. Considerations included were palatability, duration of treatment, half-
life, side effects, and cost to families.
 Inhaled corticosteroids (ICS) are not as effective as PO or IV steroids for the acute
management of exacerbations and should not be used for this purpose.
Ipratropium  There is no evidence to support the inpatient use of ipratropium to manage acute asthma
Bromide exacerbations.
IV Magnesium  Consider the use of IV magnesium sulphate in cases of severe asthma that do not appear to
Sulphate be improving despite aggressive management with bronchodilator and corticosteroid
therapy
Asthma  ICS are critical in the long-term control of asthma symptoms and should be started or
Prevention restarted at discharge following the course of systemic corticosteroids
Strategy  In line with the Canadian Paediatric Society’s recommendations, the Guideline
Committee recommends a 12-week trial of a moderate daily dose of ICS (fluticasone e-
formulary) for patients presenting with first asthma exacerbation and not previously on
maintenance ICS therapy. For patients on prior ICS therapy, consider escalation in
maintenance therapy as per Canadian asthma guidelines
 Asthma education is a key part of prevention and is a fundamental element in inpatient
management. The Guideline Committee recommends that the Asthma Teaching Checklist
and Action Plan are reviewed thoroughly prior to discharge with ongoing utilization of these
resources in the community with their primary care provider.
Monitoring and Progression through the Pathway:

 Repeated clinical assessment should be conducted based on Respiratory Assessment Criteria and Bedside PEWS
criteria for monitoring
 Weaning of salbutamol is based on asthma severity
 Seek medical reassessment for patients who are worsening or whose symptoms persist despite aggressive
management
 CCRT should be consulted and the Asthma Escalation Pathway initiated for patients with severe asthma who require
salbutamol < Q1hourly and/or have increasing oxygen requirements
 Spirometry should be ordered for children ≥ 8 years old prior to discharge
o If spirometry cannot be obtained prior to discharge in the laboratory, consider bedside spirometry performed
by respiratory therapists
Discharge and Follow Up:
© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the
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Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
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Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

 The interdisciplinary team should begin discharge planning on admission

 Discharge planning involves initiation of ICS once acute management is complete, ensuring teaching has been
performed, and establishing follow up plans with an asthma action plan in place
 The Guideline Committee recommends follow up within 72 hours of discharge for reassessment of acute
symptoms
 Referral to an Outpatient Asthma Clinic is recommended for all patients discharged from hospital

PRINTABLE VERSION OF SUMMARY OF

INPATIENT ASTHMA ASSESSMENT,
MANAGEMENT, MONITORING, AND DISCHARGE
CRITERIA

© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the
electronic SharePoint version prior to use.

Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
Approved on 2017-09-29
Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

Inpatient Asthma Exacerbation Management Recommendations

History to include: Physical exam to include:
□ Time of onset of exacerbation □ Assess the severity of the exacerbation
Child ≥ 1 year presents with acute asthma exacerbation □ Potential triggers □ Vital signs and pulse oximetry
□ Severity of symptoms compared with previous exacerbations □ Level of alertness
□ Response to treatments prior to admission □ Hydration status
□ All current medications, time of last dose □ Presence of cyanosis, pallor
□ Last course of systemic steroids □ Respiratory distress
Complete Initial Assessment and Management including: □ Estimate number of asthma-related (past year/lifetime): □ Wheezing, decreased aeration
□ Office and ED visits, hospitalizations, and ICU admissions/need for intubation □ Identify complications: pneumonia, pneumothorax, and pneumomediastinum
 History and physical examination □ Assessment of persistent symptoms: use of salbutamol, nighttime symptoms, and □ Rule out upper airway obstruction (croup, foreign body, etc.)
 Administer O2 if SpO 2 < 88% exercise intolerance
□ Presence of complicating illnesses (pulmonary, cardiac)
□ Diseases aggravated by steroid therapy (diabetes, hypertension, ulcers,
psychosis
1. Use Respiratory Assessment Criteria (RAC) to determine asthma severity □ Cigarette smoke exposure (maternal, paternal, caregiver)
□ Food allergy/allergies
□ Social and environment i.e. crowding in home, exposure to irritants
2. Assign the child to most severe category in which any parameters are met
Respiratory Assessment Criteria (RAC) Respiratory Rate
3. Administer Systemic Steroid: Dexamethasone x 2 days (total) as per e-formulary Mild Moderate Severe Age Normal to Moderate Severe
 Mild/minimal work of  Moderate work of breathing per  Significant work of breathing Mild
 If unable to tolerate PO or in severe category, consider IV Methylprednisolone; reassess in 24 hours as per e- breathing per BPEWs BPEWS ( accessory muscle use, per PEWS [accessory muscle ≥1 yr - < 5 yrs ≤40 41 -59 ≥ 60
formulary (mildly increased e ffort, nasal flaring, indrawing, use, nasal flaring, indrawing, ≥5 yr - < 12 yrs 31-39 ≥40
nasal flaring, indrawing) moderately increased effort overall) grunting, head bobbing,
≤30
 Respiratory rate: normal for  Respiratory rate: moderately tracheal tugging] ≥12 yrs ≤20 21-23 ≥24
age (refer to table) increased for age (refer to table)  Respiratory rate: significantly
 Wheeze: intermittent to  Wheeze: moderate to persistent increased for age (refer to
none  No prolonged expiration table)
 No prolonged expiration  SpO2 > 88 % on supplemental  Wheeze: absent, severe
 SpO2 > 88 % on room air oxygen (audible without stethoscope)
 No difficulty speaking  No change in mental status  Aeration: decreased throughout
 No change in mental status lung fields
 Prolonged expiration
 SpO2 > 88 % on supplemental
oxygen
 Unable to speak a full senten ce
 Any change in mental status

