Guidelines for Management of Status Asthmaticus in Children Target population: These revised guidelines are intended for the management of children > 2 years of age without underlying chronic disease. The guidelines are for inpatients on the ward, and do not include recommendations for emergency room or intensive care.
Overview: The most significant revisions to the asthma guidelines are 1) an increase in the recommended maximum doses of intermittent nebulized albuterol in the first 8-16h of care, and 2) concordance with the hospital oximetry guidelines, including criteria for weaning from supplemental oxygen. The revisions to the asthma guidelines are primarily based on the National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (February 1997, revised 6/18/97) (1). Specific published data are not available for all recommendations, but rationale or references are provided when possible. When specific data are not available, the recommendations are based on the consensus opinion of national (1) and local experts.
Revisions to the Guidelines: 1.
Repetitive or continuous administration of inhaled short-acting beta2-agonists is the most effective way to reverse airflow obstruction in asthma (1-6). The recommended maximum dose for nebulized albuterol has been increased based on limited published data (4,5) and the consensus opinion of experts (Figure 3-10 of the Expert Panel Report [1]). Albuterol doses are 0.15 to 0.3 mg/kg up to 10 mg maximum every 1-4 h as needed. The minimum dose is 2.5 mg.
2.
The revised pathway recommends albuterol dosing in mg versus cc to avoid confusion. A conversion table from cc to mg is provided in the pathway (0.5% solution = 500 mg/100 cc = 5 mg/cc). The doses will be standardized in increments of 2.5 mg.
3.
Continuous nebulized beta2-agonists are being used for both emergent and intensive care of status asthmaticus (1-4). There are limited data suggesting increased efficacy and reduced toxicity for continuous vs. high-dose intermittent albuterol therapy for severe airway obstruction (4). However, due to the safeguard of patient assessment at the time of intermittent drug administration, we currently recommend intermittent high-dose albuterol nebulization. We plan to monitor local and national experience, and the literature for the safety and efficacy of continuous nebulized therapy on pediatric wards.
4.
Adverse events to nebulized albuterol therapy may include tachycardia, tremor, asymptomatic hyperglycemia (7), and hypokalemia (6,8). The limited data available for albuterol-induced hypokalemia suggests a subset of patients (25-50%) can have a transient, asymptomatic reduction in serum potassium levels (< 3.5 meq/L). In one study using 0.3 mg/kg albuterol x 3 doses, 18/46 pts developed hypokalemia but no pts had significant symptoms or serum K+ < 2.5 meq/L (8). Therefore, nebulized albuterol may reduce serum K+ levels, but there is no evidence that short term therapy causes clinically significant hypokalemia. The prudent clinician may consider monitoring serum K+ in patients requiring high dose Albuterol for prolonged periods or patients with electrolyte losses with vomiting/diarrhea.
5.
Nebulized ipratropium bromide, a quaternary anticholinergic agent, added to repetitive or continuous albuterol dosing in children causes additional bronchodilation compared to albuterol alone (9,10). The data are from emergent care of status asthmaticus, and there are no data that inpatient use of ipratropium with albuterol effects outcome. However, based on the ER data of patients with severe airway obstruction and the consensus opinion of the Expert Panel (1), the guidelines include the option for the addition of intermittent nebulized ipratropium bromide.
6.
Oximetry use and the criteria for weaning oxygen will be per CHMC Standard Oximetry orders.
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References for Revised Asthma Guidelines 1.
National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (February 1997, revised 6/18/97). A published copy can be obtained from the NHLBI Information Center, P.O. Box 30105, Bethesda, MD, 20824-0105. There is internet access at http://www.nhlbi.nih.gov/nhlbi/lung/asthma/prof/asthgdln.htm. (230 pages).
2.
Lin RY, Sauter D, Newman T, Sirleaf J, Walters J, Tavakol M. Continuous versus intermittent albuterol nebulization in the treatment of acute asthma. Ann Emerg Med 1993; 22:1847-53.
3.
Rudnitsky GS, Eberlein RS, Schoffstall JM, Mazur JE, Spivey WH. Comparison of intermittent and continuously nebulized albuterol for treatment of asthma in an urban emergency department. Ann Emerg Med 1993; 22:1842-6.
4.
Papo MC, Frank J, Thompson AE. A prospective , randomized study of continuous versus intermittent nebulized albuterol for severe status asthmaticus in children. Crit Care Med 1993; 21:1479-1486.
5.
Schuh S, Reider MJ, Canny G, Pender E, Forbes T, Tan YK, Bailey D, Levinson H. Nebulized albuterol in acute childhood asthma: comparison of two doses. Pediatrics 1990; 86:509-13.
6.
Shrestha M, Bidadi K, Gourlay S, Hayes J. Continuous vs. intermittent albuterol, at high and low doses, in the treatment of severe acute asthma in adults. Chest 1996;110:42-47.
7.
Dawson KP, Penna AC, Manglick P. Acute asthma, salbutamol and hyperglycemia. Acta Pediatr 1995; 84: 305-7.
8.
Singhi SC, Jayashree K, Sarkar B. Hypokalemia following nebulized salbutamol in children with acute attack of bronchial asthma. J Paediatr Child Health 1996;32: 495-97.
9.
Schuh S, Johnson DW, Callahan S, Canny G, Levinson H. Efficacy of frequent nebulized ipratropium bromide added to frequent high-dose albuterol therapy in severe childhood asthma. J Pediatr 1995;126:639-45.
10. Qureshi F, Zaritsky A, Lakkis H. Efficacy of nebulized ipratropium in severely asthmatic children. Ann Emerg Med 1997; 29:205-211.
The last page of this clinical path contains an ASTHMA FOLLOW-UP AND MAINTENANCE PLAN* reference sheet.
9/11/97, Rev. 7/98 (Ron Gibson)
