Professional Documents
Culture Documents
Management of
References in parentheses ( ), Evidence strengths in [ ] (See last page for definitions)
10B
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 1 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 2 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
[4a]). The numbers needed to treat (NNT) with medicine from escaping once you have pressed
levalbuterol to prevent one hospital admission in down on the MDI canister (LocalConsensus [5]).
theses studies equals 11 and 10 respectively (Carl Spacers improve the clinical effect of inhaled
2003 [2a], Schreck 2005 [4a]). medications, especially in patients unable to use
Note: 2: Side effect reduction an MDI properly (Lavorini 2009 [5b]). The use of
Difference in the reduction of adverse events large volume spacers has been recommended for
such as tachycardia, tremor, or increase in blood any inhaled asthma drug in young children, and
pressure has not been demonstrated when as a means of reducing systemic bioavailability
equivalent doses of levalbuterol and albuterol of inhaled corticosteroids in adults and children
have been studied (Andrews 2009 [2b]). alike (Newman 2004 [5a]). One study has
The use of racemic albuterol with MDI has been demonstrated the percent difference of drug
shown to result in lower pulse rates when deposition into the lung as 4.9% to 10.9% with
compared to nebulizer (Cates 2006 [1a], Mathew 2008 spacer use compared to no spacer. This
[1b ], Deerojanawong 2005 [2b], SIGN 2008 [5a]). This represents a range of approximately 52% to 87%
may be an important consideration for children at increase in drug deposition (Vidgren 1987 [4b]).
risk for tachycardia including children with Note 2: MDIs have been shown to shorten time
congenital heart disease or known arrhythmias to discharge from the ED, to improve pulmonary
(LocalConsensus [5]). function measures, and to result in lower pulse
Note 3: Cost rates when compared to nebulizer (Cates 2006 [1a],
Given that there appears to be no safety Castro-Rodriguez 2004 [1a], Mathew 2008 [1b ],
advantage to the use of levalbuterol, and the Deerojanawong 2005 [2b], Boyd 2005 [3a],
LocalConsensus [5], SIGN 2008 [5a]).
ability to identify patients who have a differential
treatment response, the greatly increased cost of Note 3: The inhalation route for SABA
the drug would argue against its use in the administration is considered optimal.
general population. Discussion of the safety and Subcutaneous SABAs (epinephrine, terbutaline)
cost factors with parents may assist in the provide no proven advantage over inhaled
selection process (LocalConsensus [5]). medication (NAEPP 2007 [5a]). Intravenous SABAs
have not been shown to improve pulmonary
Inhalation Delivery Device Selection physiology or outcomes compared to inhaled
Devices used for the delivery of bronchodilators and routes (Travers 2001 [1a], NAEPP 2007 [5a]).
inhaled corticosteroids can be equally efficacious.
7. It is recommended that when selecting an inhalation Inhaled ipratropium bromide
delivery device that consideration be given to the 8. It is recommended that inhaled ipratropium be added
following: (Dolovich 2005 [1a], Scarfone 2002 [3b]) to SABA and corticosteroid therapies for children
device/drug availability presenting with moderate or severe acute
exacerbations or when the FEV1 is < 50% of
patient ability to use the selected device
predicted (Plotnick 2009 [1a], Rodrigo 2005 [1a], Dotson 2009
correctly [1b], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a],
device use with multiple medications Hayday 2002 [5a]) (see Table 1 Aerosolized Therapies -
cost and reimbursement drugs and dosage recommendations).
drug administration time Note 1 : Adding multiple doses (up to 3 doses)
convenience in both outpatient and inpatient of anticholinergics to SABAs appears safe,
settings improves lung function and avoids hospital
physician and patient preference. admission in 1 of 12 school-aged children with
Note 1: In children and adolescents with acute severe exacerbation (number needed to treat
asthma exacerbation, no significant difference [NNT] = 12) (Plotnick 2009 [1a]).
exists for important clinical responses such as Note 2: Although ipratropium has been shown to
time to recovery of asthma symptoms, repeat be efficacious in preventing hospitalizations for
visits, or hospital admissions when medications children with exacerbations where FEV1 is <50%
are delivered via MDI with Valved Holding of predicted, it has not been shown to provide
Chamber (VHC) or nebulizer (Mathew 2008 [1b ], significant benefit after the child is hospitalized;
Delgado 2003 [2a], Jamalvi 2006 [3a], Benito-Fernandez therefore, it is not a standard therapy to be
2004 [3a], Yilmaz 2009 [4a]). Within this guideline, a considered in the inpatient management of acute
spacer is defined as a VHC or ― delivery‖ device exacerbations (Plotnick 2009 [1a], NAEPP 2007 [5a]).
that has a one-way valve inside that prevents the
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 5 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Note 2: There is insufficient evidence regarding improvement in respiratory score and shorter ED
the use of nebulized magnesium sulfate in acute length of stay were seen when heliox was
exacerbation (Blitz 2009 [1b]). administered in moderate and severe
Epinephrine and Terbutaline exacerbation (Kim 2005 [2b]).
