Guideline for Managing Asthma Exacerbations in Children

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 1 of 36
Health Policy & Clinical Effectiveness Program
Evidence-Based Care Guideline
Management of
acute exacerbation of
ASTHMA
in children
Revision Publication Date: September 16, 2010
Revision Publication Date: September 3, 2002
Original Publication Date: July 20, 1998
Please cite as:
Acute Asthma Guideline, Cincinnati Children's Hospital
Medical Center: Evidence-based care guideline for management of
acute asthma exacerbation in children Asthma Exacerbation in
Children Pediatric Evidence Based Care Guidelines, Cincinnati
Children's Hospital Medical Center, Guideline 4, pages 1-35,
September 16, 2010
Target Population
Inclusion:
Children experiencing an acute asthma exacerbation:
up to 18 years of age with diagnosed asthma or high
probability of asthma presentation
0 to 12 months: accurate diagnosis of asthma in
this age range is difficult (see Attachment 1 Key
Indicators and Attachment 2 Differential
Diagnosis)
Exclusion: Children:
admitted to the intensive care unit (ICU)
who require intubation, ventilator support or are in
impending respiratory arrest
with bronchiolitis or conditions characterized by non-
bronchodilator-responsive wheezing
Exercise caution in managing children with comorbid
conditions such as:
congenital or acquired cardiovascular disease
cystic fibrosis
chronic lung disease or bronchopulmonary dysplasia
immunodeficiency syndromes
Target Users
Include, but are not limited to:
Patient care staff, nurses, pharmacists, respiratory
therapists
Physicians, residents
Primary care providers, physician assistants
9BIntroduction
10BReferences in parentheses ( ), Evidence strengths in [ ] (See last page for definitions)
Asthma is a disease of the respiratory tract
characterized by recurrent and/or chronic episodes of
airway inflammation and obstruction (manifested by
wheeze or cough, or demonstrated upon pulmonary
function testing) and evidence of reversibility of
obstruction.
Despite advances in the understanding of asthma and
development of effective medical interventions to
prevent morbidity and improve quality of life, asthma
remains a burden in prevalence, health care use and
mortality. There are significant ethnic and racial
disparities in asthma outcomes (Lai 2009 [4a], Ginde 2008
[4a], Jones 2008 [4a], Ferris 2006 [4a], Gupta 2006 [4a],
McDaniel 2006 [4a], Wilson 2005 [4a]) (see Section:
Disparities in Quality Care).
Prevalence in children continues to show an increasing
trend with reported rates between 8.5% and 8.9%
(Akinbami 2009 [4a], Kamble 2009 [4a], MMWR Moorman 2007
[4a]). Asthma is most prevalent in children 5 to 14 years
and in Puerto Rican and African-American children.
Among children younger than 18 years of age, asthma
is more prevalent in males (Akinbami 2009 [4a], MMWR
Moorman 2007 [4a]). The rate of asthma deaths among
children has declined from 1999 onward (Akinbami 2009
[4a], WorldHealthOrganizationWritingGroup 2006 [5a]).
Although this guideline is focused on the management
of the acute exacerbation in the emergency department
(ED) and inpatient settings (excluding the ICU), it is
recognized that asthma is a chronic inflammatory
disease and requires a safe transition of care to the
chronic care provider upon discharge.
The objectives of the guideline are to:
resolve the acute episode providing appropriate
therapies and decreasing the use of unnecessary
therapies
decrease risk of readmission to the ED or inpatient
unit
initiate or update chronic care management plan and
provide a discharge patient management plan
provide formal care transition to chronic care
provider
maintain and improve family satisfaction

Guideline Recommendations
Emergency Department Management
Initial History and Physical
1. It is recommended that before and as therapy is
initiated, a brief, focused history and physical
examination is obtained, including: (LocalConsensus [5],
NAEPP 2007 [5a])
time of onset of current exacerbation
current medications and allergies
recent frequent use of beta2-agonists
risk factors for severe, uncontrolled disease (e.g.
ED visits, admissions to the hospital and ICU,
and prior intubations)
exposure to asthma triggers
use of peak flow with home management
respiratory score.
Note 1: Indications of more severe exacerbation
include increased anxiety, decreased level of
consciousness, breathlessness, diffuse wheezing
or absence of air movement, increased
respiratory rate, and accessory muscle use or
suprasternal retractions (see Attachment 3
Formal Evaluation of Severity in the ED,
Attachment 4 ED Management of Asthma
Exacerbation Algorithm and Recommendation
#13 for severe asthma with respiratory distress).
Note 2: Perform a more detailed history and
physical assessment only after therapy has begun
(NAEPP 2007 [5a], Camargo 2009 [5b]).
Note 3: Patient and parental reports of
medication use, peak flow values and/or
environmental irritant/allergen exposure often
present a more favorable description of their
disease management than is actual (Dell 2007 [2a],
Kamps 2001 [2b], Bender 2000 [3b], Rich 2000 [3b],
Dozier 2006 [4a], Halterman 2003 [4a], NAEPP 2007
[5a]).
2. It is recommended that repeat assessments of
response to therapy be conducted, including clinical
examination, asthma score, pulse oximetry, and lung
function. In children with exacerbation, no single
assessment tool appears to be best for assessing
severity, treatment monitoring, or predicting
admission; therefore, use of one tool may not be
reliable (Sole 1999 [2a], Ribeiro de Andrade 2007 [3a], Keahey
2002 [3a], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007
[5a]).
3. It is recommended that forced expiratory volume in 1
second (FEV1) or peak flow monitoring be attempted
in children over 5 years with mild to moderate
exacerbations and who currently perform peak flow
with home management (NAEPP 2007 [5a], Camargo 2009
[5b]).
Note: Pulmonary function measurements,
although often difficult to obtain in children, are
useful in assessing the severity of an asthma
exacerbation (Gorelick 2004 [3a]). If able to obtain,
and measurement is < 40% of predicted (or
personal best), consider adjunct therapies or
admission (NAEPP 2007 [5a]).
Initial Treatment
Oxygen
4. It is recommended that supplemental oxygen be
started and monitored when the oxygen saturation is
consistently less than 91% and to wean oxygen when
saturation is higher than 94% (Geelhoed 1994 [3a], SIGN
2008 [5a], NAEPP 2007 [5a]).
Short-acting inhaled beta2-agonists
5. It is recommended that racemic albuterol, an inhaled
short-acting beta2-agonist (SABA) be administered as
the drug of choice for rapid reversal of airflow
obstruction (NAEPP 2007 [5a], Camargo 2009 [5b]).
Modify therapy based on the early clinical response
to treatments (SIGN 2008 [5a], NAEPP 2007 [5a], Camargo
2009 [5b]) (see Table 1 Aerosolized Therapies –drugs
and dosage recommendations).
Note: Albuterol treatments given every 10 to 20
minutes for a total of 3 doses can be given safely
as initial therapy (LocalConsensus [5], SIGN 2008 [5a],
NAEPP 2007 [5a]).
6. It is recommended that levalbuterol not be routinely
used in the treatment of acute exacerbation
(LocalConsensus [5]).
Confusion exists regarding the selection of albuterol
versus levalbuterol in the treatment of acute asthma.
Although levalbuterol may prove more efficacious
for some individuals, there is currently no data on
how to identify these patients (Jalba 2008 [1b]). The
following information may assist in the decision to
choose:
Note 1: Efficacy
Levalbuterol has demonstrated comparable
efficacy to albuterol for treatment of acute
exacerbations in the ED and inpatient settings
(Gupta 2007 [1b], Ralston 2005 [2a], Carl 2003 [2a],
Andrews 2009 [2b], Hardasmalani 2005 [2b], Qureshi 2005
[3a]). A large double-blind prospective trial
demonstrated a 10% reduction in hospital
admissions with the use of levalbuterol (Carl 2003
[2a]) and a retrospective review of consecutive
cases demonstrated a 4.5% reduction (Schreck 2005

