PEDIATRIC ACUTE ASTHMA SCORE (P.A.A.S.) GUIDELINES. >97% 94% to 96% 91%-93% <90% Moderate to severe expiratory wheeze

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1 Inclusion: Children experiencing acute asthma exacerbation 24 months to 18 years of age with a diagnosis of asthma Patients with a previous history of asthma (Consider differential diagnosis for infants and young children up to 24 months) Exclusion: Patients in impending respiratory failure or requiring intubation and ventilator support Diagnosis of Bronchiolitis or viral pneumonia (See Viral Bronchiolitis Pathway) Co-morbidities, cardiovascular disease, cystic fibrosis, BPD, and immunodeficiency syndrome Implement treatment protocol and monitor response to therapy: Vitals per protocol, PEFR (age dependent), continuous pulse oximetry, and level of fatigue. Use Pediatric Asthma Score to guide interventions and document response to treatment. PEDIATRIC ACUTE ASTHMA SCORE (P.A.A.S.) GUIDELINES Score PAAS Action Guide Saturation on room air Respiratory Rate 2-3 years 4-5 years 6-12 years >12 years >97% 94% to 96% 91%-93% <90% or greater 36 or greater 31 or greater 28 or greater If PAAS is: >7 and worsens by 2 or more 12 or more worsens by more than 2 within 1 hour after advancing therapy Auscultation Accessory Muscle Use Cerebral Function Normal Breath Sounds Minimal to mild wheeze Moderate to severe wheeze None Intercostal only Intercostal and sub-sternal Inspiratory and wheeze and/or diminished breath sounds Intercostal, sub-sternal and supraclavicular Unresponsive Normal Slightly decreased Lethargic Asthma Score; Normal 0-4, Mild exacerbation 5-7 Moderate exacerbation 8-11 Severe exacerbation Notify Physician If PAS had not improved by at least 2 or is 12 or more, the patient is worsening. Peak Flow (not counted in the PAAS, but can be used to assist in determining severity of the exacerbation) Severity Mild Moderate Severe Imminent Respiratory Arrest Peak Flow % predicted > 70% 40-69% 25-39% <25%

2 ACUTE MANAGEMENT GUIDELINES Initiate Therapy Initial Assessment Weaning Discharge Criteria MILD PAAS: 5-7 Initiate corticosteroids Albuterol MDI 4-8 puffs Q 20 minutes x 3 doses then Q 1-4 hours May use albuterol 2.5mg/3mL nebulizer Q 20 minutes x3 doses at physician s discretion. 1 hour continuous albuterol nebulizer at physicians discretion *ipratropium not used regularly in every asthmatic for inpatient setting, recommended for use in the ED to decrease admission rate (3 doses in 1 hr) Assess for improvement of PAAS within 2 hours of initiating If score is improving, may begin to wean sustained for 1 hour post treatment, reassess every 3-4 hours To wean, albuterol dose must be no greater than 2.5 mg. Must score a 1 in every category except oxygen saturation (may score a 2) Should stay on current therapy if the PAAS is 7-8 or if the score is >1 in any category except for oxygen saturation. If score is > 9 or 3 in any category begin Moderate Exacerbation pathway. Q4 hour albuterol x2 (per attending discretion) saturation > 90% room air x6 hours No evidence of respiratory distress PAAS of 6 or less Provided patient/ family education (MDI teaching, use of rescue versus control MDIs) Medication reconciliation Follow up appointment with primary care provider MODERATE PAAS: 8-11 Begin therapy with 2.5-5mg albuterol neb (or 4-8 puffs albuterol MDI) q1 to q2hour x3 OR initiate 10mg continuous albuterol nebulizer Initiate corticosteroids if not already given Consider magnesium sulfate for persistent symptoms Assess for transfer to a Children s Hospital or PICU for cardio-respiratory monitoring (PICU should be contacted if score is 11.) Assess for improvement of PAAS within 2 hours of initiating If score is improving, may begin to wean sustained for 1 hour post treatment, reassess every 2-3 hrs If good response, decrease dosage and frequency of albuterol to Q2-3 hrs. Reassess patient every 2 hours. sustained for 2 hours, decrease frequency to Q3-4 hrs and reassess patient every 3 hours. If poor response, increase frequency to Q1-2 hrs or initiate continuous albuterol and

3 SEVERE PAAS: No improvement in score one hour after advancing or patient condition is deteriorating saturation<90 on 40%, PCO2>42, depressed sensorium * ipratropium not used regularly in every asthmatic for inpatient setting, recommended for use in the ED to decrease admission rate (3 doses in 1 hr) Notify Physician (Admit to PICU) Initiate corticosteroids if not already given Continuous albuterol therapy and adjunct therapies (MgSO4, terbutaline) Consider High Flow, heliox therapy, CPAP/BIPAP, 100% in severe acute situations if in ED or pending transfer to Children s hospital or PICU Consider intubation, mechanical ventilation consider IV steroids if on oral Reassess patient response to treatment every 2 hours. If response improved, wean dosage back to Q4.

