Emergency Department Asthma Pathway Incorporating Heliox Driven Albuterol Nebulization

Children’s Hospital Emergency Department Asthma Pathway Guidelines

Clinical Asthma Score (1): for patients 1 year old and greater

Assigning an asthma score using above criteria is to be conducted before AND after each intervention by the Physician, RN, or RT caring for the patient and documented on the respiratory order sheet.

Practice Guideline Considerations for patients 1 year and older: 

Mild:             Asthma score 0-3: Recommend:

• Albuterol 4-8 puffs metered dose inhaler (MDI) with spacer (See MDI dosing on

    respiratory order sheet) or albuterol nebulization x 1

• Consider Prednisone/Prednisolone PO 2 mg/kg (max 60 mg) or Dexamethasone

    0.6mg/kg (max 16 mg) PO x 1

Moderate:    Asthma score 4-7: Recommend:

• Albuterol hour long nebulization (See dosing on respiratory order sheet) with ipratropium bromide. Reassess after nebulization and may require 2^nd hour long albuterol nebulization
• Prednisone/Prednisolone PO 2 mg/kg (max 60 mg)

Severe:        Asthma score 8-10: Recommend:

• Albuterol hour long nebulization (See dosing on respiratory order sheet) with ipratropium bromide. Reassess after nebulization and likely will require 2^nd hour long albuterol nebulization
• Prednisone/Prednisolone PO 2 mg/kg (max 60 mg) or methylprednisonlone IV (same

    dose)

Consider adjunctive therapies:

• Magnesium sulfate 50 mg/kg IV (max 2 grams) over 20 minutes (max rate 150

    mg/minute) AND/OR

• 70% helium: 30% oxygen (Heliox) driven continuous albuterol nebulization AND/OR
• Terbutaline SQ/IV 10 mcgm/kg loading dose (max 0.3 mg, IV over 20 minutes) followed

    by continuous IV infusion of 0.5 mcgm/kg/min. Titrate upwards every 20 minutes until

    clinical improvement noted maximum 6 mcgm.kg/min. Monitor BPs (diastolics).Optimize

    intravascular volume status with NSS IVF bolus 20 mL/kg.

• Consider PICU admission if no improvement with the above interventions

Extremely Severe (Life Threatening):        Asthma score 11-12: Recommend:

• Albuterol hour long nebulization (See dosing on respiratory order sheet) with ipratropium bromide nebulized. Reassess after nebulization and likely will require large volume albuterol nebulization for several hours.
• Methylprednisolone IV 2 mg/kg (max 60 mg), NPO
• Consider rapid escalation to adjunctive therapies:
• 70% helium: 30% oxygen (Heliox) driven continuous albuterol nebulization AND/OR
• Magnesium sulfate 50 mg/kg IV (max 2 grams) over 20 minutes (max rate 150

    mg/minute) AND/OR

• Terbutaline SQ/IV 10 mcgm/kg loading dose (max 0.3 mg, IV over 20 minutes) followed

    by continuous IV infusion of 0.5 mcgm/kg/min. Titrate upwards every 20 minutes until

    clinical improvement noted maximum 6 mcgm.kg/min. Monitor BPs (diastolics).Optimize

    intravascular volume status with NSS IVF bolus 20 mL/kg.

• Consider PICU admission if no improvement with the above interventions

i This clinical guideline is a collaborative care plan and is not intended to be construed or to serve as a standard of medical care. Rather, it is intended to serve as a guideline and promote coordination and communication with respect to patient care and may be modified to meet individual care needs.