[4a]). The numbers needed to treat (NNT) with
levalbuterol to prevent one hospital admission in
theses studies equals 11 and 10 respectively (Carl
2003 [2a], Schreck 2005 [4a]).
Note: 2: Side effect reduction
Difference in the reduction of adverse events
such as tachycardia, tremor, or increase in blood
pressure has not been demonstrated when
equivalent doses of levalbuterol and albuterol
have been studied (Andrews 2009 [2b]).
The use of racemic albuterol with MDI has been
shown to result in lower pulse rates when
compared to nebulizer (Cates 2006 [1a], Mathew 2008
[1b ], Deerojanawong 2005 [2b], SIGN 2008 [5a]). This
may be an important consideration for children at
risk for tachycardia including children with
congenital heart disease or known arrhythmias
(LocalConsensus [5]).
Note 3: Cost
Given that there appears to be no safety
advantage to the use of levalbuterol, and the
ability to identify patients who have a differential
treatment response, the greatly increased cost of
the drug would argue against its use in the
general population. Discussion of the safety and
cost factors with parents may assist in the
selection process (LocalConsensus [5]).
Inhalation Delivery Device Selection
Devices used for the delivery of bronchodilators and
inhaled corticosteroids can be equally efficacious.
7. It is recommended that when selecting an inhalation
delivery device that consideration be given to the
following: (Dolovich 2005 [1a], Scarfone 2002 [3b])
device/drug availability
patient ability to use the selected device
correctly
device use with multiple medications
cost and reimbursement
drug administration time
convenience in both outpatient and inpatient
settings
physician and patient preference.
Note 1: In children and adolescents with acute
asthma exacerbation, no significant difference
exists for important clinical responses such as
time to recovery of asthma symptoms, repeat
visits, or hospital admissions when medications
are delivered via MDI with Valved Holding
Chamber (VHC) or nebulizer (Mathew 2008 [1b ],
Delgado 2003 [2a], Jamalvi 2006 [3a], Benito-Fernandez
2004 [3a], Yilmaz 2009 [4a]). Within this guideline, a
spacer is defined as a VHC or ―delivery‖ device
that has a one-way valve inside that prevents the
medicine from escaping once you have pressed
down on the MDI canister (LocalConsensus [5]).
Spacers improve the clinical effect of inhaled
medications, especially in patients unable to use
an MDI properly (Lavorini 2009 [5b]). The use of
large volume spacers has been recommended for
any inhaled asthma drug in young children, and
as a means of reducing systemic bioavailability
of inhaled corticosteroids in adults and children
alike (Newman 2004 [5a]). One study has
demonstrated the percent difference of drug
deposition into the lung as 4.9% to 10.9% with
spacer use compared to no spacer. This
represents a range of approximately 52% to 87%
increase in drug deposition (Vidgren 1987 [4b]).
Note 2: MDIs have been shown to shorten time
to discharge from the ED, to improve pulmonary
function measures, and to result in lower pulse
rates when compared to nebulizer (Cates 2006 [1a],
Castro-Rodriguez 2004 [1a], Mathew 2008 [1b ],
Deerojanawong 2005 [2b], Boyd 2005 [3a],
LocalConsensus [5], SIGN 2008 [5a]).
Note 3: The inhalation route for SABA
administration is considered optimal.
Subcutaneous SABAs (epinephrine, terbutaline)
provide no proven advantage over inhaled
medication (NAEPP 2007 [5a]). Intravenous SABAs
have not been shown to improve pulmonary
physiology or outcomes compared to inhaled
routes (Travers 2001 [1a], NAEPP 2007 [5a]).
Inhaled ipratropium bromide
8. It is recommended that inhaled ipratropium be added
to SABA and corticosteroid therapies for children
presenting with moderate or severe acute
exacerbations or when the FEV1 is < 50% of
predicted (Plotnick 2009 [1a], Rodrigo 2005 [1a], Dotson 2009
[1b], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a],
Hayday 2002 [5a]) (see Table 1 Aerosolized Therapies -
drugs and dosage recommendations).
Note 1 : Adding multiple doses (up to 3 doses)
of anticholinergics to SABAs appears safe,
improves lung function and avoids hospital
admission in 1 of 12 school-aged children with
severe exacerbation (number needed to treat
[NNT] = 12) (Plotnick 2009 [1a]).
Note 2: Although ipratropium has been shown to
be efficacious in preventing hospitalizations for
children with exacerbations where FEV1 is <50%
of predicted, it has not been shown to provide
significant benefit after the child is hospitalized;
therefore, it is not a standard therapy to be
considered in the inpatient management of acute
exacerbations (Plotnick 2009 [1a], NAEPP 2007 [5a]).

Table 1: Aerosolized Therapies - Drugs and Dosage Recommendations
Aerosolized Therapies
Medication
(formulation)
Child Dose* Adolescent Dose Notes
Inhaled Short-Acting Beta2-Agonists (SABA)
Albuterol
Nebulizer solution
(2.5 mg/3mL,
5 mg/mL)
2.5 to 5 mg every 20 minutes for
3 doses, then 2.5 to 5 mg every
1 to 4 hours as needed
0.5 mg/kg/hour by continuous
nebulization
< 30 kg: 2.5 mg
≥ 30 kg: 5 mg
2.5 to 5 mg every 20
minutes for 3 doses,
then 2.5 to 10 mg
every 1 to 4 hours as
needed,
or 10 to 15 mg/hour
continuously
For optimal delivery, dilute aerosols to
minimum of 3 mL at gas flow of 6 to 8
L/min. Use large volume nebulizers for
continuous administration. May mix
with ipratropium nebulizer solution.
MDI
(90 mcg/puff)
6 puffs (range: 4 to 8 puffs)
every 20 minutes for 3 doses,
then every 1 to 4 hours as needed
6 puffs (range: 4 to 8 puffs)
every 20 minutes up to 4
hours, then every 1 to 4
hours as needed
In mild to moderate exacerbations,
MDI plus VHC (see recommendation
7) is as effective as nebulized therapy
with appropriate administration
technique. Add mask in children
unable to manage an MDI device.
Levalbuterol
(R-albuterol)
Nebulizer solution
(0.31mg/3 mL,
0.63 mg/3 mL,
1.25 mg/0.5mL,
1.25 mg/3 mL)
0.075 mg/kg (minimum dose
1.25 mg) every 20 minutes for 3
doses, then 0.075 to 0.15 mg/kg
(not to exceed 2.5 mg) every 1 to
4 hours as needed
1.25 to 2.5 mg every 20
minutes for 3 doses, then
1.25 to 5 mg every 1 to 4
hours as needed
See Recommendation 6 of this
guideline regarding levalbuterol.
MDI See albuterol MDI dose above. See albuterol MDI dose
(45 mcg/puff) Above.
Anticholinergics in combination with Short-Acting Beta2-Agonist (SABA)
Ipratropium
bromide
Not necessary as first line therapy in
children with mild exacerbations.
Nebulizer
solution
(500 mcg/2.5mL)
500 mcg with first 3 doses of
albuterol, (250 mcg may be used
where available)
not to exceed 1500 mcg in the
first hour of treatment
500 mcg with first 3 doses
of albuterol, not to exceed
1500 mcg in the first hour
of treatment
Add to SABA therapy for children
with moderate and severe
exacerbations.
Current formulation (HFA) is safe for
persons with peanut allergy.
MDI
(18 mcg/puff)
4 to 8 puffs every 20 minutes as
needed up to 3 hours
8 puffs every 20 minutes as
needed up to 3 hours
Ipratropium
bromide with
albuterol
May mix ipratropium bromide in same
nebulizer with albuterol.
Nebulizer
solution
(Each 3 mL vial
contains 0.5 mg
ipratropium
bromide and 2.5
mg albuterol)
1.5 mL every 20 minutes for 3
doses
3 mL every 20 minutes for
3 doses
Ipratropium is not necessary as first
line therapy in children with mild
exacerbations.
Add ipratropium to SABA therapy for
children with moderate and severe
exacerbations. Once the child is
hospitalized, further use of ipratropium
has not been shown to provide
significant benefit.
*Children < 12 years of age
Abbreviations: HFA = hydrofluoroalkane propellant; kg = kilogram; L/min = liter per minute; mcg = microgram; MDI = metered dose inhaler;
mg = milligram; mL = milliliter; SABA = short-acting beta2-agonist; VHC = valved holding chamber
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], Taketomo [5a]).

