Asthma » Acute Management

Date: September 2013

Guidelines Reviewed:

  1. NHLBI 2007 Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma
  2. Seattle Children.s Hospital Asthma Pathway v.2.2
  3. Group Health Asthma Diagnosis and Treatment Guideline, 2012

Topic Owner(s) and contact information:

  • Mollie Grow, MD MPH mollie.grow@seattlechildrens.org

OBJECTIVE: To guide appropriate, evidence-based treatment of acute pediatric asthma exacerbation in outpatient clinic settings Specific Objectives:

  1. To provide criteria for diagnosing and treating acute asthma exacerbation and disposition based on clinical assessment
  2. Potential measurable outcomes after initiation of guideline:
    1. Patients appropriately treated with oral steroids who meet criteria
    2. Number of ER visits for asthma among clinic patients
    3. Number of hospital admissions for asthma among clinic patients
    4. Percent of patients appropriately seen for follow-up

SUMMARY:

  1. BRIEF summary of recommendations:
    1. Recognize asthma exacerbation early and provide appropriate education and treatment before symptoms worsen and require ED or inpatient care.
      1. Reverse hypoxia with oxygen to maintain O2 sat>90%
      2. Reverse airway obstruction rapidly with short-acting beta agonist (SABA) +/- systemic steroids for more severe exacerbations
      3. Reduce short-term relapse with use of systemic steroids
    2. Use clinical exam to guide level of acuity.
    3. For mild exacerbation: use SABA (albuterol) metered dose inhaler (MDI) every 4 hours, consider short course of steroids, return to clinic if symptoms worsen or patient requiring more frequent albuterol dosing.
    4. For moderate exacerbation, use SABA + initiate oral steroids with dexamethasone (2 days; preferred) or prednisone (5 days).
    5. For severe exacerbation, initiate SABA + ipratropium, oral steroids, and follow response, refer to ED care if not responding adequately after 1 hour.
  2. Highlights of this particular pathway: NA
  3. Follow-up criteria/recommendations: f/u call within 1-2 days; f/u in-person within 2 weeks for moderate-severe, all patients should leave clinic with an asthma action plan and have clinic follow-up within 1-3 months
  1. Inclusion Criteria
    1. Ages 1-4, 5-11, 12+ to be evaluated with age-appropriate vital sign cut-points
    2. Dyspnea (tachypnea in young children) in patient with known or suspected asthma
  2. Exclusion Criteria
    1. Other acute primary respiratory diagnosis including pneumonia, croup, and/or bronchiolitis
    2. Children with other chronic disease such as CF, congenital heart or pulmonary disease, immune disorders (consult specialists)
    3. Unilateral wheeze, suggestive of foreign body aspiration
  3. Assessment
    1. Mild symptoms (dyspnea with activity only, end-expiratory wheeze, no or mild work of breathing (only intercostal/subcostal retractions), no tachycardia; equivalent to SCH Respiratory Score (RS) 1-5, or Peak Expiratory Flow (PEF) >80% )
      1. Albuterol MDI 4 puffs, observe response at 30 minutes (MDI strongly preferred, but if not available, give 2.5mg/3ml nebulized)
      2. Consider oral steroid based on patient history of asthma severity (see high risk patient criteria below) and control, and likelihood to progress to more severe symptoms
      3. If worsen or not improving, go to moderate pathway and give additional 4 puffs albuterol and then steroids
      4. D/c to home with albuterol 2-4 puffs prn and follow-up prn. Check-in phone call encouraged in 1-2 days
    2. Moderate symptoms (dyspnea at rest, interfering with usual activity, expiratory wheeze heard throughout, mild work of breathing, mild tachycardia; equivalent to RS 6-12 or PEF 50-79%1)
      1. Place pulse oximeter, provide oxygen prn to maintain SaO2 > 90%
      2. Albuterol MDI 8 puffs (consider 4 puffs for children <4 years) (MDI strongly preferred, but if not available, give 5mg/3ml nebulized)
      3. Start Dexamethasone 0.6mg/kg, max of 16mg (onset within 2 hours, peak effect at 6 hours)
      4. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity of exacerbation and history of severity. This dosing is used for patients admitted to SCH.
      5. If moderate at 1 hour, may repeat albuterol MDI 8 puffs and observe an additional hour
    3. Severe symptoms (dyspnea at rest, interfering with talking, loud inspiratory and expiratory wheezes, moderate to severe work of breathing, moderate tachycardia; equivalent to SCH RS 6-12 or PEF <501,)
      1. Call 911 for ambulance
      2. Place pulse oximeter, provide oxygen prn to maintain SaO2 > 90%
      3. 8 puffs or albuterol continuous nebulized 5mg/hour with ipratropium 0.75mg
      4. Start Dexamethasone 0.6mg/kg, max of 16mg (onset within 2 hours, peak effect at 6 hours)(see note above about prednisone dosing)
  4. Repeat assessment for moderate status
    1. Repeat assessments at minimum of 30 minutes, 1 hour to determine response to treatment and disposition
    2. If safe for discharge from clinic to home
      1. Provide second dose of dexamethasone 0.6mg/kg at 24 hours
      2. Continue albuterol MDI 2-4 puffs at home every 4 hours for 24 hours and then prn
  5. Disposition
    1. Criteria for ER:
      1. Moderate not responding to initial albuterol and steroid within 2 hours
      2. Severe at presentation
    2. Moderate symptoms clinic follow-up within 2 weeks, then within 1-3 months
    3. Mild symptoms responding to lower-dose albuterol, return within 1-3 months
    4. All patients to have an asthma action plan when leave clinic
  6. Differential Diagnoses to consider
    1. As above, must consider acute infection including pneumonia, croup, and/or bronchiolitis, and aspiration (especially in young children)
  7. Pitfalls/Things to be aware of
    1. Medications that lack evidence
      1. No indication for ipratropium in mild to moderate asthma exacerbation, only for severe disease
      2. Inhaled steroid initiation not equivalent to oral steroids in onset of action
      3. Lack of evidence for peak flow zones to guide disposition
    2. Early initiation of systemic steroids
      1. If steroids given within 1 hour of presentation for acute care, more likely to prevent admission to the hospital
      2. Dexamethasone for 2 days has been shown to be as effective as prednisone for 5 days in several studies for outpatient asthma medication dosing; this is the recommended strategy at SCH
    3. Unsafe practices
      1. Do not allow patients to take albuterol more often than every 4 hours for more than 24 hours at home without assessment
      2. Patients should call their provider and be assessed in person if they start oral steroids at home

