The Pediatric Page
Treating Pediatric Asthma and Bronchiolitis - April 2003
Physicians at California Pacific’s Pediatric Specialty Services have developed treatment pathways for common clinical areas. Each of these pathways are evidence-based and collaboratively developed with our hospitalists, specialists and primary care physicians, along with nursing and ancillary staff. The pathways reflect a national trend towards developing clinical guidelines in pediatrics. Following are new treatment recommendations from our recently adopted pediatric asthma and bronchiolitis pathways.
Clinical Asthma Score Indicates Severity and Treatment Path
To objectively evaluate the severity of a patient’s asthma, pediatric pulmonologists and hospitalists use the following Clinical Asthma Score. With this system, patients get assigned 0, 1 or 2 points in each category, based on their clinical severity. The point value in each row is added to generate a total asthma clinical score. The score is then used to judge a patient’s progress and response to therapy, and to help guide further treatment.
|Category||0 points||1 point||2 points|
|Inspiratory BS||Normal||Decreased||Markedly decreased|
|Accessory muscle use||Normal||Moderate||Severe|
|Wheezing during||Late expiratory phase||All expiratory phases||Inspiratory and expiratory phases|
2002 NHLBI Recommendations Incorporated in Treatment Plans
After assessing a patient’s Clinical Asthma Score, physicians begin medications, respiratory treatment, oxygenation and/or dietary interventions to improve one’s condition. The National Heart, Lung and Blood Institute’s 2002 Asthma Guidelines are incorporated when determining treatment and discharge plans. For example, for quick acute or chronic asthma relief, the guidelines recommend:
- Short-acting inhaled beta2–antagonists as needed for symptoms. Treatment intensity depends on severity of exacerbation;
- Use of short-acting beta2–antagonists >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy;
- For patients < 5 years with viral respiratory infection, use of a bronchodilator q 4-6 hours up to 24 hours and consideration of system corticosteroid if severe exacerbation
Xopenex® Nebulizer Offered as First-Line Treatment
Based on recent pediatric studies regarding the use of Xopenex in asthma, California Pacific’s pediatric hospitalist and pulmonology groups use Xopenex nebulizer as a first line of treatment instead of albuterol. The Xopenex dose is:
- Infants: 0.31 mg
- Young children: 0.63 mg
- Older children and severe asthmatics: 1.25 mg
- Marked decrease in side effects
- Decreased length of stay
- Decreased rate of admissions from ER patients
Our physicians are also looking into the use of dexamethasone in asthmatics for a two-day total course (at 0.6 mg/kg/day dose) instead of a five-day course of prednisone. Emerging literature, specifically a July 2002 article in Journal of Pediatrics by Qureshi, indicates that, in children with acute asthma, this regimen provides similar efficacy with improved compliance and fewer side effects than five doses of prednisone.
Bronchiolitis Clinical Score and Racemic Epinephrine Result in Shorter Hospital Stay
Since instituting a clinical pathway for bronchiolitis/RSV infection in 2002, California Pacific’s physicians have found that patients have shorter hospital stays and a better treatment experience in general. The new pathway includes the use of racemic ephinephrine instead of albuterol as well as airway clearance techniques and family education. Physicians also employ Bronchiolitis Clinical Scores (similar to those for asthma) to assess treatment efficacy.