Table 2: Corticosteroids - Drugs and Dosage Recommendations
Systemic Corticosteroids
Medication Dosage Notes
Prednisone
Prednisolone
Methylprednisolone
(sodium succinate)
1 mg/kg once daily
(maximum 60 mg/day)
for a total of 5 days
Dosages in excess of 1mg/kg of prednisone or
prednisolone have been associated with adverse
behavioral effects in children, whereas 1mg/kg
provides equivalent pulmonary benefit with
decreased adverse effects (Kayani 2002 [2b]).
Dexamethasone Oral:
0.6 mg/kg once daily
(max 16 mg/dose)
for 1 to 2 days (Qureshi 2001 [2a])
Intramuscular (dexamethasone sodium
phosphate):
0.6 mg/kg single dose
(max 15 mg) (Gordon 2007 [2a])
No advantage has been found for higher dose corticosteroids in severe asthma exacerbations.
There is no advantage for intravenous administration over oral therapy, provided gastrointestinal function is intact.
Therapy following a hospitalization or ED visit is typically 5 days, but may last from 3 to 10 days. Studies indicate there is
no need to taper the systemic corticosteroid dose when given up to 10 days.
Any previous IV doses may be considered as part of the total steroid dose.
Abbreviations: ED = emergency department; IV = intravenous; kg = kilogram; max = maximum; mg = milligram
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (Chang 2008 [2a], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a],
Taketomo [5a]).
Corticosteroids
9. It is recommended that oral corticosteroids be
administered to patients who do not respond
completely to initial inhaled SABAs (Edmonds 2009
[1a], NAEPP 2007 [5a], Camargo 2009 [5b]) (see Table 2
drugs and dosage recommendations).
Note 1: Corticosteroids speed the resolution of
airflow obstruction, reduce the rate of relapse,
and may reduce hospitalizations, especially if
administered within one hour of presentation to
the ED (Rowe 2009a [1a], Edmonds 2009 [1a]).
Note 2: Oral prednisone has effects equivalent to
those of intravenous methylprednisolone
including tolerance by children (Rowe 2009a [1a],
SIGN 2008 [5a], NAEPP 2007 [5a], Camargo 2009 [5b]).
Note 3: For treatment of acute exacerbation,
insufficient evidence exists for inhaled
corticosteroid therapy alone or as an additive
benefit when used with systemic corticosteroids
(Edmonds 2009 [1a], Schuh 2006 [2b], Nakanishi 2003
[2b], NAEPP 2007 [5a], Camargo 2009 [5b]).
Note 4: If the patient is on routine inhaled
steroids for chronic control it is not necessary to
stop their use during exacerbation. The inhaled
corticosteroids can be started at anytime
regardless of oral dosing for the exacerbation
(LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a]).
Note 5: It is recognized that many children will
have problems with treatment adherence due to
an oral aversion to medicine, especially bitter-
tasting corticosteroid preparations. In such cases,
alternatives such as intramuscularly administered
dexamethasone, oral dexamethasone, and orally
administered intravenous versions of
corticosteroids have been proven efficacious
(Rowe 2009a [1a], Smith 2009 [1a], Gordon 2007 [2a],
Altamimi 2006 [2a], Qureshi 2001 [2a], Greenberg 2008
[2b], Huang 2007 [2b], Gries 2000 [2b]).
Adjunctive Therapies
Magnesium Sulfate
10. It is recommended in children with moderate to
severe exacerbations who are minimally responsive
or unresponsive to initial treatment (SABA, oral
corticosteroids, and ipratropium), that intravenous
magnesium sulfate be administered (Rowe 2009b [1a],
Mohammed 2007 [1a], Ciarallo 2000 [2b], SIGN 2008 [5a])
(see Table 3 Adjunctive Therapies - drugs and
dosage recommendations).
Note 1: In patients with acute exacerbation who
have been maximized on standard therapy,
intravenous magnesium sulfate has been shown
to reduce hospitalizations and to improve lung
function without significant side effects. Possible
side effects to be aware of include hypotension,
hypotonia, or abnormal reflexes when given
doses above that recommended for asthma (Rowe
2009b [1a], Mohammed 2007 [1a], Alter 2000 [1a]).

Note 2: There is insufficient evidence regarding
the use of nebulized magnesium sulfate in acute
exacerbation (Blitz 2009 [1b]).
Epinephrine and Terbutaline
11. It is recommended for patients who are minimally
responsive or responding poorly to SABA /
ipratropium / systemic corticosteroid/magnesium
sulfate therapies, or who are unable to tolerate
aerosol treatments, that parenteral epinephrine or
terbutaline be considered (NAEPP 2007 [5a]) see Table
3 Adjunctive Therapies - drugs and dosage
recommendations).
Heliox
12. There is insufficient evidence and lack of consensus
regarding the effectiveness of heliox in acute
exacerbation of asthma to make a recommendation
for its routine use (Rivera 2006 [2b], SIGN 2008 [5a]).
Note: Heliox-driven albuterol nebulization may
be considered for patients who have life-
threatening exacerbation or who remain in severe
exacerbation after intensive conventional
adjunctive therapy (Rodrigo 2006 [1a], Kim 2005 [2b],
NAEPP 2007 [5a]). In one small study,
improvement in respiratory score and shorter ED
length of stay were seen when heliox was
administered in moderate and severe
exacerbation (Kim 2005 [2b]).
Severe Asthma with Respiratory Distress and
Normal Mental Status
13. It is recommended that multiple therapies as
described below be started simultaneously while
either a consult from the Pediatric Intensive Care is
requested or transport to a higher level of care is
arranged (LocalConsensus [5]) (see Table 3 Adjunctive
Therapies- drugs and dosage recommendations)
Administer:
continuous albuterol
ipratropium bromide, up to 3 doses
systemic coticosteroids
(dexamethasone IM or
methylprednisolone IV)
epinephrine IM
magnesium Sulfate IV
consider terbutaline IV bolus, and infusion.
Table 3: Adjunctive Therapies - Drugs and Dosage Recommendations
Medication Child (< 12 years of age) Adolescent Notes
Magnesium
Sulfate
Intravenous (IV)
Bolus: 50 mg/kg/dose (25 to 100 mg/kg/dose;
max 2 gms)
Administer over 20 minutes
There is insufficient evidence regarding the benefit
from continuous infusion of Magnesium Sulfate
(Mohammed 2007 [1a]).
Systemic (injected) Beta2-Agonists
Epinephrine
Intramuscular (IM)
1:1,000
(1 mg/mL)
0.01 mg/kg
(max 0.3 to 0.5 mg)
every 20 minutes
for 3 doses
0.3 to 0.5 mg
every 20 minutes
for 3 doses
One small study demonstrated more rapid absorption
and higher plasma levels of epinephrine when
administered intramuscularly into the thigh compared
to subcutaneously or intramuscularly into the arm (up
to 4 times faster)(Simons 1998 [2b]).
Terbutaline
Intravenous (IV) or
Subcutaneous (SQ)
(1 mg/mL)
0.01 mg/kg bolus
(max 0.4 mg )
Over 10 minutes
0.01 mg/kg
(max 0.25 mg)
May repeat every 15
minutes for 3 doses
0.01 mg/kg bolus
(max 0.75 mg)
Over 10 minutes
0.01 mg/kg
(max 0.25 mg)
May repeat every 15
minutes for 3 doses
Starting continuous infusion dose in the ED or PICU
settings: 1 mcg/kg/minute
Abbreviations: ED = emergency department; gms = grams; kg = kilogram; max = maximum; mcg = microgram; mg = milligram;
mL = milliliter; PICU = pediatric intensive care unit
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a], Taketomo [5a]).

Timing of Disposition from the Emergency
Department
The response to initial treatment in the ED after a period
of observation is a better predictor of the need for
hospitalization than is the severity of an exacerbation
(NAEPP 2007 [5a]).
14. It is recommended that the current severity of the
exacerbation be in the ―mild‖ range when evaluating
a child for discharge from ED or hospital
(LocalConsensus [5]) (see Attachment 3 Formal
Evaluation of Severity in the ED, Attachment 4 ED
Management of Asthma Exacerbation Algorithm) .
Note 1: In the ED, if initial severity is moderate
or severe, then the severity assessment 1 hour
after treatment is better than initial severity
assessment for determining the need for hospital
admission as well as for predicting the need for
ICU in patients initially assessed as severe (Kelly
2004 [3a], LocalConsensus [5]).
Note 2: In acute childhood asthma, a repeat pulse
oximetry of < 92 to 94 % at 1 hour after treatment
better predicts need for hospitalization than the
initial pulse oximetry (Kelly 2004 [3a], Wright 1997
[3b], LocalConsensus [5]).
Inpatient Management
General Therapy
15. It is recommended, with the exception of the use of
anticholinergics such as ipratropium, that usual
inpatient hospital management be viewed as a
continuation of any therapies initiated in the ED
including: (NAEPP 2007 [5a])
aerosolized bronchodilators
oxygen
corticosteroids
initiation and continuation of controller (anti-
inflammatory) agents
continued assessment
intermittent assessment of oxygen saturation
FEV1 or peak expiratory flow (PEF) on
admission, 15 to 20 minutes after bronchodilator
therapy during acute phase and daily until
discharge (in children > 5 years of age if able to
perform).
Failure to Progress
16. It is recommended that the following care be
initiated for patients who fail to progress after 12
hours of care: (LocalConsensus [5])
notify treating healthcare provider of any child
that has not progressed after 12 hours of care
assessment:
physical examination and respiratory score
explore reason/s for failure to progress (e.g.
poor SABA responder, pneumonia or other
diagnosis, suboptimal steroid dose or
suboptimal frequency of administration)
escalate plan based on assessment findings
treatment considerations, as indicated:
albuterol treatments every 10 to 20 minutes
for 3 doses or continuous albuterol
administered over 30 minutes, and reassess
chest x-ray
administer or re-administer IV steroid if
greater than or equal to 12 hours since last
dose (oral or IM if cannot acquire IV
access)
venous or capillary blood gas
if status is improved after treatment escalation,
then reassess hourly
if status is not improved, discuss potential for
transfer to PICU or higher level of care
consider subspecialty consult.
Decompensation
17. It is recommended that the following care be
initiated for the patient whose condition is assessed
as decompensating from a prior stabilized state: (this
is not for the patient in an obvious medical
emergency for whom a medical code needs to be
initiated): (LocalConsensus [5])
albuterol treatments every 10 to 20 minutes for a
total of 3 doses or continuous albuterol over 30
minutes, and reassess
initiate the Medical Response Team (MRT) or the
team responsible for immediate assessment of a
child with a change in condition
notify treating healthcare provider that child is
decompensating
assess for treatment escalation options:
consider other adjunctive medications
- epinephrine IM
- ipratropium unless previously given
- magnesium sulfate unless previously given
administer or readminister steroid if indicated
(oral, IM, or IV if available)
insert IV
portable chest x-ray
prohibit eating or drinking (NPO)
consider capillary or venous blood gas
consider subspecialty consult
reassess after treatment escalation
if improved, resume hourly assessment
if not improved, transfer to PICU or higher
level of care.