11. It is recommended for patients who are minimally Severe Asthma with Respiratory Distress and
responsive or responding poorly to SABA / Normal Mental Status
ipratropium / systemic corticosteroid/magnesium 13. It is recommended that multiple therapies as
sulfate therapies, or who are unable to tolerate described below be started simultaneously while
aerosol treatments, that parenteral epinephrine or either a consult from the Pediatric Intensive Care is
terbutaline be considered (NAEPP 2007 [5a]) see Table requested or transport to a higher level of care is
3 Adjunctive Therapies - drugs and dosage arranged (LocalConsensus [5]) (see Table 3 Adjunctive
recommendations). Therapies- drugs and dosage recommendations)
Heliox Administer:
12. There is insufficient evidence and lack of consensus continuous albuterol
regarding the effectiveness of heliox in acute ipratropium bromide, up to 3 doses
exacerbation of asthma to make a recommendation systemic coticosteroids
for its routine use (Rivera 2006 [2b], SIGN 2008 [5a]). (dexamethasone IM or
Note: Heliox-driven albuterol nebulization may methylprednisolone IV)
be considered for patients who have life- epinephrine IM
threatening exacerbation or who remain in severe magnesium Sulfate IV
exacerbation after intensive conventional consider terbutaline IV bolus, and infusion.
adjunctive therapy (Rodrigo 2006 [1a], Kim 2005 [2b],
NAEPP 2007 [5a]). In one small study,
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 6 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Timing of Disposition from the Emergency physical examination and respiratory score
Department explore reason/s for failure to progress (e.g.
The response to initial treatment in the ED after a period poor SABA responder, pneumonia or other
of observation is a better predictor of the need for diagnosis, suboptimal steroid dose or
hospitalization than is the severity of an exacerbation suboptimal frequency of administration)
(NAEPP 2007 [5a]). escalate plan based on assessment findings
14. It is recommended that the current severity of the treatment considerations, as indicated:
exacerbation be in the ― mild‖ range when evaluating albuterol treatments every 10 to 20 minutes
a child for discharge from ED or hospital for 3 doses or continuous albuterol
(LocalConsensus [5]) (see Attachment 3 Formal
administered over 30 minutes, and reassess
Evaluation of Severity in the ED, Attachment 4 ED chest x-ray
Management of Asthma Exacerbation Algorithm) . administer or re-administer IV steroid if
Note 1: In the ED, if initial severity is moderate greater than or equal to 12 hours since last
or severe, then the severity assessment 1 hour dose (oral or IM if cannot acquire IV
after treatment is better than initial severity access)
assessment for determining the need for hospital venous or capillary blood gas
admission as well as for predicting the need for if status is improved after treatment escalation,
ICU in patients initially assessed as severe (Kelly then reassess hourly
2004 [3a], LocalConsensus [5]). if status is not improved, discuss potential for
Note 2: In acute childhood asthma, a repeat pulse transfer to PICU or higher level of care
oximetry of < 92 to 94 % at 1 hour after treatment consider subspecialty consult.
better predicts need for hospitalization than the Decompensation
initial pulse oximetry (Kelly 2004 [3a], Wright 1997 17. It is recommended that the following care be
[3b], LocalConsensus [5]). initiated for the patient whose condition is assessed
as decompensating from a prior stabilized state: (this
Inpatient Management is not for the patient in an obvious medical
General Therapy emergency for whom a medical code needs to be
15. It is recommended, with the exception of the use of initiated): (LocalConsensus [5])
anticholinergics such as ipratropium, that usual albuterol treatments every 10 to 20 minutes for a
inpatient hospital management be viewed as a total of 3 doses or continuous albuterol over 30
continuation of any therapies initiated in the ED minutes, and reassess
including: (NAEPP 2007 [5a]) initiate the Medical Response Team (MRT) or the
aerosolized bronchodilators team responsible for immediate assessment of a
oxygen child with a change in condition
corticosteroids notify treating healthcare provider that child is
initiation and continuation of controller (anti- decompensating
inflammatory) agents assess for treatment escalation options:
continued assessment consider other adjunctive medications
intermittent assessment of oxygen saturation - epinephrine IM
FEV1 or peak expiratory flow (PEF) on - ipratropium unless previously given
admission, 15 to 20 minutes after bronchodilator - magnesium sulfate unless previously given
therapy during acute phase and daily until administer or readminister steroid if indicated
discharge (in children > 5 years of age if able to (oral, IM, or IV if available)
perform). insert IV
portable chest x-ray
Failure to Progress
16. It is recommended that the following care be prohibit eating or drinking (NPO)
initiated for patients who fail to progress after 12 consider capillary or venous blood gas
hours of care: (LocalConsensus [5]) consider subspecialty consult
notify treating healthcare provider of any child reassess after treatment escalation
that has not progressed after 12 hours of care if improved, resume hourly assessment
assessment: if not improved, transfer to PICU or higher
level of care.
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 7 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 8 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Interpreter Services Consultation: Indication for 28. It is recommended that oral albuterol not be used
considering services: for acute exacerbation (LocalConsensus [5]).
family in need of language interpretation
Therapy Cautions/Considerations
Pharmacist Consultation: Indications for 29. It is recommended that for therapies outlined in this
considering pharmacist consultation (where section, caution and consideration be used in
available) include review of the medication regimen treatment selections (LocalConsensus [5]).
of a patient admitted for asthma exacerbation
Ibuprofen: In children without known Aspirin Induced
Note: Medication regimen evaluation may
Asthma (AIA), ibuprofen may be a better choice than
include: screening for adverse drug reactions,
acetaminophen for the treatment of fever/pain in children
screening for drug interactions, ensuring
presenting with acute asthma exacerbations.
appropriate medication use and dosing,
Acetaminophen has been associated with an increased risk
appropriate route of administration, appropriate
of wheezing (Kanabar 2007 [1a], Karimi 2006 [4a]).
dosing intervals and/or comparison of the
In children with known AIA, it is prudent to counsel
medication reconciliation record with the
parents regarding the potential for cross-sensitivities to
current medication orders (Sanghera 2006 [1a],
non-steroidal anti-inflammatory drugs (NSAIDs) (Debley
Kaushal 2008 [3a]).
