THIS PATHWAY

CLINICAL PATHWAY: SERVES AS A GUIDE

Inpatient Asthma
AND DOES NOT
REPLACE CLINICAL
JUDGMENT.

The following tests and treatments

Inclusion Criteria: 1 yrs old, inadequate response to ED asthma treatment (see ED Asthma Pathway)
are NOT routinely indicated for the
Exclude Criteria: < 1yr old, primary diagnosis of bronchiolitis or pneumonia, active cardiac disease
treatment of asthma:
 Ipratropium bromide should
Admit to Medical/ Surgical Unit not be administered after 24
 Oxygen: Titrate per order hours of hospitalization
 Oral Steroid:  Chest x-rays (features typically
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 associated with positive chest
dexamethasone. Total steroid course: 5 days) x-ray findings include fever,
o OR give additional dose of Dexamethasone 0.6 mg/kg (max no family history of asthma,
16mg) PO/IM prior to discharge and localized lung exam
 Determine initial MPIS findings)
 If poor PO, place PIV and administer IVF with potassium MPIS 7-10
MPIS 11  Use asthma-specific H&P to document asthma severity and control  Antibiotics (unless diagnosed
(Appendix A, Appendix B, Appendix C) with a bacterial infection)
 Consider ordering medications for bedside delivery on admission

Initiate Phase 1:
 Albuterol via continuous neb:
o <20kg: 10 mg/hr
o 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
Improvement?
(Two consecutive scores in
appropriate range)
No
Initiate Phase 2 and follow
MPIS 13 x 1
 Increase Albuterol to
20 mg/hr if on 10 mg/hr
 Notify attending
 Obtain PICU consult
 Consider Mg sulfate
Continue on pathway
Improvement? Yes
No
Consider transfer
to PICU
Initiate Phase 2:
 Albuterol MDI w/ spacer 8 puffs q2hr
(nebulizer can be used if patient sleeping or unable to
perform proper MDI technique)
 Initiate Albuterol Wean Protocol*
 Assess severity and treatment recommendations, start
Inhaled Corticosteroids (Appendix A, Appendix B,
Appendix C, Appendix D)
 Initiate Asthma Education and home treatment plan
 Discontinue CR monitor
 Vital signs q4hr, MPIS q2hr
 Discontinue O2 when RA sat >92%
 Intermittent pulse ox once off O2
Improvement?
(MPIS 6 x2)
No Yes
Continue on pathway Initiate Phase 3
as MPIS dictates  Albuterol MDI w/ spacer 8 puffs q4hr
(nebulizer can be used if pt sleeping or
Yes unable to perform proper MDI technique)
 Continue Inhaled Corticosteroids (Appendix
A, Appendix B, Appendix C, Appendix D),
pathway 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)
as MPIS dictates
 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 indicated

MPIS SCORING TOOL

* ALBUTEROL WEAN PROTOCOL:
 RT s wean Albuterol O2 Saturation Accessory
(RA) Muscle Use I:E Ratio Wheezing Heart Rate Respiratory Rate
according to this MPIS-driven
protocol
 Wean when two consecutive
Score Score Score Score <3 yr old >3 yr old Score <6 yr old >6 yr old Score
scores are in appropriate
None: Good
range
>95% 0 None 0 2:1 0 aeration 0 <120 <100 0 <30 <20 0
 RT s inform MD/APRN/PA of
End
ALL changes in Albuterol 93-95% 1 Mild 1 1:1 1 expiratory 1 121-140 101-120 1 31-45 21-35 1
dosing
 Any escalation in care Insp/Exp:
requires an exam by MD/ 90-92% 2 Moderate 2 1:2 2 Good aeration 2 141-160 121-140 2 46-60 36-50 2
APRN/PA at bedside Insp/Exp:
 MD/APRN/PA can authorize Decreased
variance from protocol <90% 3 Severe 3 1:3 3 aeration 3 >160 >140 3 >60 >50 3

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 CLINICAL PATHWAY: THIS PATHWAY
SERVES AS A GUIDE
Inpatient Asthma AND DOES NOT
Appendix A: Simplified Controller Flowchart REPLACE CLINICAL
JUDGMENT.