Consistency of Care
18. It is recommended that available protocols such as
clinical pathways or protocols be used, directing
consistent provision of care for patients presenting
with an acute asthma exacerbation (SIGN 2008 [5a],
NAEPP 2007 [5a]). At Cincinnati Children’s Hospital
Medical Center, such protocol usage includes:
Asthma Clinical Order set
Aerosol and Oxygen Protocol.
Note: Use of a clinical pathway or designated
care providers for inpatient management has
been shown to decrease length of stay, use of
SABA therapy, nursing and laboratory costs,
and to improve quality of care with no increase
in readmission rates (Johnson 2000 [2a], McDowell
1998 [2a], Norton 2007 [4a], Wazeka 2001 [4a],
Ebbinghaus 2003 [4b], Kelly 2000 [4b]).
Complementary and Alternative Medicine
19. It is recommended that the clinician ask
patients/parents about all medications and treatments
they are using for asthma (LocalConsensus [5], NAEPP
2007 [5a]).
Note 1: A high level of use of complementary
and alternative medicine (CAM) has been
reported in several studies: 45% of care providers
reported using herbal products with their children
(Lanski 2003 [3a]), 63% of adolescents reported the
use of complementary medicine when surveyed
(Reznik 2002 [3a]), and a review of literature of
CAM use in asthma found the level ranged from
33% to 89% in studies of children and adolescents
(Mark 2007 [1b]). Currently there is insufficient
evidence to support or refute the use of CAM
therapies (Altunc 2007 [1a], Hondras 2005 [1a], Mark
2007 [1b]).
Note 2: Patients who use herbal treatments may
need caution regarding the potential for harmful
ingredients in herbal treatments and interactions
with asthma medications (Lanski 2003 [3a], NAEPP
2007 [5a]).
20. It is recommended that acupuncture not be used for
the treatment of asthma. No evidence of an effect of
acupuncture in reducing asthma symptoms has been
demonstrated (McCarney 2009 [1a], Martin 2002 [1a],
NAEPP 2007 [5a]).
ED or Inpatient Management
Screening
21. It is recommended that systematic screening be
conducted using a broad assessment tool, such as
Child Asthma Risk Assessment Tool (CARAT) for
identification of risks including medical,
environmental, adherence, financial, psychosocial or
health literacy (LocalConsensus [5]). The CARAT may
be accessed via the following URL:
http://carat.asthmarisk.org
Consultations
22. It is recommended that the need for consultations be
considered at the time of presentation or as early as
possible in the acute course (LocalConsensus [5]).
Medical consultation: Usual indications for medical
consultation (usually, a fellowship-trained allergist or
pulmonologist; occasionally, other physicians who
have expertise in asthma management, developed
through additional training and experience) in
childhood asthma include: (LocalConsensus [5], NAEPP
2007 [5a])
the diagnosis of asthma is in question
current life-threatening or severe asthma
exacerbation possibly requiring MRT (medical
response team)
poor-responder or requiring escalation in routine
care or unexplained deterioration
repeated life-threatening hospital admissions,
history of intensive care admission, frequent ED
visits for asthma
patient has required more than two bursts of oral
corticosteroids in the past 12 months
any exacerbation requiring hospitalization in the
last 12 months
evaluation for addition or discontinuation of
LABA therapy
conditions complicating asthma or its diagnosis
(e.g. sinusitis, nasal polyps, aspergillosis, severe
rhinitis, vocal cord dysfunction, gastroesophageal
reflux, and chronic obstructive pulmonary
disease)
need for extensive education and guidance on
allergen avoidance, problems with adherence to
therapy and poor control, or complications of
therapy.
Mental Health consultation: Patients who have
significant psychiatric, psychosocial, or family
problems that interfere with their asthma therapy may
need referral to an appropriate mental health
professional for counseling or treatment.
Social Service Consultation: Indications for
considering social service consultation include:
family's social or financial difficulties might be
impediments to adherence with the treatments and
medical follow-up
family resources are compromised or uncertain

Interpreter Services Consultation: Indication for
considering services:
family in need of language interpretation
Pharmacist Consultation: Indications for
considering pharmacist consultation (where
available) include review of the medication regimen
of a patient admitted for asthma exacerbation
Note: Medication regimen evaluation may
include: screening for adverse drug reactions,
screening for drug interactions, ensuring
appropriate medication use and dosing,
appropriate route of administration, appropriate
dosing intervals and/or comparison of the
medication reconciliation record with the
current medication orders (Sanghera 2006 [1a],
Kaushal 2008 [3a]).
Therapies Generally NOT Recommended
23. It is recommended that theophylline or
aminophylline not be administered routinely in the
ED or hospitalized patient because they do not appear
to provide additional benefit to optimal SABA therapy
(D'Avila 2008 [2b]) and may increase frequency of
adverse effects in acute exacerbation (Mitra 2009 [1a],
SIGN 2008 [5a], NAEPP 2007 [5a]).
Note 3: Patients using theophylline as
outpatients may continue on their usual doses in
the hospital; obtaining a therapeutic level while
the child is hospitalized may be considered,
because illness can affect serum levels.
Additionally, a pharmacist consult may be
useful for review of drug interactions (NAEPP
2007 [5a]).
24. It is recommended that antibiotics not be used
routinely for acute asthma exacerbations in the
absence of an identified bacterial focus (Graham 2009
[1a], SIGN 2008 [5a], NAEPP 2007 [5a], Blasi 2007 [5b]).
25. It is recommended that aggressive rehydration not
be used routinely for acute asthma exacerbation in
the absence of clinical dehydration (NAEPP 2007 [5a]).
26. It is recommended that chest physiotherapy (CPT),
incentive spirometry, and mucolytics not be used
routinely for acute asthma exacerbations as they can
trigger bronchospasm or worsen cough or air flow
obstruction during an acute asthma attack (NAEPP
2007 [5a]).
27. It is recommended that anxiolytic and hypnotic
drugs not be used routinely for acute asthma
exacerbations outside of an intensive care setting, as
they may cause respiratory depression (NAEPP 2007
[5a]).
28. It is recommended that oral albuterol not be used
for acute exacerbation (LocalConsensus [5]).
Therapy Cautions/Considerations
29. It is recommended that for therapies outlined in this
section, caution and consideration be used in
treatment selections (LocalConsensus [5]).
Ibuprofen: In children without known Aspirin Induced
Asthma (AIA), ibuprofen may be a better choice than
acetaminophen for the treatment of fever/pain in children
presenting with acute asthma exacerbations.
Acetaminophen has been associated with an increased risk
of wheezing (Kanabar 2007 [1a], Karimi 2006 [4a]).
In children with known AIA, it is prudent to counsel
parents regarding the potential for cross-sensitivities to
non-steroidal anti-inflammatory drugs (NSAIDs) (Debley
2005 [1a]). This patient population demonstrates less cross-
sensitivity to acetaminophen.
Cross-Sensitivities: (Jenkins 2004 [1a])
ibuprofen < 400mg 98%
naproxen < 100mg 100%
diclofenac < 40mg 93%
acetaminophen > 500mg 7%
Long-Acting Beta2-Agonists
Epidemiological evidence suggests a link between long-
acting beta2-agonists (LABAs) and increases in asthma
mortality. Concern remains that symptomatic benefit
from treatment with LABAs might lead to
underestimation of acute attack severity and long-term
use could lead to tolerance to their bronchodilator
effects (Cates 2009b [1a], Cates 2009a [1a]). In addition,
recent analyses by the Food and Drug Administration
(FDA) and others concluded that use of LABAs is
associated with an increased risk of severe worsening of
asthma symptoms, leading to hospitalization in both
children and adults and death in some patients with
asthma (Salpeter 2010 [1a], Walters 2007 [1a], Salpeter 2006
[1a], FDA 2010 [5]). The FDA is requiring further studies
for safety evaluation and has concluded that although
these medicines play an important role in helping some
patients control asthma symptoms, their use be limited
to patients whose asthma cannot be controlled with
inhaled corticosteroids alone (FDA 2010 [5]). There is no
good evidence as to which subpopulation would benefit
or be harmed with use of a LABA. One recent study,
evaluating step-up therapy in children, concluded that
response to LABA was more likely to provide a better
response compared to ICS or leukotriene-receptor
antagonist (LTRA). However many children had a best
response to ICS or LTRA step-up, highlighting the need
to regularly monitor and appropriately adjust each