2005 [1a]). This patient population demonstrates less cross-
Therapies Generally NOT Recommended sensitivity to acetaminophen.
23. It is recommended that theophylline or Cross-Sensitivities: (Jenkins 2004 [1a])
aminophylline not be administered routinely in the ibuprofen < 400mg 98%
ED or hospitalized patient because they do not appear naproxen < 100mg 100%
to provide additional benefit to optimal SABA therapy diclofenac < 40mg 93%
(D'Avila 2008 [2b]) and may increase frequency of acetaminophen > 500mg 7%
adverse effects in acute exacerbation (Mitra 2009 [1a],
SIGN 2008 [5a], NAEPP 2007 [5a]). Long-Acting Beta2-Agonists
Note 3: Patients using theophylline as Epidemiological evidence suggests a link between long-
outpatients may continue on their usual doses in acting beta2-agonists (LABAs) and increases in asthma
the hospital; obtaining a therapeutic level while mortality. Concern remains that symptomatic benefit
the child is hospitalized may be considered, from treatment with LABAs might lead to
because illness can affect serum levels. underestimation of acute attack severity and long-term
Additionally, a pharmacist consult may be use could lead to tolerance to their bronchodilator
useful for review of drug interactions (NAEPP effects (Cates 2009b [1a], Cates 2009a [1a]). In addition,
2007 [5a]). recent analyses by the Food and Drug Administration
(FDA) and others concluded that use of LABAs is
24. It is recommended that antibiotics not be used
associated with an increased risk of severe worsening of
routinely for acute asthma exacerbations in the
asthma symptoms, leading to hospitalization in both
absence of an identified bacterial focus (Graham 2009
children and adults and death in some patients with
[1a], SIGN 2008 [5a], NAEPP 2007 [5a], Blasi 2007 [5b]) .
asthma (Salpeter 2010 [1a], Walters 2007 [1a], Salpeter 2006
25. It is recommended that aggressive rehydration not [1a], FDA 2010 [5]). The FDA is requiring further studies
be used routinely for acute asthma exacerbation in for safety evaluation and has concluded that although
the absence of clinical dehydration (NAEPP 2007 [5a]). these medicines play an important role in helping some
patients control asthma symptoms, their use be limited
26. It is recommended that chest physiotherapy (CPT),
to patients whose asthma cannot be controlled with
incentive spirometry, and mucolytics not be used
inhaled corticosteroids alone (FDA 2010 [5]). There is no
routinely for acute asthma exacerbations as they can
good evidence as to which subpopulation would benefit
trigger bronchospasm or worsen cough or air flow
or be harmed with use of a LABA. One recent study,
obstruction during an acute asthma attack (NAEPP
evaluating step-up therapy in children, concluded that
2007 [5a]).
response to LABA was more likely to provide a better
27. It is recommended that anxiolytic and hypnotic response compared to ICS or leukotriene-receptor
drugs not be used routinely for acute asthma antagonist (LTRA). However many children had a best
exacerbations outside of an intensive care setting, as response to ICS or LTRA step-up, highlighting the need
they may cause respiratory depression (NAEPP 2007 to regularly monitor and appropriately adjust each
[5a]).
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
child’s asthma therapy within this level of care before that problems with details associated with follow-up
further step-up (Lemanske 2010 [2a]). have been resolved prior to discharge.
Until further studies are concluded, it is suggested Recommendations for comprehensive management of
that all patients treated with LABA be individually chronic asthma can be found in the most recent update
evaluated to ensure that this is the best option for of the national asthma guideline (NAEPP 2007 [5a]).
asthma control (Cates 2009b [1a], Cates 2009a [1a]).
Such evaluation may best be performed in 30. It is recommended that planning for discharge begin
conjunction with an Asthma Specialist when the child first presents to the ED or hospital
(LocalConsensus [5]) (see Recommendation #35 for unit (LocalConsensus [5]).
evaluation of LABA use). 31. It is recommended that prior to discharge the patient
Disparities in quality of care: When treating children undergo Severity Classification of chronic asthma (see
with asthma, it is important to consider the Attachment 5 Severity Classification). This will
socioeconomic factors that might lead to avoidable support a patient-centered approach to therapy (NAEPP
hospitalizations and premature mortality (Cope 2008 [4a], 2007 [5a]). Also, Severity Classification may be useful
Gupta 2006 [4a]). Special consideration of the following to the primary care provider in identifying children
conditions assists in the provision of patient-centered, with special health care needs and facilitating care
equitable care: coordination (LocalConsensus [5]).