4 Hospital Based Medications Medication Child Dose (2-12yo) Adolescent Dose (>12yo) Inhaled Short Acting Beta-2 Agonists (SABA) Albuterol MDI 90mcg/puff 4-8 puffs every 20 minutes for 3 doses then every 1-4 hrs. as needed 4-8 puffs every 20 minutes for up to 4 hrs. then every 1-4 hrs. as needed Albuterol Nebulizer (2.5mg/3mL, 2.5mg/0.5mL) 2.5 to 5mg every 20 min for 3 doses then ever 1-4 hrs. as needed 2.5 to 5 mg every 20 minutes for 3 doses then every 1-4 hours as needed Continuous: 10mg per hour Continuous for PICU and ED: 5-10kg, 10mg per hour 10-20kg, 15mg per hour >20kg, 20mg per hour Continuous: 10mg per hour Continuous for PICU and ED: 5-10kg, 10mg per hour 10-20kg, 15mg per hour >20kg, 20mg per hour Anticholinergics (*decreased admission rate seen when 3 doses of ipratropium bromide given in ED) Ipratropium Bromide MDI (17mcg/puff) 4-8 puffs every 20 minutes as needed for the first 3 hours 8 puffs every 20 minutes as needed for the first 3 hours Ipratropium Bromide Nebulizer (500mcg/2.5mL) 500 mcg with the first 3 doses of albuterol not to exceed 1500 mcg in the first hour of treatment 500 mcg with the first 3 doses of albuterol not to exceed 1500 mcg in the first hour of treatment SABA/Anticholinergic combination Duoneb Nebulizer 3 ml every 20 minutes for 3 doses 3 ml every 20 minutes for 3 doses (0.5 ipratropium and 2.5 albuterol/3ml) Systemic Corticosteroids Prednisone (2.5/5/10/20/50 mg tablets) 60 mg daily (QD or BID) Methylprednisolone (40mg/mL IV, 125mg/2mL IV) 60 mg daily (QD or BID) Prednisolone (15mg/5mL, 10mgODT, 15mgODT) 60 mg daily (QD or BID) Dexamethasone 0.3 mg/kg once daily (max 16 mg/dose) 0.3 mg/kg once daily (max 16 mg/dose) Others Magnesium Sulfate (IV) 50mg/kg/dose (25-50mg/kg/dose)-max 2 grams-administer over 20 minutes 50mg/kg/dose (25-50mg/kg/dose)-max 2 grams-administer over 20 minutes Terbutaline Load: 10 mcg/kg over minutes Continuous: mcg/kg/min Load: 10 mcg/kg over minutes Continuous: mcg/kg/min

5 References Acute Asthma Guidelines, Cincinnati Children s Hospital Medical Center, Evidence Based care Guidelines For Management of Acute Asthma Exacerbation in Children. Guidelines 4, pages 1-35 September 16, Gorelick M, Stevens M, Schultz T., and Scribano V. Performance of a Novel Clinical Score, the Pediatric Asthma Severity Score (PASS), in the Evaluation of Acute Asthma. Academy of Emergency Medicine, Vol. 11, Issue 1, pages 10-18, January 2004 National Heart Lung and Blood Institute, Managing Exacerbation of Asthma-National Education and Prevention Program NAEPP. Expert Panel 3: guidelines for the diagnosis and management of asthma. National guidelines Clearing House October 2007 Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of Nebulized Ipratropium on the Hospitalization Rates of Children with Asthma N Eng J Med 1998; 339 (15): Methods of Calculating the Asthma Score and the Severity of Asthma From: Qureshi: N Eng J Med, Volume 339(15).October 8,

Asthma Care in the Emergency Department Clinical Practice Guideline

Asthma Care in the Emergency Department Clinical Practice Guideline Inclusion: 1) Children 2 years of age or older with a prior history of wheezing, and 2) Children less than 2 years of age with likely