child’s asthma therapy within this level of care before
further step-up (Lemanske 2010 [2a]).
Until further studies are concluded, it is suggested
that all patients treated with LABA be individually
evaluated to ensure that this is the best option for
asthma control (Cates 2009b [1a], Cates 2009a [1a]).
Such evaluation may best be performed in
conjunction with an Asthma Specialist
(LocalConsensus [5]) (see Recommendation #35 for
evaluation of LABA use).
Disparities in quality of care: When treating children
with asthma, it is important to consider the
socioeconomic factors that might lead to avoidable
hospitalizations and premature mortality (Cope 2008 [4a],
Gupta 2006 [4a]). Special consideration of the following
conditions assists in the provision of patient-centered,
equitable care:
Medicaid-covered, minority children have worse
asthma status (parental report) and are less likely to
be using preventive, anti-inflammatory agents than
white children (Ferris 2006 [4a], Lieu 2002 [4a]).
Children uninsured or on Medicaid have ranked
significantly lower on seven quality measures
including ED utilization, prescriptions from the ED,
and access to and use of a primary care provider
(Lara 2003 [2a], Knudson 2009 [4a], Wilson 2005 [4a], Ferris
2001 [4a]).
Black children demonstrate more likelihood to have
asthma and to experience ED visits for asthma,
compared with otherwise comparable white children
(Flores 2005 [3a], Jones 2008 [4a]).
The effect of comorbid conditions and mental illness
in mothers of asthmatic children has recently been
shown to impact asthma control and health services
utilization related to asthma (Coughlan 2001 [1a],
Bartlett 2001 [3a], Belamarich 2000 [3a], Rodriguez 2002
[4a], Shalowitz 2001 [4a], NAEPP 2007 [5a]) (see
Recommendation #22, Consultations, Social
Services).
Discharge/Transition Preparation
Although this guideline is focused on the acute
management of asthma exacerbations, it is recognized
that asthma is a chronic disease. Discharge planning is
intended to assist the transition from the acute
exacerbation to chronic management, identifying factors
within the chronic action plan that may need adjusting to
prevent future exacerbations and improve long-term
patient outcomes. The transition plan is expected to
enhance the likelihood that the family, and ultimately
the child, will become skilled in self-management of this
chronic condition. Early planning is important to assure
that problems with details associated with follow-up
have been resolved prior to discharge.
Recommendations for comprehensive management of
chronic asthma can be found in the most recent update
of the national asthma guideline (NAEPP 2007 [5a]).
30. It is recommended that planning for discharge begin
when the child first presents to the ED or hospital
unit (LocalConsensus [5]).
31. It is recommended that prior to discharge the patient
undergo Severity Classification of chronic asthma (see
Attachment 5 Severity Classification). This will
support a patient-centered approach to therapy (NAEPP
2007 [5a]). Also, Severity Classification may be useful
to the primary care provider in identifying children
with special health care needs and facilitating care
coordination (LocalConsensus [5]).
32. It is recommended that case or care management by
trained health professionals be considered for
patients who have poorly controlled asthma and have
recurrent visits to the ED or hospital. Care-
management processes are tools to improve the
efficiency and quality of primary care delivery, self
management, and have demonstrated a reduction in
ED visits (Schulte 2004 [1b], Levy 2006 [2a], Walders 2006
[2a], Griffiths 2004 [2a], Portnoy 2006 [4a], Rosen 2006 [4a],
Spiegel 2006 [4a], Wood 2006 [4a], Allcock 2009 [4b], CMSA
2010 [5]).
33. It is recommended, before the patient is discharged
from the ED or inpatient unit, that education be
provided that is tailored to the identified needs,
beliefs, and learning styles of the patient and family
and addresses identified patient-desired outcomes
(Zorc 2005 [2a], LocalConsensus [5], Mansour 2009 [5a], SIGN
2008 [5a], NAEPP 2007 [5a]).
Note 1: When usual care for asthma was
compared to more intensive educational programs
(provided in either the ED, hospital, home or
clinic), reduction in subsequent ED visits and
hospital admissions occurred in those receiving
intensive education (Boyd 2009 [1a], Wolf 2008 [1a],
Karnick 2007 [2a], Brown 2006 [2a], Ng 2006 [2a],
Sockrider 2006 [2a]). The most effective type,
duration or intensity of education has not been
determined (Boyd 2009 [1a], Coffman 2008 [1a], Wolf
2008 [1a], Zorc 2009 [2a]). Patient-centered, specific
education efforts may be more effective than
general or poorly targeted interventions (Canino
2008 [2a], Forbis 2002 [2b], NAEPP 2007 [5a]).
Note 2: Asthma education plans have been
successfully implemented in busy EDs (Boychuk
2006 [3a], NAEPP 2007 [5a]).

Components of education programs have not been
comparatively studied; however, programs that have
demonstrated improvement have included the following
components: (Boyd 2009 [1a], Coffman 2008 [1a], Wolf 2008 [1a])
etiology, prognosis, and risk factors emphasizing
chronicity of condition
medication purpose, and when and how to use
medications (Smith 2008 [4a])
provision or updating of written asthma plan
Note: Parental attitudes toward and knowledge of
asthma (pathophysiology, medications, action
plans, and environmental triggers) influenced
adherence to prescribed asthma medications and
action plans in several studies (Jones 2002 [2a],
Douglas 2002 [2b], NAEPP 2007 [5a]).
identification of environmental triggers for prevention
of acute exacerbations (Lanphear 2001b [4a], Lanphear
2001a [4a]) (see Attachment 6 How to Control what
Makes Your Asthma Worse)
Note: Multifaceted allergen education and control
interventions delivered in the home setting have
been shown to be effective in reducing exposures
to cockroach, rodent, and dust-mite allergens and
associated asthma morbidity (Arshad 2007 [2a],
Morgan 2004 [2a], Schonberger 2004 [2a], Chan-Yeung 2002
[2a], Custovic 2001 [2a], Finn 2000 [3a], NAEPP 2007 [5a]).
demonstration of correct use of inhaler / spacer (Hussain-
Rizvi 2009 [2b]) (see Attachment 7 MDI Use)
demonstration of peak flow technique if sending home
with peak flow meter – (for patients with moderate or
severe persistent asthma or a history of severe
exacerbations, or patients who are poor perceivers of
airflow obstruction) (see Attachment 8 Peak Flow Use)
Note: Peak flow measurement can be a useful
addition for severity assessment of an asthma
exacerbation and is most useful in patients with
moderate to severe persistent asthma (McMullen 2002
[2a], Yoos 2002 [2a]). It can be used in short-term
monitoring, acute exacerbations, and daily chronic
monitoring (Goldberg 2001 [4a], Brand 1999 [4a], NAEPP
2007 [5a]).
home management of exacerbation or relapse
including evaluation of early clinical signs and
symptoms of airway inflammation
Note: Beginning treatment at home may avoid
treatment delays, prevent exacerbations from
becoming severe, and also adds to patients’ sense
of control over their asthma. The degree of care
provided in the home depends on the patients’ (or
parents’) abilities and experience and on the
availability of emergency care (NAEPP 2007 [5a]).
Accurate evaluation of symptom severity by
parents and children will assist to avoid delays
in care and inappropriate home management
(Garbutt 2009 [2a]).
importance and purpose of follow-up appointment –
explore action plan, evaluate patient goal attainment,
identify barriers to meeting activity goals, identify
potential treatment adjustments to help meet goals and
prevent future exacerbations (Zorc 2005 [2a], Zorc 2003
[2a], Flores 2005 [3a]):
• schedule before discharge for hospitalized
patient 1 to 5 days after discharge
• contact primary care provider before discharge
from ED
importance of continual and consistent care in
outpatient setting, partnering with primary care
provider to tailor interventions toward the child’s
goals for activity
provision of Asthma Specialists resource information
if indicated.
34. It is recommended that SABAs be used at home on an
as-needed basis after recovery from an acute asthma
exacerbation (Walters 2002 [1a], NAEPP 2007 [5a]). If
patient’s need is greater than 6 puffs every 3 to 4
hours by 24 to 48 hours after discharge provide family
with instruction to seek medical care (LocalConsensus
[5]).
35. It is recommended that if a LABA was in use before
admission, it be suspended during hospitalization for
exacerbation and the patient be evaluated for
continuation of therapy after discharge: (LocalConsensus
[5], SIGN 2008 [5a]).
Note 1: There is no evidence that continuing a
LABA during exacerbation is beneficial and
concern remains regarding harm with its
continued use.
Note 2: The beneficial effects of LABA in
combination therapy for the patients who require
more therapy than low-dose ICS alone to control
asthma need to be weighed against the potential
increased risk of severe exacerbations, associated
with the daily use of LABAs in some patients
(Cates 2009b [1a], Cates 2009a [1a], Nelson 2006 [2a],
NAEPP 2007 [5a]).
Consider consultation with an Asthma Specialist
for questions regarding continuation of LABA
following hospital discharge (LocalConsensus [5]).
Note 3: In February of 2010 the FDA announced
new safety controls for LABAs as follows:
―LABAs are contraindicated without the use
of an asthma controller medication such as
inhaled corticosteroid, and should not be
used alone‖ (FDA 2010 [5], NAEPP 2007 [5a]).