Medicaid-covered, minority children have worse 32. It is recommended that case or care management by
asthma status (parental report) and are less likely to trained health professionals be considered for
be using preventive, anti-inflammatory agents than patients who have poorly controlled asthma and have
white children (Ferris 2006 [4a], Lieu 2002 [4a]). recurrent visits to the ED or hospital. Care-
Children uninsured or on Medicaid have ranked management processes are tools to improve the
significantly lower on seven quality measures efficiency and quality of primary care delivery, self
including ED utilization, prescriptions from the ED, management, and have demonstrated a reduction in
and access to and use of a primary care provider ED visits (Schulte 2004 [1b], Levy 2006 [2a], Walders 2006
(Lara 2003 [2a], Knudson 2009 [4a], Wilson 2005 [4a], Ferris [2a], Griffiths 2004 [2a], Portnoy 2006 [4a], Rosen 2006 [4a],
2001 [4a]). Spiegel 2006 [4a], Wood 2006 [4a], Allcock 2009 [4b], CMSA
Black children demonstrate more likelihood to have 2010 [5]).
asthma and to experience ED visits for asthma, 33. It is recommended, before the patient is discharged
compared with otherwise comparable white children from the ED or inpatient unit, that education be
(Flores 2005 [3a], Jones 2008 [4a]).
provided that is tailored to the identified needs,
The effect of comorbid conditions and mental illness beliefs, and learning styles of the patient and family
in mothers of asthmatic children has recently been and addresses identified patient-desired outcomes
shown to impact asthma control and health services (Zorc 2005 [2a], LocalConsensus [5], Mansour 2009 [5a], SIGN
utilization related to asthma (Coughlan 2001 [1a], 2008 [5a], NAEPP 2007 [5a]).
Bartlett 2001 [3a], Belamarich 2000 [3a], Rodriguez 2002 Note 1: When usual care for asthma was
[4a], Shalowitz 2001 [4a], NAEPP 2007 [5a]) (see compared to more intensive educational programs
Recommendation #22, Consultations, Social (provided in either the ED, hospital, home or
Services). clinic), reduction in subsequent ED visits and
Discharge/Transition Preparation hospital admissions occurred in those receiving
Although this guideline is focused on the acute intensive education (Boyd 2009 [1a], Wolf 2008 [1a],
Karnick 2007 [2a], Brown 2006 [2a], Ng 2006 [2a],
management of asthma exacerbations, it is recognized
Sockrider 2006 [2a]). The most effective type,
that asthma is a chronic disease. Discharge planning is
intended to assist the transition from the acute duration or intensity of education has not been
exacerbation to chronic management, identifying factors determined (Boyd 2009 [1a], Coffman 2008 [1a], Wolf
2008 [1a], Zorc 2009 [2a]). Patient-centered, specific
within the chronic action plan that may need adjusting to
prevent future exacerbations and improve long-term education efforts may be more effective than
patient outcomes. The transition plan is expected to general or poorly targeted interventions (Canino
2008 [2a], Forbis 2002 [2b], NAEPP 2007 [5a]).
enhance the likelihood that the family, and ultimately Note 2: Asthma education plans have been
the child, will become skilled in self-management of this successfully implemented in busy EDs (Boychuk
chronic condition. Early planning is important to assure 2006 [3a], NAEPP 2007 [5a]).
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Components of education programs have not been in care and inappropriate home management
comparatively studied; however, programs that have (Garbutt 2009 [2a]).
demonstrated improvement have included the following importance and purpose of follow-up appointment –
components: (Boyd 2009 [1a], Coffman 2008 [1a], Wolf 2008 [1a]) explore action plan, evaluate patient goal attainment,
etiology, prognosis, and risk factors emphasizing identify barriers to meeting activity goals, identify
chronicity of condition potential treatment adjustments to help meet goals and
medication purpose, and when and how to use prevent future exacerbations (Zorc 2005 [2a], Zorc 2003
medications (Smith 2008 [4a]) [2a], Flores 2005 [3a]):
provision or updating of written asthma plan • schedule before discharge for hospitalized
Note: Parental attitudes toward and knowledge of patient 1 to 5 days after discharge
asthma (pathophysiology, medications, action • contact primary care provider before discharge
plans, and environmental triggers) influenced from ED
adherence to prescribed asthma medications and importance of continual and consistent care in
action plans in several studies (Jones 2002 [2a], outpatient setting, partnering with primary care
Douglas 2002 [2b], NAEPP 2007 [5a]). provider to tailor interventions toward the child’s
identification of environmental triggers for prevention goals for activity
of acute exacerbations (Lanphear 2001b [4a], Lanphear provision of Asthma Specialists resource information
2001a [4a]) (see Attachment 6 How to Control what if indicated.
Makes Your Asthma Worse) 34. It is recommended that SABAs be used at home on an
Note: Multifaceted allergen education and control as-needed basis after recovery from an acute asthma
interventions delivered in the home setting have exacerbation (Walters 2002 [1a], NAEPP 2007 [5a]). If
been shown to be effective in reducing exposures patient’s need is greater than 6 puffs every 3 to 4
to cockroach, rodent, and dust-mite allergens and hours by 24 to 48 hours after discharge provide family
associated asthma morbidity (Arshad 2007 [2a], with instruction to seek medical care (LocalConsensus
Morgan 2004 [2a], Schonberger 2004 [2a], Chan-Yeung 2002
[5]).