Assessing Asthma Severity and Treatment Recommendations: Ages 5 and Up

> 2 days/week but

Symptom Frequency 2 days/week Daily Throughout the day
NOT daily
Assess and Night time
2x/month 3-4x/month >1x/week Every Night
DOCUMENT awakenings
Asthma Control Albuterol for
2 days/week >2 days/week Daily
Several times per
for 2 Weeks Prior symptom control day

1 to Exacerbation Interfere with

None Minor Limitation Some Limitation Extremely Limited
normal activity
Exacerbations
Determine requiring systemic 0-1/year 2/year with more frequent or intense events = greater severity
severity if new steroids
diagnosis of If currently on Increase Step by 1
asthma medication & well If on meds, taking
NO appropriately*?
YES UNLESS well controlled
controlled, continue (all green answers above)
current treatment

2 Classify Asthma Worst symptom

documented above Intermittent Mild Persistent Moderate Persistent Severe Persistent
Severity determines severity

(STEP 3)
If starting tx: 1 Puff (STEP 3 or 4)
Fluti casone 110 BID
(STEP 2) If stepping up tx: 1 Puff 2 Puff Fluticasone/
(STEP 1)
5-11 Years Old 2 Puffs Fluticasone Fluti casone 110 BID + Salmeterol 115/21 BID
Albuterol PRN Montelukast
44 BID OR 2 Puffs Fl uticasone/
OR
Treatment Salmeterol 45/21 BID +/- Consult Pulmonary

3
Recommendation Montelukast

(NHLBI STEP (STEP 3)

(STEP 3 or 4)
CORRELARY) Fluticasone/
2 Puffs Fluticasone
(STEP 2) Salmeterol 115
(STEP 1) 44 BID +
12+ Years Old 2 Puffs Fluticasone mcg/21 mcg 2 Puff
Albuterol PRN Montelukast OR 2
44 BID BID vs Fluticasone
Puff Fluticasone 110
110mcg 2 Puffs BID
BID
+ Montelukast

4 Consult (PRN) Consult Pulmonology If: Patient Requires Step 5 Treatment, Or High Dose Inhaled Steroids
(2+ Puffs 110 for 5-11yo, 2+ puffs 220 for >12 year old)

*Taking Controller Medications Appropriately:

 Taking medications as prescribed >80% of the time (self report, pharmacy refills)
 Using correct technique (using a spacer correctly)
If insurance does not cover the recommended medication, see below for equivalent doses of inhaled steroids

Fluticasone Beclomethasone
Fluticasone/ Budesonide/ Mometasone/
Salmeterol Formoterol Formoterol Montelukast
Dosing (Flovent) (Qvar)
(Advair) (Symbicort) (Dulera)
Conversion <6 years old 4mg daily;
Chart 44 mcg 40 mcg 45/21 mcg 80/4.5 mcg 100/5 mcg 6-14 years old: 5mg daily;
>14 years old: 10mg daily
110 mcg 80 mcg 115/21 mcg 160/4.5 mcg 200/5 mcg

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THE BEGINNING

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 LAST UPDATED: 11.11.19
INITIAL VISIT: CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY
(in patients who are not currently taking long-term control medications)
Inpatient Asthma

Level of severity (Columns 2–5) is determined by events listed in Column 1 for both impairment (frequency and intensity of symptoms and functional limitations) and risk (of
exacerbations). Assess impairment by patient’s or caregiver’s recall of events during the previous 2–4 weeks; assess risk over the last year. Recommendations for initiating therapy
based on level of severity are presented in the last row.
CLINICAL PATHWAY:

Persistent
Intermittent
Components of Mild Moderate Severe

©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004

Severity
Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages Ages
0–4 years 5–11 years ≥12 years 0–4 years 5–11 years ≥12 years 0–4 years 5–11 years ≥12 years 0–4 years 5–11 years ≥12 years
Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day

