CLINICAL PATHWAY: THIS PATHWAY SERVES AS A GUIDE Emergency Department Asthma · 2020-02-06 · Emergency Department Asthma CONTACTS: ERIC HOPPA, MD | KRISTIN WELCH, MD ... Resume
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
THIS PATHWAY SERVES AS A GUIDE AND DOES NOT REPLACE CLINICAL JUDGMENT.
Inclusion Criteria: 1 yrs old, previous diagnosis of asthma or 2 previous episodes of wheezing, MPIS 5Exclusion Criteria: <1 yrs old, bronchiolitis or pneumonia as primary diagnosis, chronic cardiac or lung disease other than asthma
Discharge Criteria/Instructions: MDI/spacer teach F/u with PCP in 2-3 days Medications: Albuterol PRN
*Consider Prednisolone/Prednisone for patients thatmight benefit from longer steroids. Start 24 hours
after Dexamethasone dose.
MPIS 6 MPIS 7
Reassess in 15-30 minutes Calculate MPIS
MPIS 6 MPIS 7
Albuterol 4 puffsMDI/spacer(with teach)
if not already done
Long Albuterol treatment:• <20 kg: 10 mg over 1 hour
• >20 kg: 20 mg over 1 hour
• Reassess in 15-30 minutes• Calculate MPIS
MPIS 6 MPIS 13
Observe for 1 hour
Reassess Calculate MPIS
MPIS 6 MPIS 7
Discharge Criteria and Instructions:
MDI/spacer teach F/u with PCP in 2-3 days Medications: Albuterol q4hr
*Consider Prednisolone/Prednisone for patients that might benefit from longer steroids. Start
24 hours after Dexamethasone dose.
MPIS 11-12
Medications: Resume continuous
Albuterol at 20 mg/hr Consider additional
therapies per PICU consultation (e.g, methylprednisolone if not done, MgSO4, terbutaline)
Nursing: Place PIV (if not done)
Consults: Consult PICU attending
in ED: observe in ED for further improvement vs admission to PICU
Admission:- Admit to MS floor or PICU in discussion with IMT and
PICU attending- If to be admitted to MS floor,
ED provider to place order Initiate Albuterol wean . RT will rescore MPIS and speak
with provider to place appropriate
Albuterol order.
Medications: Resume continuous
Albuterol atprevious dose
ED provider to place order Initiate Albuterol wean
RT will rescore MPIS and speak with provider to place appropriate Albuterol order
Nursing: Place PIV
Admission: Admit to MS (PHM or Pulmonary if patient is known to them) See Inpatient Asthma Pathway
At time of transfer: Re-assess patient and calculate MPIS Inform attending and admitting team if MPIS is increasing Hold transfer if MPIS 13 and consider PICU consult
MPIS 7-8
Medications: Albuterol 5 mg neb
q2hr ED provider to place
order Initiate Albuterol wean
RT will rescore MPISand speak with provider to place appropriate Albuterol order
Nursing: Place PIV if
inadequate oral intake, or unable to take oral steroids
MPIS 9-10
Medications: Resume continuous
Albuterol atprevious dose
ED provider to place order Initiate Albuterol wean
RT will rescore MPIS and speak with provider to place appropriate Albuterol order
Nursing: Place PIV if
inadequate oral intake, or unable to take oral steroids
THIS PATHWAY SERVES AS A GUIDE AND DOES NOT REPLACE CLINICAL JUDGMENT.
CLINICAL PATHWAY: Inpatient Asthma
CONTACTS: CHRISTINA GIUDICE, APRN | ALEX HOGAN, MD | ANAND SEKARAN, MD
LAST UPDATED: 11.11.19
Admit to Medical/ Surgical Unit Oxygen: Titrate per order Oral Steroid:
o Prednisone or Prednisolone 1mg/kg/dose q12hr; <12 yr old: max 60 mg/day, 12 y/o: max 80 mg/day (Start 24 hr after dexamethasone. Total steroid course: 5 days)
o OR give additional dose of Dexamethasone 0.6 mg/kg (max 16mg) PO/IM prior to discharge
Determine initial MPIS If poor PO, place PIV and administer IVF with potassium Use asthma-specific H&P to document asthma severity and control
(Appendix A, Appendix B, Appendix C) Consider ordering medications for bedside delivery on admission
Inclusion Criteria: 1 yrs old, inadequate response to ED asthma treatment (see ED Asthma Pathway)Exclude Criteria: < 1yr old, primary diagnosis of bronchiolitis or pneumonia, active cardiac disease
Improvement? (Two consecutive scores in
appropriate range)
Improvement?