[2a], Custovic 2001 [2a], Finn 2000 [3a], NAEPP 2007 [5a]).
demonstration of correct use of inhaler / spacer (Hussain- 35. It is recommended that if a LABA was in use before
Rizvi 2009 [2b]) (see Attachment 7 MDI Use) admission, it be suspended during hospitalization for
demonstration of peak flow technique if sending home exacerbation and the patient be evaluated for
with peak flow meter – (for patients with moderate or continuation of therapy after discharge: (LocalConsensus
severe persistent asthma or a history of severe [5], SIGN 2008 [5a]).
exacerbations, or patients who are poor perceivers of Note 1: There is no evidence that continuing a
airflow obstruction) (see Attachment 8 Peak Flow Use) LABA during exacerbation is beneficial and
Note: Peak flow measurement can be a useful concern remains regarding harm with its
addition for severity assessment of an asthma continued use.
exacerbation and is most useful in patients with Note 2: The beneficial effects of LABA in
moderate to severe persistent asthma (McMullen 2002 combination therapy for the patients who require
[2a], Yoos 2002 [2a]). It can be used in short-term more therapy than low-dose ICS alone to control
monitoring, acute exacerbations, and daily chronic asthma need to be weighed against the potential
monitoring (Goldberg 2001 [4a], Brand 1999 [4a], NAEPP increased risk of severe exacerbations, associated
2007 [5a]). with the daily use of LABAs in some patients
home management of exacerbation or relapse (Cates 2009b [1a], Cates 2009a [1a], Nelson 2006 [2a],
including evaluation of early clinical signs and NAEPP 2007 [5a]).
symptoms of airway inflammation Consider consultation with an Asthma Specialist
Note: Beginning treatment at home may avoid for questions regarding continuation of LABA
treatment delays, prevent exacerbations from following hospital discharge (LocalConsensus [5]).
becoming severe, and also adds to patients’ sense Note 3: In February of 2010 the FDA announced
of control over their asthma. The degree of care new safety controls for LABAs as follows:
provided in the home depends on the patients’ (or ―LABAs are contraindicated without the use
parents’) abilities and experience and on the of an asthma controller medication such as
availability of emergency care (NAEPP 2007 [5a]). inhaled corticosteroid, and should not be
Accurate evaluation of symptom severity by used alone‖ (FDA 2010 [5], NAEPP 2007 [5a]).
parents and children will assist to avoid delays
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
―LABAs ought to only be used long-term in filled have been an increase in missed school and
patients whose asthma cannot be adequately work days (Qureshi 2001 [2a]). It is also believed
controlled on other asthma controller that providing medicines will result in decrease
medications‖ (FDA 2010 [5]). readmission rates (LocalConsensus [5], NAEPP 2007
― LABAs ought to only be used for the [5a]).
shortest duration of time required to achieve 38. It is recommended that patients have a written plan
control of asthma symptoms and that reflects adjustments necessary due to the current
discontinued, if possible, once asthma exacerbation and includes a stepwise approach
control is achieved‖ (FDA 2010 [5]). coordinating with the child’s plan for chronic
Note 4: Of the adjunctive therapies available, management (Zemek 2008 [1a], Bhogal 2006 [1a], NAEPP
LABAs are the preferred therapy to combine with 2007 [5a]) (see Attachment 9, Stepwise Management).
ICS in youths ≥ 12 years of age and adults (NAEPP
2007 [5a]). 39. It is recommended that every attempt be made to
Note 5: For patients ≥ 5 years of age who have schedule the follow-up appointment before the
moderate persistent asthma or asthma child is discharged from the facility. When this is
inadequately controlled on low-dose ICS, the not possible, attempt to notify the primary care
option to increase the ICS dose may be given provider of the current exacerbation event (Zorc 2005
equal weight to the option of adding LABA [2a], Zorc 2003 [2a], LocalConsensus [5], NAEPP 2007
(NAEPP 2007 [5a]). A recent study suggests that [5a]).
patients are most likely to have a differential Note: A significant number of patients from the
response to the addition of LABA to low dose Cincinnati population consider the ED their
ICS compared to increasing ICS or adding a regular source of care, and a commonly held
leukotriene receptor antagonist. However, the health belief is that the ED is the appropriate place
safety of long term use of LABA remains to seek care for a breathing problem (Mansour 2000
[2b]). Having fewer general practice contacts in
uncertain (Lemanske 2010 [2a]).
Note 6: For patients ≥ 5 years of age who have the previous year has been independently
severe persistent asthma or asthma inadequately associated with an increased risk of fatal asthma,
controlled, the combination of LABA and ICS is increasing the importance of the follow-up visit
the preferred therapy (NAEPP 2007 [5a]). either with the primary care provider or asthma
Note 7: For patients < 4 years of age, there is specialist (LocalConsensus [5], NAEPP 2007 [5a]).
insufficient evidence for use of a LABA. These Discharge readiness
drugs are not labeled for use in this age group. Ongoing assessment will provide the needed information
Consider consultation with an Asthma Specialist of the patient progression to determine the readiness for
for questions regarding this subset of asthma discharge. Discharge readiness usually includes the
patients before adding LABA therapy following:
(LocalConsensus [5], NAEPP 2007 [5a]). child stable on therapies that can be administered at
36. It is recommended that patients already on ICS home
continue ICS therapy after discharge from ED or home environment is able to safely fulfill discharge
inpatient setting. Consider initiating ICS for patients plan
with persistent asthma if not already receiving (SIGN sufficient knowledge of asthma to manage care at
2008 [5a], NAEPP 2007 [5a]). home or seek help if symptoms worsen
Note: Initiating ICS at discharge for patients not arrangements for any special medications or
already on ICS has demonstrated a decreased risk equipment required for home therapies are complete
of subsequent ED visits for patients with persistent transition plan based on admission screening is
asthma (Sin 2002 [4a], NAEPP 2007 [5a]). complete and reflects the patients continuum of care
needs
37. It is recommended, when possible, that long term
controller medications and medicines to complete follow-up care is arranged, coordinating with
exacerbation therapy are provided to the patient prior primary care provider or asthma specialist if
to discharge (Qureshi 2001 [2a], Cooper 2001 [4a]). indicated, and providers agree with plans.