    High-risk patients:

    • History of sudden severe exacerbations
    • Prior ICU admissions
    • Prior intubation for asthma
    • Over 12 months, 2+ admits or 3+ ED visits
    • Used > 1 albuterol canister per month
    • Chronic use of oral corticosteroids
    • Cannot sense airflow obstruction or its severity
    • Sense of danger or fright from symptoms
    • Medical comorbidity (e.g. obesity)
    • Risk for medication non-adherence: depression, high stress, socioeconomic risks, attitudes/beliefs against medication benefit

    Topic of the Week: Acute Asthma

    Mollie Grow MD MPH

    Case 1: A 4-year-old boy presents with coughing and shortness of breath

    Michael, a 4 y.o. boy with a history of eczema, comes in for an acute visit in February. He had bronchiolitis twice as an infant. He has had some eczema all his life, which is worse in winter, and his eczema has flared recently. He has had 3 days of cold symptoms and for the past 2 days, he has been coughing a lot. Today mom notices that when he is playing, he seems to be getting a little short of breath and his breathing is noisy.

    His father has hay fever, his aunt has asthma (but she lives in another state) and his grandmother smokes (she cares for him 3 days a week while mom works).

    On exam, Michael.s BMI is at the 50th percentile and he is afebrile. His respiratory rate is 24 and HR is 78. He has some nasal erythema and clear rhinorrhea. His lungs have scattered high-pitched expiratory wheezes bilaterally. He coughs a lot during the exam when he takes a deep breath. A trial of 4 puffs of albuterol in clinic results in less wheezing 30 minutes later.

    1. Does Michael have asthma? (What guidelines could be used to determine this?)
    2. What is Michael.s respiratory severity today? (What guidelines could be consulted?)
    3. How would you treat Michael today?
    4. What is your follow-up plan after today's visit?

    Case 2: A 12 year old girl with a history of asthma presenting with acute exacerbation

    Isabelle is a 12 year old with a diagnosis of asthma that has been well-controlled for the past 2 years, such that she stopped using her inhaled steroid Flovent 6 months ago. 3 days ago she got a cold and today she woke up with wheezing and shortness of breath. She felt better after 2 puffs of albuterol but she needed more albuterol 2 hours later. Mom is bringing her into the office today, as she has had exacerbations before that needed oral steroids. The last was 2 years ago.