MILD MODERATE SEVERE Caution should be exercised in managing children with the following
comorbidities:
Salbutamol: Salbutamol Salbutamol dosage: □ Congenital or acquired cardiovascular disease
□ Cystic fibrosis
 Inhaled Q4H via metered dose  Inhaled Q2H via MDI as per e-  Inhaled Q20 minutes x 3; then Q1H
□ Chronic lung disease or bronchopulmonary dysplasia
inhaler (MDI) as per e- formulary via MDI (consider nebulized) as per □ Immunodeficiency syndromes
formulary e-formulary □ Sickle Cell Disease
Reassessment: □ Multiple co-morbidities
Reassessment:  Q1H using RAC Reassessment: □ On beta blocker
 Q2H using RAC  Q30 minutes using RAC; and then
PRN The following treatments are NOT routinely recommended for asthma
management:
 MD to reassess, If receiving
□ Methylxanthines
Salbutamol Q1H x 6 hours □ Antibiotics except as needed for comorbid conditions
□ Aggressive hydration is not recommended for older children but may be
Considerations: indicated for some infants and young children
 Checking serum potassium (if □ Cardiopulmonary physical therapy
Ventolin Q1h X 6hours) □ Mucolytics
 Establishing IV access □ Sedation
 NPO status (administer D5W NS
plus 20mmol/l KCL if NPO)
 If patient continues to require < Q1H
Salbutamol: consult CCRT and refer
to Asthma Escalation Pathway for
further management

Discharge Instructions:

□ Salbutamol inhaler Q4H x 24 hours; then as needed Q4H PRN as per e-formulary
□ Initiate/resume inhaled corticosteroids (e.g. Fluticasone) for 12 weeks (in total)
Assess for discharge readiness if; as per e-formulary
□ Complete systemic steroid course (total 2 days Dexamethasone or 5 days Prednisone/
Inhaled Salbutamol is q4h x 2 Prednisolone) as per e-formulary
and □ Review Paediatric Asthma Action Plan
□ Review Asthma Teaching Checklist Patient discharged home with appropriate follow-up
Child has mild presentation based □ Review MDI spacer technique (resources provided from AboutKidsHealth)
on Respiratory Assessment □ Ensure family knows to see primary care physician within 72 hours of discharge for re-
Criteria assessment
□ Referral to SickKids Outpatient Asthma Clinic is recommended for all patient
discharged from the hospital
□ If ≥ 8 years old, spirometry to be completed (in lab or bedside); consult Respiratory
Medicine if FEV 1 <40

PRINTABLE VERSION OF ASTHMA CARE PATHWAY

© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the
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Document Scope: Hospital-wide Patient Care

Document Type: Clinical Practice Guideline
Approved on 2017-09-29
Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

3.0 Implementation and Evaluation Plan

Implementation Plan

 Education and awareness building by the Paediatric Medicine Division’s practice champions during resident/fellow
orientation, resident educational rounds, and nursing orientation/staff meetings/situational bedside teaching.
 Inpatient Medical Director to communicate updates in practice to the Division of Paediatric Medicine.
 Lead respirologists to communicate updates in practice to the Division of Respirology
 E-formulary to be updated to reflect recommended medications and dosing.