Note: Prescriptions are not always filled after
discharge (Qureshi 2001 [2a], Cooper 2001 [4a]).
Outcomes demonstrated from prescriptions not
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 1
Consider a diagnosis of asthma and performing spirometry if any of these indicators is present.*
These indicators are not diagnostic by themselves, but the presence of multiple key indicators
increases the probability of a diagnosis of asthma. Spirometry is needed to establish a diagnosis of
asthma.
*Eczema, hay fever or a family history of asthma or atopic diseases are often associated with asthma, but
they are not key indicators.
(NAEPP 2007 [5a])
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 2
Other causes
Diagnosed recurrent cough not due to asthma
Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux
Adults
COPD (e.g., chronic bronchitis or emphysema)
Congestive heart failure
Pulmonary embolism
Mechanical obstruction of the airways (benign and malignant tumors)
Pulmonary infiltration with eosinophilia
Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors)
Vocal cord dysfunction
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 15 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 3
Formal Evaluation of Asthma Exacerbation Severity in ED or Urgent Care Setting
Mild Moderate Severe Subset: Respiratory
Arrest Imminent
Symptoms
Breathlessness While walking While at rest (infant: While at rest (infant: While at rest
softer, shorter cry, stops feeding)
difficulty feeding)
Can lie down Prefers sitting Sits upright
Talks in Sentences Phrases Words Cannot talk
Alertness Normal or may be Usually agitated Usually agitated Drowsy or confused
agitated
Signs
Respiratory rate Normal or increased Increased Increased, often Normal or decreased
>30/minute
Guide to rates of breathing in awake children:
Age Normal Rate
< 2 months < 60/minute
2 to 12 months < 50/minute
1 to 5 years < 40/minute
6 to 8 years < 30/minute
Use of accessory muscles; Usually not Commonly Usually Paradoxical
suprasternal retractions; thoracoabdominal
nasal flaring; abdominal movement
breathing
Wheeze Moderate, often only Loud; throughout Loud, throughout Minimal or absent
end expiratory exhalation inspiration and
exhalation or may be
absent
Pulse/minute (at initial < 100 100 to 120 > 120 Bradycardia
presentation)
Pulsus paradoxus Absent <10 mmHg May be present Often present Absence suggests
10 to 25 mmHg > 25 mmHg (adult) respiratory muscle fatigue
20 to 40 mmHg (child)
Functional Assessment
PEF (peak expiratory > 70% Approx. 40 to 69% or < 40% < 25%
flow) Response to treatment Note: PEF testing may not
Percent predicted or lasts < 2 hours be needed in very severe
percent personal best attacks
PaO2 (arterial oxygen Normal (test not > 60 mmHg (test not < 60 mmHg: possible
pressure, on room air) usually necessary) usually necessary) cyanosis
and/or
PCO2 (partial pressure of < 42 mmHg (test not < 42 mmHg (test not > 42 mmHg: possible
carbon dioxide) usually necessary) usually necessary) respiratory failure
SaO2 (oxygen saturation) > 95% 90 to 95% < 90%
(on room air)
at sea level Hypercapnia (hypoventilation) develops more easily in young children than
in adolescents and adults.
The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation
Many of these parameters have not been systematically studied, especially as they correlate with each other and thus serve only as
general guides
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a]).
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 16 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Emergency Department Management of Asthma Exacerbations – Algorithm Attachment 4
Initial Assessment: Brief History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, pulse
oximetry), PEF or FEV1 (if performed), or Asthma score, oxygen saturation, and other tests as indicated
Mild: see Attachment 3 for Moderate: see Attachment 3 Severe: see Attachment 3 for Respiratory Arrest or Impending
details of signs and for details of signs and details of signs and symptoms: Respiratory Failure:
symptoms: symptoms: Speaks in phrases see Attachment 3 for details of
Speaks in sentences Speaks in words Wheeze loud (throughout signs and symptoms:
Wheeze mild to moderate Wheeze loud (throughout inhalation or exhalation) or Cannot speak
(end expiratory) exhalation) absent Wheeze absent
Repeat Assessment: Symptoms, physical examination, Asthma Score or PEF, FEV1 (if performed), oxygen saturation, other tests as
indicated
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 17 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 5
Severity Classification
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 18 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 5
Severity Classification (continued)
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 19 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (NAEPP 2007 [5a]).
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 20 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
How to Control What Makes Your Asthma Worse (continued) Attachment 6
You can help prevent asthma episodes by staying away from things that make your asthma worse. This guide suggests
many ways to help you do this. You need to find out what makes your asthma worse. Some things that make asthma
Indoor
worse forMold
some people are not a problem for others. You do not need to do all of the things listed in this guide. Look
Fix leaking
at the things listed faucets,
below andpipes
put a or othernext
check sources
to theofones
water.
that you know make your asthma worse, particularly if you
Clean
are allergic moldy
to those surfaces.
things. Then decide with your doctor what steps you will take. Start with the things in your
bedroomDehumidify basements,
that bother your asthma.ifTry
possible.
something simple first.