Nighttime awakenings 0 ≤2x/month 1–2x/month 3–4x/month 3–4x/month >1x/week but not nightly >1x/week Often 7x/week

SABA use for >2 days/week but

>2 days/week
symptom control ≤2 days/week not daily and not more Daily Several times per day
but not daily
(not to prevent EIB ) than once on any day

Interference with
None Minor limitation Some limitation Extremely limited
normal activity
Appendix B: NHLBI Asthma Classification

Normal FEV1 Normal FEV1

Impairment
Lung function between between
exacerbations exacerbations
Not Not Not Not
FEV1 (% predicted) >80% >80% >80% >80% 60–80% 60–80% <60% <60%
applicable applicable applicable applicable

FEV1 /FVC >85% Normal† >80% Normal† 75–80% Reduced 5%† <75% Reduced >5%†

RETURN TO
≥2 exacerb.

THE BEGINNING
in 6 months, Generally, more frequent and intense events indicate greater severity.
or wheezing
Asthma exacerbations ≥4x per
requiring oral systemic year lasting
0–1/year ≥2/year Generally, more frequent and intense events indicate greater severity.
corticosteroids‡ >1 day
AND risk

CONTACTS: CHRISTINA GIUDICE, APRN | ALEX HOGAN, MD | ANAND SEKARAN, MD

Risk
factors for
persistent
asthma

Consider severity and interval since last asthma exacerbation. Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV1 .

Recommended Step for Step 3

Initiating Therapy Step 3
medium-dose Step 4
Step 3 medium-dose Step 3 Step 3
(See “Stepwise Approach for Step 1 Step 2 ICS option or 5
ICS option
Managing Asthma Long Term,” or Step 4
page 7)
The stepwise approach is meant Consider short course of oral systemic corticosteroids.
to help, not replace, the clinical
decisionmaking needed to meet In 2–6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed.
individual patient needs. For children 0–4 years old, if no clear benefit is observed in 4–6 weeks, consider adjusting therapy or alternate diagnoses.

Abbreviations: EIB, exercise-induced bronchospam; FEV1 , forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; SABA, short-acting beta2-agonist.

† Normal FEV1 /FVC by age: 8–19 years, 85%; 20–39 years, 80%; 40–59 years, 75%; 60–80 years, 70%.
‡ Data are insufficient to link frequencies of exacerbations with different levels of asthma severity. Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids)
Asthma Care Quick Reference

indicate greater underlying disease severity. For treatment purposes, patients with ≥2 exacerbations may be considered to have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
5
JUDGMENT.
THIS PATHWAY

AND DOES NOT

REPLACE CLINICAL
SERVES AS A GUIDE
 LAST UPDATED: 11.11.19
6
FOLLOW-UP VISITS: ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY
Inpatient Asthma

Level of control (Columns 2–4) is based on the most severe component of impairment (symptoms and functional limitations) or risk (exacerbations). Assess impairment by patient’s or caregiver’s
recall of events listed in Column 1 during the previous 2–4 weeks and by spirometry and/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment,
such as inquiring whether the patient’s asthma is better or worse since the last visit. Assess risk by recall of exacerbations during the previous year and since the last visit. Recommendations for
adjusting therapy based on level of control are presented in the last row.
CLINICAL PATHWAY:

Well Controlled Not Well Controlled Very Poorly Controlled

Components of Control Ages Ages Ages Ages Ages Ages Ages Ages Ages

©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004

0–4 years 5–11 years ≥12 years 0–4 years 5–11 years ≥12 years 0–4 years 5–11 years ≥12 years
≤2 days/week but >2 days/week or
Symptoms ≤2 days/week not more than ≤2 days/week >2 days/week multiple times on >2 days/week Throughout the day
once on each day ≤2 days/week

Nighttime awakenings ≤1x/month ≤2x/month >1x/month ≥2x/month 1–3x/week >1x/week ≥2x/week ≥4x/week
Asthma Care Quick Reference