Evaluation Plan

 Compare baseline pre-implementation and post-implementation data for Paediatric Medicine:

 Number (#) of patients admitted with acute asthma exacerbations from the Emergency Department to the
Paediatric Medicine inpatient wards;
 Average length of stay of patients admitted with acute asthma exacerbations;
 # of patients admitted to Paediatric Medicine that required transfer to the PICU;
 # of patients readmitted with acute asthma exacerbations within 7 days of discharge from the hospital;
 # of patients representing to the Emergency Department within 48 hours of discharge with recurrence of
asthma symptoms;

4.0 Guideline Group and Reviewers

Guideline Group Membership:

1. Aliya Jaffer, Nurse Practitioner, Division of Paediatric Medicine

2. Iris Liu, Nurse Practitioner, Division of Paediatric Medicine
3. Dr. Sanjay Mahant, Staff Physician, Division of Paediatric Medicine
4. Dr. Laila Premji, Staff Physician, Division of Paediatric Medicine
5. Dr. Michael Weinstein, Staff Physician, Division of Paediatric Medicine
6. Dr. Padmaja Subbarao, Staff Physician, Division of Paediatric Respiratory Medicine
7. Dr. Theo Moraes, Staff Physician, Division of Paediatric Respiratory Medicine
8. Adelina Morra, Nurse Educator, Asthma Clinic & Division of Paediatric Medicine
9. Susan Balkovec, Asthma Educator, Paediatric Respiratory Medicine
10. Jas Otal, Clinical Pharmacist, Division of Paediatric Medicine
11. Andrew Joaquin, Clinical Pharmacist, Division of Paediatric Medicine
12. Gaaya Thurairajah, Nursing Team Lead, Streamlined Care Unit
© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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Next Review Date: 2018-09-29

Inpatient Management of Acute Asthma Version: 2

Exacerbation

13. Amy Sawyer, Nursing Team Lead, Streamlined Care Unit

14. Carolyn Jeffs, Nursing Team Lead, Streamlined Care Unit
15. Lynn Mack, 7BCD Quality Leader
16. Fatma A. Rajwani, PT, Quality Management

Internal reviewers:

1. Dr. Jeremy Friedman, Staff Paediatrician, Paediatric Medicine

2. Dr. Carolyn Beck, Staff Paediatrician, Paediatric Medicine

5.0 References
1. Alberta Health Services. Alberta acute childhood asthma pathway: Evidence based recommendations. 2013.
http://pert.ucalgary.ca/airways/AHS%20INPATIENT%20CARE%20PATHWAY%20(14x8.5)%202012%20v5.pdf

2. Alnaji F, Zemek R, Barrowman N, & Plint A. PRAM score as predicator of pediatric asthma hospitalization. Academic Emergency Medicine.
2014, 872-878.

3. Canadian Lung Association. Asthma action plan. 2015. https://www.lung.ca/lung-health/lung-disease/asthma/asthma-action-plan

4. Canadian Paediatric Society. Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric
Society position paper. Canadian Respiratory Journal. 2015, 22(3): 135-143.

5. Canadian Paediatric Society. Managing the paediatric patient with an acute asthma exacerbation. Paediatrics and Child Health. 2012, 17(5):
251-256.

6. Canadian Thoracic Society Asthma Clinical Assembly. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of
asthma in preschoolers, children and adults. Canadian Respiratory Journal. 2012, 19(2): 127-164.

7. Calgary Health Region. Pediatric acute asthma pathway-Inpatient care. 2008.

http://www.ucalgary.ca/icancontrolasthma/files/icancontrolasthma/inpatientpathway.pdf

8. Kenyon C, Zorc J, Dunn M, McCloskey M, et al. Inpatient asthma pathway. 2016. http://www.chop.edu/clinical-pathway/asthma-inpatient-care-
clinical-pathway

9. Pound C, Gelt V, Akiki S, et al. Nurse-driven clinical pathway for inpatient asthma: A randomized controlled trial. American Academy of
Pediatrics. 2017, 7(4): 204-213

10. National Heart, Lung, and Blood Institute (NHLBI). Guidelines for the diagnosis and management of asthma. National Institutes of Health.
2007, 1-60.

Attachments:

© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical
purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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Next Review Date: 2018-09-29

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Exacerbation

Asthma Printable Version_Oct 1_17.pdf

Asthma Escalation Pathway_September 21_2017.docx

Asthma Clinical Recommendations_Sept 25.pdf

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purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or
otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice
Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to
the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside
SickKids.

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