VacuumSmoke
Tobacco Cleaning
Try�toIfget
yousomeone
smoke, else to vacuum
ask your doctorfor
foryou
waysonce or twice
to help a week
you quit. Ask family members to quit smoking, too.
If able:
� Do not allow smoking in your home, car, or around you.
� BeStay
sureout
no of rooms
one smokeswhile
at athey are being
child’s daycarevacuumed
center orand for a short while afterward.
school.
If unable:
Smoke, Strong Odors, and Sprays
Use a dust mask (from a hardware store), a central cleaner with a collecting bag outside the home, or a
� If possible, do not use a wood-burning stove, kerosene heater, fireplace, unvented gas stove, or heater.
vacuum cleaner with a HEPA filter or a double-layered bag.
� Try to stay away from strong odors and sprays, such as perfume, talcum powder, hair spray, paints, new
Pollen carpet,
and Outdoor Mold
or particle board.
During your allergy season (when pollen or mold spore counts are high)
Dust Mites
� Try to keep your windows closed.
Many people who have asthma are allergic to dust mites. Dust mites are like tiny ―bug s‖ you cannot see that live in
� If possible, stay indoors with windows closed during the midday and afternoon. Pollen and some mold spore
cloth or carpet. Things that will help the most:
counts are highest at that time.
� Encase your mattress in a special dust mite proof cover.
� Ask your doctor whether you need to take or increase anti-inflammatory medicine before your allergy season
� Encase your pillow in a special dust mite-proof cover or wash the pillow each week in hot water. Water must
starts.
be hotter than 130 °F to kill the mites. Cooler water used with detergent and bleach can also be effective.
Exercise or Sports
� Wash the sheets and blankets on your bed each week in hot water. (NAEPP 2007 [5a])
� You should be able to be active without symptoms. See your doctor if you have asthma symptoms when you
are active—such as when you exercise, do sports, play, or work hard.
Cockroaches
� Ask with
Many people your asthma
doctor about takingtomedicine
are allergic the driedbefore you exercise
droppings to prevent
and remains symptoms.
of cockroaches.
Warm
��Keep all up forout
food a period
of yourbefore you exercise.
bedroom.
Check
��Keep foodtheand
air garbage
quality index and containers
in closed try not to work
(neverorleave
play hard
food outside
out). when the air pollution or pollen levels (if
�you
Useare allergic
poison to powders,
baits, the pollen) are or
gels, high.
paste (for example, boric acid) to eliminate cockroaches.
You can also use traps.
Seasonal Exposures
� If a spray is used to kill roaches, stay out of the room until the odor goes away.
Maintain good hand-washing habits
Avoid
Other things exposure
that can help:to crowds during high viral seasons, as much as is possible
Discuss
� Reduce with your
indoor healthcare
humidity provide
to or below 60 the benefits
percent; of a 30–50
ideally seasonal influenza
percent. vaccine
Dehumidifiers or central air
conditioners can do this.
Other Try not That
� Things to sleep
Can or Make
lie on cloth-covered
Asthma Worse cushions or furniture.
Sulfitescarpets
��Remove in foods: Doyour
from not drink beerand
bedroom or wine
thoseorlaid
eaton
shrimp, driedif fruit,
concrete, or processed potatoes if they cause
you can.
�asthma symptoms.
Keep stuffed toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and
Cold air:
�bleach. Covertoys
Placing your nose and
weekly in amouth with
dryer or a scarf
freezer onhelp.
may cold Prolonged
or windy days.
exposure to dry heat or freezing can kill
Otherbut
�mites medicines: Tell your doctor
does not remove allergen. about all the medicines you may take. Include cold medicines, aspirin,
herbal or alternative medicines, and even eye drops.
Animal Dander
Some people are allergic to the flakes of skin or dried saliva from animals.
The best thing to do:
� Keep animals with fur or hair out of your home.
If you can’t keep the pet outdoors, then:
� Keep the pet out of your bedroom, and keep the bedroom door closed.
� Remove carpets and furniture covered with cloth from your home. If that is not possible, keep the pet out
of the rooms where these are.
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (NAEPP 2007 [5a]).
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 21 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 7
How to Use Your Metered-Dose Inhaler
Using an inhaler seems simple, but most people do not use it the right way. When an inhaler is used the wrong
way, less medicine gets to the lungs. Use of a holding chamber/spacer increases reliability of drug effectiveness,
especially when inhalers are not used correctly.
For the next few days, read these steps aloud as you do them or ask someone to read them to you. Ask your
primary care provider to check how well you/your child are using the inhaler.
Use the inhaler in the way pictured below.
Clean your inhaler as needed, and know when to replace your inhaler. For instructions, read the package insert or
talk to your primary care provider or pharmacist. It is important to refill your prescription before the medicine
runs out or the inhaler expires to ensure medicine is available when needed.
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (Roller 2007 [4a], LocalConsensus [5], NAEPP 2007 [5a]).
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 22 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 8
Peak Flow Use
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 23 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 8
Peak Flow Use (continued)
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 24 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 9
Stepwise Approaching to Managing Asthma in Children 0 to 4 years of age
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 25 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Attachment 9
Stepwise Approaching to Managing Asthma in Children 5 to 11 years of age
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 26 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
the title, abstract, and indexing terms. The citations were reduced
Members of Asthma Team 2010 by: eliminating duplicates, review articles, non-English articles,
and adult articles. The resulting abstracts were reviewed by a
Community Physicians methodologist to eliminate low quality and irrelevant citations.