―LABAs ought to only be used long-term in
patients whose asthma cannot be adequately
controlled on other asthma controller
medications‖ (FDA 2010 [5]).
―LABAs ought to only be used for the
shortest duration of time required to achieve
control of asthma symptoms and
discontinued, if possible, once asthma
control is achieved‖ (FDA 2010 [5]).
Note 4: Of the adjunctive therapies available,
LABAs are the preferred therapy to combine with
ICS in youths ≥ 12 years of age and adults (NAEPP
2007 [5a]).
Note 5: For patients ≥ 5 years of age who have
moderate persistent asthma or asthma
inadequately controlled on low-dose ICS, the
option to increase the ICS dose may be given
equal weight to the option of adding LABA
(NAEPP 2007 [5a]). A recent study suggests that
patients are most likely to have a differential
response to the addition of LABA to low dose
ICS compared to increasing ICS or adding a
leukotriene receptor antagonist. However, the
safety of long term use of LABA remains
uncertain (Lemanske 2010 [2a]).
Note 6: For patients ≥ 5 years of age who have
severe persistent asthma or asthma inadequately
controlled, the combination of LABA and ICS is
the preferred therapy (NAEPP 2007 [5a]).
Note 7: For patients < 4 years of age, there is
insufficient evidence for use of a LABA. These
drugs are not labeled for use in this age group.
Consider consultation with an Asthma Specialist
for questions regarding this subset of asthma
patients before adding LABA therapy
(LocalConsensus [5], NAEPP 2007 [5a]).
36. It is recommended that patients already on ICS
continue ICS therapy after discharge from ED or
inpatient setting. Consider initiating ICS for patients
with persistent asthma if not already receiving (SIGN
2008 [5a], NAEPP 2007 [5a]).
Note: Initiating ICS at discharge for patients not
already on ICS has demonstrated a decreased risk
of subsequent ED visits for patients with persistent
asthma (Sin 2002 [4a], NAEPP 2007 [5a]).
37. It is recommended, when possible, that long term
controller medications and medicines to complete
exacerbation therapy are provided to the patient prior
to discharge (Qureshi 2001 [2a], Cooper 2001 [4a]).
Note: Prescriptions are not always filled after
discharge (Qureshi 2001 [2a], Cooper 2001 [4a]).
Outcomes demonstrated from prescriptions not
filled have been an increase in missed school and
work days (Qureshi 2001 [2a]). It is also believed
that providing medicines will result in decrease
readmission rates (LocalConsensus [5], NAEPP 2007
[5a]).
38. It is recommended that patients have a written plan
that reflects adjustments necessary due to the current
exacerbation and includes a stepwise approach
coordinating with the child’s plan for chronic
management (Zemek 2008 [1a], Bhogal 2006 [1a], NAEPP
2007 [5a]) (see Attachment 9, Stepwise Management).
39. It is recommended that every attempt be made to
schedule the follow-up appointment before the
child is discharged from the facility. When this is
not possible, attempt to notify the primary care
provider of the current exacerbation event (Zorc 2005
[2a], Zorc 2003 [2a], LocalConsensus [5], NAEPP 2007
[5a]).
Note: A significant number of patients from the
Cincinnati population consider the ED their
regular source of care, and a commonly held
health belief is that the ED is the appropriate place
to seek care for a breathing problem (Mansour 2000
[2b]). Having fewer general practice contacts in
the previous year has been independently
associated with an increased risk of fatal asthma,
increasing the importance of the follow-up visit
either with the primary care provider or asthma
specialist (LocalConsensus [5], NAEPP 2007 [5a]).
Discharge readiness
Ongoing assessment will provide the needed information
of the patient progression to determine the readiness for
discharge. Discharge readiness usually includes the
following:
child stable on therapies that can be administered at
home
home environment is able to safely fulfill discharge
plan
sufficient knowledge of asthma to manage care at
home or seek help if symptoms worsen
arrangements for any special medications or
equipment required for home therapies are complete
transition plan based on admission screening is
complete and reflects the patients continuum of care
needs
follow-up care is arranged, coordinating with
primary care provider or asthma specialist if
indicated, and providers agree with plans.

Future Research Agenda
Clinical questions of potential interest to CCHMC
investigators related to the population of children 12
months to 18 years of age with acute asthma:
1. Does the discontinuation of LABA upon
exacerbation compared to continuation of LABA:
decrease the length of exacerbation?
decrease the number of treatment failures (e.g.
decompensation, admission)?
2. Does the use of same dose Levalbuterol compared
to Albuterol:
decrease admissions?
decrease costs?
decrease cardiac adverse events (e.g.
tachycardia, arrhythmia)?
3. Does the use of a respiratory score compared to no
score:
decrease length of stay?
CCHMC Guideline Implementation Tools
Any available implementation tools are available online
and may be distributed by any organization for the
global purpose of improving child health outcomes.
Website address:
http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-
based/default.htm

Attachment 1
KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA
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.
Wheezing—high-pitched whistling sounds when breathing out—especially in children. (Lack
of wheezing and a normal chest examination do not exclude asthma.)
History of any of the following:
Cough, worse particularly at night
Recurrent wheeze
Recurrent difficulty in breathing
Recurrent chest tightness
Symptoms occur or worsen in the presence of:
Exercise
Viral infection
Animals with fur or hair
House-dust mites (in mattresses, pillows, upholstered furniture, carpets)
Mold
Smoke (tobacco, wood)
Pollen
Changes in weather
Strong emotional expression (laughing or crying hard)
Airborne chemicals or dusts
Menstrual cycles
Symptoms occur or worsen at night, awakening the patient.
*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])

Attachment 2
DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA
Infants and Children
Upper airway diseases
Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Heart disease
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
(NAEPP 2007 [5a])

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
Can lie down
While at rest (infant:
softer, shorter cry,
difficulty feeding)
Prefers sitting
While at rest (infant:
stops feeding)
Sits upright
While at rest
Talks in Sentences Phrases Words Cannot talk
Alertness Normal or may be
agitated
Usually agitated Usually agitated Drowsy or confused
Signs
Respiratory rate Normal or increased Increased Increased, often
>30/minute
Normal or decreased
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;
suprasternal retractions;
nasal flaring; abdominal
breathing
Usually not Commonly Usually Paradoxical
thoracoabdominal
movement
Wheeze Moderate, often only
end expiratory
Loud; throughout
exhalation
Loud, throughout
inspiration and
exhalation or may be
absent
Minimal or absent
Pulse/minute (at initial
presentation)
< 100 100 to 120 > 120 Bradycardia
Pulsus paradoxus Absent <10 mmHg May be present
10 to 25 mmHg
Often present
> 25 mmHg (adult)
20 to 40 mmHg (child)
Absence suggests
respiratory muscle fatigue
Functional Assessment
PEF (peak expiratory
flow)
Percent predicted or
percent personal best
> 70% Approx. 40 to 69% or
Response to treatment
lasts < 2 hours
< 40% < 25%
Note: PEF testing may not
be needed in very severe
attacks
PaO2 (arterial oxygen
pressure, on room air)
and/or
PCO2 (partial pressure of
carbon dioxide)
Normal (test not
usually necessary)
> 60 mmHg (test not
usually necessary)
< 60 mmHg: possible
cyanosis
< 42 mmHg (test not
usually necessary)
< 42 mmHg (test not
usually necessary)
> 42 mmHg: possible
respiratory failure
SaO2 (oxygen saturation)
(on room air)
> 95% 90 to 95% < 90%
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
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a]).

