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    Asthma Order Set/Pathway

    Initial acute: assuming not seen in ED or PMD and gotten the 3 or more treatments.

    • Generate Clinical Asthma Score (CAS) initially and after 3 treatments.

    • Give Albuterol + Atrovent by neb (Duoneb) q 20 min x 3 and reassess.

    • Give Xopenex (1.25 mg) by Neb q 20 min x 3 treatments and reassess.

    • If post RX CAS >= 7 consider ABG and PICU transfer.


    Acute phase -- Ward:
    • Admit to Ward

    • Diet: Regular vs. Clears vs. NPO

    • Activity: Bed rest vs. Ad lib

    • Diagnosis: Asthma Acute phase

    • IVF: NS ___ cc infuse over ___ hr.

      D5 1/4 ns w. 20 meq kcl at ___ cc/ hr

    • Initiate family education: Asthma teaching protocol and action plan.


    Monitoring:
    • Check height and weight on admission.

    • Check spot pulse ox on RA and then PRN to wean Oxygen.

    • Assess respiratory status and assign initial CAS and acuity level (see tables).

    • Document Peak Flows and compare to expected (for > 4 years old)

    • Log all asthma score and assessments at bedside chart

    • Assign CAS Q 2hrs by RN or RT and Q shift by MD.

    • Call H.O. if CAS increasing.


    If on intermittent treatments:
    1. Check HR, RR, pulse ox with every Rx

    2. Check PF's pre and post respiratory therapy when applicable.


    Routine vitals:
    1. Vitals: Temp, HR and RR q 4 hrs, Pulse ox q Shift, BP q AM.

    2. Daily weights

    3. Record I’s and O’s per shift


    Airway and Oxygenation:
    • O2 to keep sat over 93 % by NC or mask.

    • Wean O2 as tolerated.

    • Nasal Suction PRN for children < 2 yrs of age.


    Medications:
    Steroids: 2 mg/kg/dose load IV /IM /PO.

    Then: PO’s: 2mg/kg/day qd or BID

    Orapred (5mg/ml) ___ mg PO q___hrs

    Prednisilone (15mg/5ml) ___ mg PO Q ___ hrs


    IV: Solumedrol (1mg/kg/dose x q 6hrs) ___mg Q 6hrs.


    May use Dexamethasone IM 0.6mg x1 total dose if no PO or IV.

    Respiratory Treatments: Adjust per CAS and acuity level.

    Albuterol:
    • Via Nebulizer 1 unit dose q __ hrs and q __hrs PRN

    • Via MDI w. Spacer /Mask ___puffs q __hrs w. q __hrs PRN.


    Xopenex:
    • (Use 0.63mg sol’n for CAS<5 or 1.25 mg sol’n for CAS >= 5.)

    • Via Nebulizer: ___mg q__hrs and q __ hrs PRN.


    Suggested Frequency for nebs:
    CAS> /= 7 (Moderate to severe) Consider continuous Albuterol and PICU transfer.

    CAS = 5-6 (Moderate) consider q 2 hrs w. 1 hr PRN and wean as tolerated.

    CAS<5 hrs consider q 3-4 hrs and wean as tolerated.

    Atrovent: 1 unit dose q __ hrs
    (May use duoneb when coincide w. Albuterol treatment).

    Adjust frequency q6-8 hrs to coincide w. other treatments).

    Other Medications:
    • Continue w. home controller regimen (inhaled steroids, leukotriene inhibitors, etc).

    • Hold Serevent.

    • Inhaled steroids: asses need for as per NIH guidelines.

    • Acetaminophen: Syrup / Tabs/ supp ___mg PO/PR q 4-6 hrs PRN fever >38.5 or pain.

    • Consider Antibiotics for documented infections only.


    Diagnostic Tests:
    CXR PA and Lat vs. AP portable Urgent (consider for suspicion of pneumothorax, FB aspiration or persistent focality on exam)

    RSV rapid Ag test by NP wash urgent. (Consider for first time wheezer, less then 2 yrs old during winter season). If RSV positive change to Bronchiolitis pathway.

    Other interventions:
    Consider PEP / airway clearance techniques for: atelectasis, poor airway self clearance, inability to ambulate.

    Transition Phase:
    Medications and treatments: (please see attached sheet for MEDICAL coverage)
    Steroids: Change to PO’s when tolerated; treat for 5-7 days total.
    Nebulized Rx: Wean as tolerated
    Suggested: q 3hrs for CAS 5-6; q 4-6 hrs for CAS <5
    Albuterol: Via Nebulizer 1 unit dose q __ hrs; via MDI __puffs w, spacer mask q__ hrs
    Xopenex: (Use 0.63mg sol’n for CAS<5 or 1.25 mg sol’n for CAS >= 5.); via Nebulizer: ___mg q __hrs and q __ hrs PRN.
    Atrovent: Wean to coincide w. above
    Inhaled steroids: (initiate teaching prior to discharge)
    Vanceril MDI w. Spacer __ puffs q __ hrs
    Flovent MDI w. Spacer (__mcg) __ puffs qd / BID
    Pulmocort respules via Neb 0.5 mg qd / BID

    Monitoring:
    Assign CAS as before w. every Rx.
    Check O2 sat on RA q shift while on oxygen and then as needed.

    Diagnostic tests:
    Check CXR for persistent focal crackles or if not improving.

    Education:
    MD to develop Asthma action plan w. family in conjunction w. PMD

    Discharge:
    All patients are to go home w. Albuterol / Xopenex MDI and spacer.
    • Consider home Nebulizer for:

      1. Severe asthma (see NIH guidelines)

      2. Multiple hospitalizations / ED visits

      3. Compliance issues


    Discharge planning:
    Asses for home equipment and notify case manager

    Consults:
    Consider pulmonary - acutely if diagnosis is in doubt; as out patient as per PMD and NIH guidelines.

    Category0 points1 point2 points
    RA SPO2>94%90-94%<90%
    Inspiratory BSNormalDecreasedMarkedly decreased
    Accessory muscle useNormalModerateSevere
    Wheezing duringLate expiratory phaseAll expiratory phasesInspiratory and expiratory phases
    I:E>11:1<1
    Mental statusNormalAgitatedLethargic
    Column total:   
    Grand total:   


    Developed by:
    Pediatric Hospitalist Group
    Bay Area Pediatric Pulmonology
    Andree Hest, R.PH. MScPharm
    Oded Herbsman, M.D.
    A. Marmor, M.D.
    Karen Hardy, M.D.
    David Tejeda, M.D.