Interference with
None Some limitation Extremely limited
normal activity

SABA use for

symptom control ≤2 days/week >2 days/week Several times per day
(not to prevent EIB )
Appendix B: NHLBI Asthma Classification

Lung function

FEV1 (% predicted)
or peak flow Not applicable Not applicable Not applicable

Impairment
>80% >80% 60–80% 60–80% <60% <60%
(% personal best)

FEV1 /FVC >80% Not applicable 75–80% Not applicable <75% Not applicable

Validated questionnaires†

RETURN TO
ATAQ Not applicable Not applicable 0 Not applicable Not applicable 1–2 Not applicable Not applicable 3–4

THE BEGINNING
ACQ ≤0.75‡ ≥1.5 Not applicable
ACT ≥20 16–19 ≤15

Asthma exacerbations 0–1/year 2–3/year ≥2/year >3/year ≥2/year

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requiring oral systemic
corticosteroids§ Consider severity and interval since last asthma exacerbation.

Reduction in lung
Evaluation requires long-term Evaluation requires long-term Evaluation requires long-term

Risk
growth/Progressive loss Not applicable Not applicable Not applicable
follow-up care. follow-up care. follow-up care.
of lung function

Treatment-related Medication side effects can vary in intensity from none to very troublesome and worrisome.
adverse effects The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

Recommended Action Step up at least

Step up 1 step Step up 1 step
for Treatment 1 step Consider short course of oral systemic corticosteroids.

(See “Stepwise Approach for Maintain current step. Reevaluate in 2–6 weeks to achieve control. Step up 1–2 steps.
Managing Asthma Long Term,” Regular follow-up every 1–6 months.
page 7) For children 0–4 years, if no clear benefit observed in 4–6 Reevaluate in 2 weeks to achieve control.
Consider step down if well controlled for at least weeks, consider adjusting therapy or alternative diagnoses.
The stepwise approach is meant
to help, not replace, the clinical 3 months.
Before step up in treatment:
decisionmaking needed to meet Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used,
individual patient needs. discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.

Abbreviations: ACQ, Asthma Control Questionnaire©; ACT, Asthma Control TestTM; ATAQ, Asthma Therapy Assessment Questionnaire©; EIB, exercise-induced bronchospasm; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second;
SABA, short-acting beta2-agonist.

† Minimal important difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.
‡ ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.
§ Data are insufficient to link frequencies of exacerbations with different levels of asthma control. Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids)
indicate poorer asthma control.
JUDGMENT.
THIS PATHWAY

AND DOES NOT

REPLACE CLINICAL
SERVES AS A GUIDE
 CLINICAL PATHWAY: THIS PATHWAY
SERVES AS A GUIDE
Inpatient Asthma AND DOES NOT
Appendix C: NHLBI Step-Up Therapy REPLACE CLINICAL
JUDGMENT.

Asthma Care Quick Reference 7

STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERM

The stepwise approach tailors the selection of medication to the level of asthma severity (see page 5) or asthma control (see page 6).
Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids)

The stepwise approach is meant to help, not replace, the clinical decisionmaking needed to meet individual patient needs.
Abbreviations: ACQ, Asthma Control Questionnaire©; ACT, Asthma Control TestTM; ATAQ, Asthma Therapy Assessment Questionnaire©; EIB, exercise-induced bronchospasm; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second;
discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.

STEP UP IF NEEDED (first, check medication adherence, inhaler technique, environmental control, and comorbidities)
ASSESS
CONTROL:
STEP DOWN IF POSSIBLE (and asthma is well controlled for at least 3 months)

STEP 5 STEP 6
STEP 3 STEP 4
STEP 1 STEP 2
At each step: Patient education, environmental control, and management of comorbidities

Intermittent Persistent Asthma: Daily Medication

Asthma Consult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2.

Preferred SABA as low-dose ICS medium-dose medium-dose high-dose ICS high-dose ICS
Treatment† needed ICS ICS + +
+ either LABA or either LABA or
0–4 years of age

either LABA or montelukast montelukast

montelukast +
oral corticosteroids

Alternative cromolyn or
Treatment†,‡ montelukast

If clear benefit is not observed in 4–6 weeks, and medication technique and adherence are satisfactory,
consider adjusting therapy or alternate diagnoses.