Emergency Department Management of Asthma Exacerbations – Algorithm Attachment 4
Good Response
Asthma Score, PEF or FEV1
(> 70%)
Response sustained at least 60
minutes after last treatment
No distress
Physical exam: normal
Incomplete Response
Unchanging Asthma Score,
PEF or FEV1 (40 – 69%)
Symptoms persist
Poor Response
Unchanging or worsening
Asthma Score, PEF or FEV1
(< 40%)
Symptoms worsening
Admit to Hospital Ward
Oxygen as needed
Inhaled SABA
Systemic (oral or intravenous)
corticosteroid
Consider adjunct therapies
Monitor vital signs, Asthma Score,
PEF or FEV1, SaO2
Transfer to higher level
of care
Moderate Exacerbation
Asthma Score, PEF or FEV1 (40 to 69%
predicted/personal best)
Inhaled SABA every 60 minutes
Oral systemic corticosteroids
Continue treatment 1 to 3 hours,
provided there is improvement; make
admit decision in < 4 hours
Severe Exacerbation
Asthma Score, PEF or FEV1 (<40% predicted/personal best)
History: high risk patient
No improvement after initial treatment
Oxygen
Nebulized SABA, hourly or continuous, plus ipratropium
Oral systemic corticosteroids (see Table 2)
Consider adjunct therapies (see Table 3)
Decide patient’s disposition
Repeat Assessment: Symptoms, physical examination, Asthma Score or PEF, FEV1 (if performed), oxygen saturation, other tests as
indicated
Mild
Oxygen to achieve SaO2 > 90%
Inhaled SABA by nebulizer or MDI
with valved holding chamber, up to 3
doses in 1st
hour
Oral systemic corticosteroids if no
response or if patient recently took oral
systemic corticosteroids
Moderate / Severe
Oxygen to achieve SaO2 > 90%
High-dose inhaled SABA by nebulizer or
MDI with valved holding chamber, every
10 to 20 minutes or continuously for 1
hour PLUS ipratropium
Oral systemic corticosteroids
Impending or Actual Respiratory Arrest
Support airway
100% O2
Continuous SABA
Intravenous corticosteroids
Consider Adjunct therapies (see Table 3)
Transfer to higher level of care
Severe: see Attachment 3 for
details of signs and symptoms:
Speaks in phrases
Wheeze loud (throughout
inhalation or exhalation) or
absent
Respiratory Arrest or Impending
Respiratory Failure:
see Attachment 3 for details of
signs and symptoms:
Cannot speak
Wheeze absent
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
details of signs and
symptoms:
Speaks in sentences
Wheeze mild to moderate
(end expiratory)
Moderate: see Attachment 3
for details of signs and
symptoms:
Speaks in words
Wheeze loud (throughout
exhalation)
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],
WorldHealthOrganizationWritingGroup 2006 [5a]).
Discharge Home
Continue treatment with inhaled SABAs.
Continue course of oral systemic
corticosteroid.
Continue on ICS. For those not on long-term
control therapy, consider initiation of an ICS.
Patient education (e.g., review medications
including inhaler technique; review/initiate
action plan; recommend close medical follow-
up and, whenever possible, environmental
control measures).
Before discharge, schedule follow-up
appointment with PCP and /or asthma
specialist in 1-5 days.
If unable to schedule from ED, notify PCP of
status
Improve

Attachment 5
Severity Classification
(NAEPP 2007 [5a])

Attachment 5
Severity Classification (continued)
(NAEPP 2007 [5a])

How to Control What Makes Your Asthma Worse Attachment 6
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (NAEPP 2007 [5a]).
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
worse for some people are not a problem for others. You do not need to do all of the things listed in this guide. Look
at the things listed below and put a check next to the ones that you know make your asthma worse, particularly if you
are allergic to those things. Then decide with your doctor what steps you will take. Start with the things in your
bedroom that bother your asthma. Try something simple first.
Tobacco Smoke
� If you smoke, ask your doctor for ways to help you quit. Ask family members to quit smoking, too.
� Do not allow smoking in your home, car, or around you.
� Be sure no one smokes at a child’s daycare center or school.
Smoke, Strong Odors, and Sprays
� If possible, do not use a wood-burning stove, kerosene heater, fireplace, unvented gas stove, or heater.
� Try to stay away from strong odors and sprays, such as perfume, talcum powder, hair spray, paints, new
carpet, or particle board.
Dust Mites
Many people who have asthma are allergic to dust mites. Dust mites are like tiny ―bugs‖ you cannot see that live in
cloth or carpet. Things that will help the most:
� Encase your mattress in a special dust mite proof cover.
� Encase your pillow in a special dust mite-proof cover or wash the pillow each week in hot water. Water must
be hotter than 130 °F to kill the mites. Cooler water used with detergent and bleach can also be effective.
� Wash the sheets and blankets on your bed each week in hot water.
Cockroaches
Many people with asthma are allergic to the dried droppings and remains of cockroaches.
� Keep all food out of your bedroom.
� Keep food and garbage in closed containers (never leave food out).
� Use poison baits, powders, gels, or paste (for example, boric acid) to eliminate cockroaches.
You can also use traps.
� If a spray is used to kill roaches, stay out of the room until the odor goes away.
Other things that can help:
� Reduce indoor humidity to or below 60 percent; ideally 30–50 percent. Dehumidifiers or central air
conditioners can do this.
� Try not to sleep or lie on cloth-covered cushions or furniture.
� Remove carpets from your bedroom and those laid on concrete, if you can.
� Keep stuffed toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and
bleach. Placing toys weekly in a dryer or freezer may help. Prolonged exposure to dry heat or freezing can kill
mites but does not remove allergen.
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.

How to Control What Makes Your Asthma Worse (continued) Attachment 6
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (NAEPP 2007 [5a]).
(NAEPP 2007 [5a])
Indoor Mold
Fix leaking faucets, pipes or other sources of water.
Clean moldy surfaces.
Dehumidify basements, if possible.
Vacuum Cleaning
Try to get someone else to vacuum for you once or twice a week
If able:
Stay out of rooms while they are being vacuumed and for a short while afterward.
If unable:
Use a dust mask (from a hardware store), a central cleaner with a collecting bag outside the home, or a
vacuum cleaner with a HEPA filter or a double-layered bag.
Pollen and Outdoor Mold
During your allergy season (when pollen or mold spore counts are high)
� Try to keep your windows closed.
� If possible, stay indoors with windows closed during the midday and afternoon. Pollen and some mold spore
counts are highest at that time.
� Ask your doctor whether you need to take or increase anti-inflammatory medicine before your allergy season
starts.
Exercise or Sports
� 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.
� Ask your doctor about taking medicine before you exercise to prevent symptoms.
� Warm up for a period before you exercise.
� Check the air quality index and try not to work or play hard outside when the air pollution or pollen levels (if
you are allergic to the pollen) are high.
Seasonal Exposures
Maintain good hand-washing habits
Avoid exposure to crowds during high viral seasons, as much as is possible
Discuss with your healthcare provide the benefits of a seasonal influenza vaccine
Other Things That Can Make Asthma Worse
� Sulfites in foods: Do not drink beer or wine or eat shrimp, dried fruit, or processed potatoes if they cause
asthma symptoms.
� Cold air: Cover your nose and mouth with a scarf on cold or windy days.
� Other medicines: Tell your doctor about all the medicines you may take. Include cold medicines, aspirin,
herbal or alternative medicines, and even eye drops.
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
worse for some people are not a problem for others. You do not need to do all of the things listed in this guide. Look
at the things listed below and put a check next to the ones that you know make your asthma worse, particularly if you
are allergic to those things. Then decide with your doctor what steps you will take. Start with the things in your
bedroom that bother your asthma. Try something simple first.
Tobacco Smoke
� If you smoke, ask your doctor for ways to help you quit. Ask family members to quit smoking, too.
� Do not allow smoking in your home, car, or around you.
� Be sure no one smokes at a child’s daycare center or school.
Smoke, Strong Odors, and Sprays
� If possible, do not use a wood-burning stove, kerosene heater, fireplace, unvented gas stove, or heater.
� Try to stay away from strong odors and sprays, such as perfume, talcum powder, hair spray, paints, new
carpet, or particle board.
Dust Mites
Many people who have asthma are allergic to dust mites. Dust mites are like tiny ―bugs‖ you cannot see that live in
cloth or carpet. Things that will help the most:
� Encase your mattress in a special dust mite proof cover.
� Encase your pillow in a special dust mite-proof cover or wash the pillow each week in hot water. Water must
be hotter than 130 °F to kill the mites. Cooler water used with detergent and bleach can also be effective.
� Wash the sheets and blankets on your bed each week in hot water.
Cockroaches
Many people with asthma are allergic to the dried droppings and remains of cockroaches.
� Keep all food out of your bedroom.
� Keep food and garbage in closed containers (never leave food out).
� Use poison baits, powders, gels, or paste (for example, boric acid) to eliminate cockroaches.
You can also use traps.
� If a spray is used to kill roaches, stay out of the room until the odor goes away.
Other things that can help:
� Reduce indoor humidity to or below 60 percent; ideally 30–50 percent. Dehumidifiers or central air
conditioners can do this.
� Try not to sleep or lie on cloth-covered cushions or furniture.
� Remove carpets from your bedroom and those laid on concrete, if you can.
� Keep stuffed toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and
bleach. Placing toys weekly in a dryer or freezer may help. Prolonged exposure to dry heat or freezing can kill
mites but does not remove allergen.
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.