Scott Callahan, MD, Co-Chair (General Pediatrics) During the course of the guideline development, additional clinical
William DeBuys, MD (General Pediatrics) questions were generated and subjected to the search process, and
CCHMC Physicians some relevant review articles were identified. September, 2002 was
Carolyn Kercsmar, MD, Co-Chair (Allergy and Pulmonary the last date for which literature was reviewed for the previous
Medicine) version of this guideline. The details of that review strategy are
Jeffrey Simmons, MD, Methodologist (General Pediatrics) documented and maintained in an asthma literature binder.
*Michele Lierl, MD (Allergy and Pulmonary Medicine) However, all previous citations were reviewed for appropriateness
Craig Gosdin, MD (General Pediatrics) to this revision. Any new literature encountered for this October,
Laurie Johnson, MD (Emergency Medicine) 2010 version was reviewed by two or more team members and then
Sue Poynter, MD (Critical Care Medicine) discussed as a team.
Rajit Basu, MD (Critical Care Medicine)
Experience with the implementation of earlier publications of this
Residents guideline has provided learnings which have been incorporated into
Angela Statile, MD (Chief Resident) this revision.
Corrine Bria, MD (Chief Resident)
Nursing Once the guideline has been in place for five years, a team
Sue Wieser, RN reconvenes to explore the continued validity of the guideline. This
Lisa Crosby, RN phase can be initiated at any point that evidence indicates a critical
change is needed.
Pharmacy
Bradley McCrory, PharmD The guideline was externally appraised by three reviewers using the
Michelle Caruso, PharmD, BCPS AGREE instrument and the results by domain are:
Respiratory Therapy • Scope and Purpose 100%
Edward Conway, RRT (Certified Asthma Educator) • Stakeholder Involvement 86%
Lisa Devoto, RN, RT, CPN (Certified Asthma Educator) • Rigor of Development 92%
Rachel Keller, RRT, RPFT (Certified Asthma Educator) • Clarity and Presentation 97%
• Applicability 74%
James M. Anderson Center (AC) - Support • Editorial Independence 72%
*Eloise Clark, MPH, MBA (Lead Program Administrator)
*Wendy Gerhardt, MSN, RN-BC (Program Administrator) Recommendations have been formulated by a consensus process
Danette Stanko-Lopp, MA, MPH (Epidemiologist) directed by best evidence, patient and family preference and
Karen Vonderhaar, RN, MSN (Program Administrator) clinical expertise. During formulation of these recommendations,
Ad hoc Advisors the team members have remained cognizant of controversies and
Lorie Ferenzi, (Allergy and Pulmonary Medicine) disagreements over the management of these patients. They have
*Richard Ruddy, MD (Director, Emergency Medicine) tried to resolve controversial issues by consensus where possible
*Amal Assa'ad, MD (Allergy) and, when not possible, to offer optional approaches to care in the
Karen McDowell, MD (Pulmonary Medicine) form of information that includes best supporting evidence of
Christopher J Cates, Division of Population Hlth Sci and Educ, St. efficacy for alternative choices.
George’s, U of London, UK The guideline has been reviewed and approved by clinical experts
Annie Lintzenich, MD, Gen Peds, Med U of SC not involved in the development process, distributed to senior
Ronald J Teufel II, MD, MSCR, Pediatrics/Internal Medicine, Gen management, and other parties as appropriate to their intended
Peds Hospital Section, Med U of SC purposes.
*Member of 2002 Development Team The guideline was developed without external funding. All Team
Members and AC Support staff listed, have declared whether they
have any conflict of interest and none were identified.
Development Process
Copies of this Evidence-based Care Guideline (EBCG) and any
available implementation tools are available online and may be
The process by which this guideline was developed is documented in distributed by any organization for the global purpose of improving
the Guideline Development Process Manual; relevant development child health outcomes. Website address:
materials are kept electronically. The recommendations contained in http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-
this guideline were formulated by an interdisciplinary working group based/default.htm
which performed systematic search and critical appraisal of the Examples of approved uses of the EBCG include the following:
literature, using the Table of Evidence Levels described following the • copies may be provided to anyone involved in the organization’s
references, and examined current local clinical practices. process for developing and implementing evidence-based care
To select evidence for critical appraisal for this guideline, the guidelines;
Medline, EmBase and the Cochrane databases were searched for • hyperlinks to the CCHMC website may be placed on the
dates of January, 2002 to November, 2009 to generate an unrefined, organization’s website;
―combined evidence‖ database using a search strategy focused on • the EBCG may be adopted or adapted for use within the
answering clinical questions relevant to acute exacerbation of organization, provided that CCHMC receives appropriate
asthma and employing a combination of Boolean searching on attribution on all written or electronic documents; and
human-indexed thesaurus terms (MeSH headings using an OVID • copies may be provided to patients and the clinicians who manage
Medline interface) and ― natural language‖ searching on words in their care.
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 27 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 28 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
12. Bhogal, S.; Zemek, R.; and Ducharme, F. M.: Written
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus
process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
1. Grade of the Body of Evidence (see note above)
2. Safety / Harm
3. Health benefit to patient (direct benefit)
4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
5. Cost-effectiveness to healthcare system (balance of cost / savings of resources, staff time, and supplies based on published studies or
onsite analysis)
6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention,
comparison, outcome])
7. Impact on morbidity/mortality or quality of life
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