No
Initiate Phase 2 and follow pathway
Improvement? (MPIS 6 x2)
* ALBUTEROL WEAN PROTOCOL: RT s wean Albuterol
according to this MPIS-driven protocol
Wean when two consecutive scores are in appropriate range
RT s inform MD/APRN/PA of ALL changes in Albuterol dosing
Any escalation in care requires an exam by MD/ APRN/PA at bedside
MD/APRN/PA can authorize variance from protocol
Continue on pathway as MPIS dictates
Continue on pathway as MPIS dictates
No Yes
Yes
No Yes
Initiate Phase 1: Albuterol via continuous neb:
o <20kg: 10 mg/hro 20kg: 20 mg/hr
Initiate Albuterol Wean Protocol*o Option: If improving on 20 mg/hr, wean to
10 mg/hr prior to going to q2hr If not tolerating oral steroid:
o Methylprednisolone 1 mg/kg/dose IV q6hr (<12 yr old: max 60 mg/day; 12 max 80 mg/day)
Place PIV, if not already done CR monitor w/continuous pulse oximetry Vital signs q4hr, MPIS q2hr Initiate Asthma Education
(nebulizer can be used if pt sleeping or unable to perform proper MDI technique)
Continue Inhaled Corticosteroids (Appendix A, Appendix B, Appendix C, Appendix D), and consider ordering medications for bedside delivery if not done
Discontinue O2 when RA sat >92% Intermittent pulse ox once off O2 Vital signs q4hr, MPIS q4hr Complete Asthma Education Supply nebulizer or spacer, if needed
Discharge Criteria:Off supplemental oxygen, MPIS 5 on q4hr albuterol, hydrated without need for IVFs,
asthma home management plan of care complete, asthma education complete and family given copy, appropriate follow up in place
Discharge Medications (to be outlined in Asthma Action Plan) Albuterol MDI with spacer: 4 puffs (or 2.5mg via neb) q4hr while awake Total oral steroid x3-5 days (prednisone/prednisolone vs 2nd dose of dexamethasone) Controller therapy (Appendix C, Appendix D), based on chronic severity (Appendix A,
Appendix B) Screen for Flu vaccine (Oct-March); administer if indicatedConsider transfer
to PICU
MPIS SCORING TOOLO2 Saturation
(RA)Accessory
Muscle Use I:E Ratio Wheezing Heart Rate Respiratory Rate
Score Score Score Score <3 yr old >3 yr old Score <6 yr old >6 yr old Score
The following tests and treatments are NOT routinely indicated for the treatment of asthma: Ipratropium bromide should
not be administered after 24 hours of hospitalization
Chest x-rays (features typically associated with positive chest x-ray findings include fever, no family history of asthma, and localized lung exam findings)
Antibiotics (unless diagnosed with a bacterial infection)
STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERMThe stepwise approach tailors the selection of medication to the level of asthma severity (see page 5) or asthma control (see page 6).
The stepwise approach is meant to help, not replace, the clinical decisionmaking needed to meet individual patient needs.
At each step: Patient education, environmental control, and management of comorbidities
0–4
ye
ars
of
ag
e
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2.
PreferredTreatment†
SABA as needed
low-dose ICS medium-dose ICS
medium-dose ICS+either LABA or montelukast
high-dose ICS+either LABA or montelukast
high-dose ICS+either LABA or montelukast+oral corticosteroids
AlternativeTreatment†,‡
cromolyn or montelukast
If clear benefit is not observed in 4–6 weeks, and medication technique and adherence are satisfactory, consider adjusting therapy or alternate diagnoses.