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.
Steps for using your inhaler:
Getting ready 1. Take off the cap, shake the inhaler and attach spacer
2. Breathe out all the way.
3. Hold the inhaler the way instructed by your primary care provider (see picture).
4. Press down on the inhaler, within 5 seconds, begin to breathe in slowly through your
mouth.
5. Keep breathing in slowly, as deeply as possible.
6. Hold your breath and count to 10 slowly, if possible.
7. Remove the inhaler and breathe out through pursed lips (like blowing out a candle)
8. For inhaled quick-relief medicine (beta2-agonists), wait about 1 minute between puffs.
There is no need to wait between puffs for other medicines.
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.
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (Roller 2007 [4a], LocalConsensus [5], NAEPP 2007 [5a]).

Attachment 8
Peak Flow Use
(NAEPP 2007 [5a])

Attachment 8
Peak Flow Use (continued)
(NAEPP 2007 [5a])

Attachment 9
Stepwise Approaching to Managing Asthma in Children 0 to 4 years of age
(NAEPP 2007 [5a])

Attachment 9
Stepwise Approaching to Managing Asthma in Children 5 to 11 years of age
(NAEPP 2007 [5a])

Members of Asthma Team 2010
Community Physicians
Scott Callahan, MD, Co-Chair (General Pediatrics)
William DeBuys, MD (General Pediatrics)
CCHMC Physicians
Carolyn Kercsmar, MD, Co-Chair (Allergy and Pulmonary
Medicine)
Jeffrey Simmons, MD, Methodologist (General Pediatrics)
*Michele Lierl, MD (Allergy and Pulmonary Medicine)
Craig Gosdin, MD (General Pediatrics)
Laurie Johnson, MD (Emergency Medicine)
Sue Poynter, MD (Critical Care Medicine)
Rajit Basu, MD (Critical Care Medicine)
Residents
Angela Statile, MD (Chief Resident)
Corrine Bria, MD (Chief Resident)
Nursing
Sue Wieser, RN
Lisa Crosby, RN
Pharmacy
Bradley McCrory, PharmD
Michelle Caruso, PharmD, BCPS
Respiratory Therapy
Edward Conway, RRT (Certified Asthma Educator)
Lisa Devoto, RN, RT, CPN (Certified Asthma Educator)
Rachel Keller, RRT, RPFT (Certified Asthma Educator)
James M. Anderson Center (AC) - Support
*Eloise Clark, MPH, MBA (Lead Program Administrator)
*Wendy Gerhardt, MSN, RN-BC (Program Administrator)
Danette Stanko-Lopp, MA, MPH (Epidemiologist)
Karen Vonderhaar, RN, MSN (Program Administrator)
Ad hoc Advisors
Lorie Ferenzi, (Allergy and Pulmonary Medicine)
*Richard Ruddy, MD (Director, Emergency Medicine)
*Amal Assa'ad, MD (Allergy)
Karen McDowell, MD (Pulmonary Medicine)
Christopher J Cates, Division of Population Hlth Sci and Educ, St.
George’s, U of London, UK
Annie Lintzenich, MD, Gen Peds, Med U of SC
Ronald J Teufel II, MD, MSCR, Pediatrics/Internal Medicine, Gen
Peds Hospital Section, Med U of SC
*Member of 2002 Development Team
Development Process
The process by which this guideline was developed is documented in
the Guideline Development Process Manual; relevant development
materials are kept electronically. The recommendations contained in
this guideline were formulated by an interdisciplinary working group
which performed systematic search and critical appraisal of the
literature, using the Table of Evidence Levels described following the
references, and examined current local clinical practices.
To select evidence for critical appraisal for this guideline, the
Medline, EmBase and the Cochrane databases were searched for
dates of January, 2002 to November, 2009 to generate an unrefined,
―combined evidence‖ database using a search strategy focused on
answering clinical questions relevant to acute exacerbation of
asthma and employing a combination of Boolean searching on
human-indexed thesaurus terms (MeSH headings using an OVID
Medline interface) and ―natural language‖ searching on words in
the title, abstract, and indexing terms. The citations were reduced
by: eliminating duplicates, review articles, non-English articles,
and adult articles. The resulting abstracts were reviewed by a
methodologist to eliminate low quality and irrelevant citations.
During the course of the guideline development, additional clinical
questions were generated and subjected to the search process, and
some relevant review articles were identified. September, 2002 was
the last date for which literature was reviewed for the previous
version of this guideline. The details of that review strategy are
documented and maintained in an asthma literature binder.
However, all previous citations were reviewed for appropriateness
to this revision. Any new literature encountered for this October,
2010 version was reviewed by two or more team members and then
discussed as a team.
Experience with the implementation of earlier publications of this
guideline has provided learnings which have been incorporated into
this revision.
Once the guideline has been in place for five years, a team
reconvenes to explore the continued validity of the guideline. This
phase can be initiated at any point that evidence indicates a critical
change is needed.
The guideline was externally appraised by three reviewers using the
AGREE instrument and the results by domain are:
• Scope and Purpose 100%
• Stakeholder Involvement 86%
• Rigor of Development 92%
• Clarity and Presentation 97%
• Applicability 74%
• Editorial Independence 72%
Recommendations have been formulated by a consensus process
directed by best evidence, patient and family preference and
clinical expertise. During formulation of these recommendations,
the team members have remained cognizant of controversies and
disagreements over the management of these patients. They have
tried to resolve controversial issues by consensus where possible
and, when not possible, to offer optional approaches to care in the
form of information that includes best supporting evidence of
efficacy for alternative choices.
The guideline has been reviewed and approved by clinical experts
not involved in the development process, distributed to senior
management, and other parties as appropriate to their intended
purposes.
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.
Copies of this Evidence-based Care Guideline (EBCG) and any
available implementation tools are available online and may be
distributed by any organization for the global purpose of improving
child health outcomes. Website address:
http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-
based/default.htm
Examples of approved uses of the EBCG include the following:
• copies may be provided to anyone involved in the organization’s
process for developing and implementing evidence-based care
guidelines;
• hyperlinks to the CCHMC website may be placed on the
organization’s website;
• the EBCG may be adopted or adapted for use within the
organization, provided that CCHMC receives appropriate
attribution on all written or electronic documents; and
• copies may be provided to patients and the clinicians who manage
their care.

Notification of CCHMC at HPCEInfo@cchmc.org for any EBCG, or
its companion documents, adopted, adapted, implemented or
hyperlinked by the organization is appreciated.
NOTE: These recommendations result from review of
literature and practices current at the time of their
formulations. This guideline does not preclude using care
modalities proven efficacious in studies published subsequent to
the current revision of this document. This document is not
intended to impose standards of care preventing selective
variances from the recommendations to meet the specific and
unique requirements of individual patients. Adherence to this
guideline is voluntary. The clinician in light of the individual
circumstances presented by the patient must make the ultimate
judgment regarding the priority of any specific procedure.
For more information about this guideline, its supporting
evidences and the guideline development process, contact the AC
office at: 513-636-2501 or HPCEInfo@cchmc.org .

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Note: When using the electronic version of this document, 
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within the CCHMC network
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Guideline for Managing Asthma Exacerbations in Children

Guideline for Managing Asthma Exacerbations in Children

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