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Asthma_Exacerbation_Management

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					                Management of an Acute Exacerbation of Asthma

Inpatient Management
    1. Continue management initiated in ER except anticholinergics
            Continue inhaled corticosteroids to reduce severity and duration of exacerbation1
            Chest PT and incentive spirometry are specifically NOT recommended during an
               acute exacerbation as this can trigger bronchospasm2
    2. Clinical pathway- decreases length of stay, use of beta-2 agonists, nursing costs, improves
       quality of care3

    Respiratory rate                   0= normal
                                       1= tachypnea (infant > 50, child > 40, adol > 20)
    Accessory muscles                  0= normal
                                       1= suprasternal/subcostal/intercostals rtx
                                       2= neck or abdominal muscles
    Air exchange                       0= normal
                                       1= localized decreased
                                       2= multiple areas decreased
    Wheeze                             0= end expiratory or none
                                       1= entire expiration
                                       2= entire expiration and inspiration
    I:E ratio                          0= <1:2
                                       1= >1:3
    Total score:

Assessments should occur every hour if the patient is on continuous, or before scheduled treatments
If total score is 2 or more, give albuterol treatment .
If score is 0 or1, wean to next frequency
At q3h, change from nebulizer to MDI with spacer (see dosage guidelines above).

    3. IV fluids- not routinely required unless patient is dehydrated
    4. Consults (allergy or pulmonary)- consider if diagnosis is unclear, for life-threatening
       exacerbation, if patient is poorly-controlled or poorly-compliant, or if there are other
       complicating conditions4




1
  NHLBI: NIH Guidelines for the Diagnosis and Management of Asthma, 1997 (updated 2002)
2
  NHLBI: NIH Guidelines for the Diagnosis and Management of Asthma, 1997 (updated 2002)
3
  Evidence Based Clinical Practice Guideline: Managing an Acute Exacerbation of Asthma, Concinnati Children’s
Hospital Medical Center
4
  NHLBI: NIH Guidelines for the Diagnosis and Management of Asthma, 1997 (updated 2002)
Discharge Planning
    1. Patient is ready for discharge when weaned to treatments every 4 hours, O2 sat >90%
    2. Determine severity of asthma. Start patient on appropriate controller medicines as needed.

Severity5                       Symptoms: day/night                   Treatment

Step 4 (severe persistent)      Continual/frequent                    High-dose inhaled corticosteroid
                                                                      AND long-acting beta2 agonist
Step 3 (moderate                Daily/> 1 night per week              Low-to-medium dose inhaled
persistent)                                                           corticosteroid and long-acting
                                                                      beta2-agonist
                                                                      OR medium-dose ICS (for
                                                                      children < 5yo)
Step 2 (mild persistent)        >2x per week/ > 2x per month          Low-dose inhaled corticosteroid
                                                                      (nebulizer or MDI with
                                                                      mask/spacer)
Step 1 (mild intermittent       < 2x per week/ < 2x per month         No daily meds needed

    3. Go over asthma action plan with patient and family. Self-management education programs in
       children improve a wide range of outcomes6. Action plans based on peak flow (children > 6
       yo) are equivalent to those based on symptoms7. (I have several examples that we can look
       at.)
    4. Continue steroids at home to complete a 5 day course- can give once per day if preferred
       (best time to give is 3PM if giving once per day).8
    5. Follow-up with PMD in 3-5 days.




Created by:
Nancy Hillis MD, Virtua Inpatient Pediatrics




5
  NHLBI: NIH Guidelines for the Diagnosis and Management of Asthma, 1997 (updated 2002)
6
  Wolf et al. “Education interventions for asthma in children.” Cochrane Database of Systematic Reviews. 1, 2005.
7
  Powell et al. “Options for self-management education for adults with asthma.” Cochrane Database of Systematic
Reviews. 1, 2005.
8
  NHLBI: NIH Guidelines for the Diagnosis and Management of Asthma, 1997 (updated 2002)

				
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posted:11/14/2011
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