    Her brother and father also have asthma. No one smokes at home, but she sometimes babysits for neighbors who smoke.

    On exam, Isabelle has a BMI at the 85th percentile. Her RR is 30 and HR is 102. She is coughing. She has clear rhinorrhea and partially edematous nasal turbinates. Her lung exam is notable for diffuse expiratory wheezes, mild intercostal retractions, and a prolonged expiratory phase.

    1. What is Isabelle.s respiratory severity today? (what guidelines can you consult?)
    2. What treatments will you initiate today?
    3. What education should you provide at today.s visit? (what tools can you use?)
    4. What will be your follow-up plan after today.s visit?

    Outpatient Acute Asthma Exacerbations

    Both of the case patients described have findings consistent with acute asthma. In the case of the younger child, this could be termed wheezing or reactive airway disease that may warrant an asthma diagnosis in the future if he has more wheezing episodes that are responsive to albuterol. This is covered in more detail in a separate TOW on asthma diagnosis.

    New UW/SCH outpatient guidelines are available

    • Treating asthma exacerbations can be guided by a number of resources. Most recently, our UW General Pediatric Division continuity clinics have worked together to develop outpatient clinical guidelines based on evidence and experience from other guidelines and institutions.
    • This TOW is focused on introducing the UW General Pediatrics Outpatient Acute Asthma Treatment Guideline. Please see the accompanying guidelines that consist of a flow diagram (algorithm) and accompanying text.
    • Please also refer to the complementary UW General Pediatrics Outpatient Asthma Diagnosis Guidelines.

    Treatment is guided by severity

    • The two case patients vary in severity. The younger one has a history and exam consistent with a more mild respiratory status. The older patient has a moderate (verging on severe) respiratory status. Determining severity is based on level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating the respiratory scores used at Seattle Children.s Hospital (SCH), such as in their asthma pathway.
    • See the attached UW General Pediatrics outpatient clinic guidelines for recommended treatment approaches you would use to decide on Michael.s mild asthma, Isabelle.s moderate asthma, and to treat more severe cases you might encounter in clinic.

    Education and tools should be provided

    • All patients diagnosed with asthma should have an asthma action plan, which should be reviewed during an exacerbation. This is an important teachable moment for families.
      • Many are available, see discussion in asthma diagnosis guidelines
      • SCH version online is from Nemours Health
        • http://www.seattlechildrens.org/kids-health/page.aspx?id=62137
    • Additional educational materials to consider
      • Patient handouts about asthma (one good website is Nemours Health which has English and Spanish materials www.kidshealth.org )
      • How-to. videos -see below for Boston Children.s Hospital
      • Provider talking points (see 2007 NHLBI Summary Report Figure 7)
      • Asthma assessment tools (such as the Childhood Asthma Control Test)
    • Families should receive coaching on how to administer medications through MDIs.
    • Children should use a valved holding chamber with MDI.s (VHCs or .aerochamber.) not just a "spacer".

    Follow-up should be provided

    • Patients with mild asthma can have follow-up as needed, ideally assessed by a provider (MD or RN) within 1-2 days by phone.
    • All patients with moderate to severe asthma should ideally have follow-up within two weeks after exacerbation.
    • Patients should also have a check-up scheduled to assess their asthma control within 1-3 months after an exacerbation.

    References:

    NHLBI 2007 Asthma Guidelines — full report and summary reports available
    http://www.nhlbi.nih.gov/guidelines/current.htm

    Asthma Best Practices British Medical Journal Compilation
    http://bestpractice.bmj.com/best-practice/monograph/1098/treatment/guidelines.html

    Seattle Children's Pathways — see asthma
    http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways/

    Group Health asthma guidelines based on 2007 NHLBI
    http://www.ghc.org/all-sites/guidelines/asthma.pdf

    Cincinnati Children's Hospital Guidelines (used for SCH guidelines)
    http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9199/6318985e-a921-4d93-95b7-33b6a827f9a5.pdf

    UpToDate
    Acute asthma exacerbations in children: Outpatient management
    http://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-outpatient-management

    Boston Children.s Hospital Outpatient clinic how-to videos
    http://www.childrenshospital.org/az/Site2174/mainpageS2174P0.html


    Acute Asthma Treatment Flowchart