Quick-Relief Medication
�� SABA as needed for symptoms; intensity of treatment depends on severity of symptoms.�� With viral respiratory symptoms: SABA every 4–6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if asthma exacerbation is severe or patient has history of severe exacerbations.�� Caution: Frequent use of SABA may indicate the need to step up treatment.
5–1
1 ye
ars
of
ag
e
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
PreferredTreatment†
SABA as needed low-dose ICS low-dose ICS+either LABA, LTRA, or theophylline(b)
OR
medium-dose ICS
medium-dose ICS+LABA
high-dose ICS+LABA
high-dose ICS+LABA+oral corticosteroids
AlternativeTreatment†,‡
cromolyn, LTRA, or theophylline§
medium-dose ICS+either LTRA or theophylline§
high-dose ICS+either LTRA or theophylline§
high-dose ICS +either LTRA or theophylline§
+oral corticosteroids
Consider subcutaneous allergen immunotherapy for patients who have persistent, allergic asthma.
Quick-Relief Medication
�� SABA as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.�� Caution: Increasing use of SABA or use >2 days/week for symptom relief (not to prevent EIB ) generally indicates inadequate control and the need to step up treatment.
≥12
ye
ars
of
ag
e
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
PreferredTreatment†
SABA as needed low-dose ICS low-dose ICS+LABA
OR
medium-dose ICS
medium-dose ICS+ LABA
high-dose ICS+LABA
AND
consider omalizumab for patients who have allergies††
high-dose ICS+LABA+oral corticosteroid§§
AND
consider omalizumab for patients who have allergies††
AlternativeTreatment†,‡
cromolyn, LTRA,or theophylline§
low-dose ICS+either LTRA,theophylline,§ or zileuton‡‡
medium-dose ICS+either LTRA, theophylline,§ or zileuton‡‡
Consider subcutaneous allergen immunotherapy for patients who have persistent, allergic asthma.
Quick-Relief Medication
�� SABA as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.�� Caution: Use of SABA >2 days/week for symptom relief (not to prevent EIB ) generally indicates inadequate control and the need to step up treatment.
† Treatment options are listed in alphabetical order, if more than one. ‡ If alternative treatment is used and response is inadequate, discontinue and use preferred treatment before stepping up.§ Theophylline is a less desirable alternative because of the need to monitor serum concentration levels.
Based on evidence for dust mites, animal dander, and pollen; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults.
†† Clinicians who administer immunotherapy or omalizumab should be prepared to treat anaphylaxis that may occur.‡‡ Zileuton is less desirable because of limited studies as adjunctive therapy and the need to monitor liver function.§§ Before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton, may be considered, although this approach has not been studied
in clinical trials.
ASSESS CONTROL:
STEP UP IF NEEDED (first, check medication adherence, inhaler technique, environmental control, and comorbidities)
STEP DOWN IF POSSIBLE (and asthma is well controlled for at least 3 months)
�� 0.25–2 mg/kg daily in single dose in a.m. or every other day as needed for control�� Short course “burst”: 1–2 mg/kg/day, max 60 mg/d for 3–10 days
�� 0.25–2 mg/kg daily in single dose in a.m. or every other day as needed for control�� Short course “burst”: 1–2 mg/kg/day, max 60 mg/d for 3–10 days
�� 7.5–60 mg daily in single dose in a.m. or every other day as needed for control�� Short course “burst”: to achieve control, 40–60 mg/day as single or 2 divided doses for 3–10 days
* Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use.
† Abbreviations: DPI, dry powder inhaler; IgE, immunoglobulin E; MDI, metered-dose inhaler; N/A, not available (not approved, no data available, or safety and efficacy not established for this age group).
The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician must monitor the patient’s response on several clinical parameters (e.g., symptoms; activity level; measures of lung function) and adjust the dose accordingly. Once asthma control is achieved and sustained at least 3 months, the dose should be carefully titrated down to the minimum dose necessary to maintain control.
10 Asthma Care Quick Reference
RETURN TOTHE BEGINNING
CONTACTS: CHRISTINA GIUDICE, APRN | ALEX HOGAN, MD | ANAND SEKARAN, MD