ƒƒ SABA as needed for symptoms; intensity of treatment depends on severity of symptoms.

Quick-Relief ƒƒ With viral respiratory symptoms: SABA every 4–6 hours up to 24 hours (longer with physician consult). Consider short
Medication course of oral systemic corticosteroids if asthma exacerbation is severe or patient has history of severe exacerbations.
ƒƒ Caution: Frequent use of SABA may indicate the need to step up treatment.
Intermittent Persistent Asthma: Daily Medication
Asthma Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.

Preferred SABA as needed low-dose ICS low-dose ICS medium-dose high-dose ICS high-dose ICS
Treatment† + ICS + +
either LABA, + LABA LABA
LTRA, or LABA +
5–11 years of age

theophylline(b) oral corticosteroids

OR
Alternative cromolyn, LTRA, medium-dose ICS high-dose ICS high-dose ICS
medium-dose
Treatment†,‡ or theophylline§ + + +
ICS either LTRA or either LTRA or either LTRA or
theophylline§ theophylline§ theophylline§
Consider subcutaneous allergen immunotherapy for +
patients who have persistent, allergic asthma. oral corticosteroids

ƒƒ SABA as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments
§ Data are insufficient to link frequencies of exacerbations with different levels of asthma control.

Quick-Relief every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
Medication ƒƒ Caution: Increasing use of SABA or use >2 days/week for symptom relief (not to prevent EIB ) generally indicates
† Minimal important difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.

inadequate control and the need to step up treatment.

Intermittent Persistent Asthma: Daily Medication

Asthma Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.

Preferred SABA as needed low-dose ICS low-dose ICS medium-dose high-dose ICS high-dose ICS
‡ ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.

Treatment† + ICS + +
LABA + LABA LABA
OR LABA AND +
oral
≥12 years of age

medium-dose ICS consider

corticosteroid§§
omalizumab for
Alternative cromolyn, LTRA, low-dose ICS medium-dose ICS patients who AND
Treatment†,‡ or theophylline§ + + have allergies†† consider
either LTRA, either LTRA, omalizumab for
theophylline,§ theophylline,§ patients who
or zileuton‡‡ or zileuton‡‡ have allergies††
Consider subcutaneous allergen immunotherapy
for patients who have persistent, allergic asthma.

ƒƒ SABA as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments
SABA, short-acting beta2-agonist.

indicate poorer asthma control.

Quick-Relief every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
Medication ƒƒ Caution: Use of SABA >2 days/week for symptom relief (not to prevent EIB ) generally indicates inadequate control
individual patient needs.

and the need to step up treatment.

Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled
short-acting beta2-agonist.
† 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.

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LAST UPDATED: 11.11.19

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 LAST UPDATED: 11.11.19
8
Inpatient Asthma

ESTIMATED COMPARATIVE DAILY DOSAGES: INHALED CORTICOSTEROIDS FOR LONG-TERM ASTHMA CONTROL
CLINICAL PATHWAY:

0–4 years of age 5–11 years of age ≥12 years of age

©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004

Daily Dose Low Medium High Low Medium High Low Medium High

MEDICATION

Beclomethasone MDI† N/A N/A N/A 80–160 mcg >160–320 mcg >320 mcg 80–240 mcg >240–480 mcg >480 mcg

40 mcg/puff 1–2 puffs 3–4 puffs 1–3 puffs 4–6 puffs

Asthma Care Quick Reference

2x/day 2x/day 2x/day 2x/day

1 puff 2x/day 2 puffs 2x/day 1 puff am, 2–3 puffs ≥4 puffs

80 mcg/puff ≥3 puffs 2x/day
2 puffs pm 2x/day 2x/day
Appendix D: Comparative Daily Dosages

Budesonide DPI† N/A N/A N/A 180–360 mcg >360–720 mcg >720 mcg 180–540 mcg >540–1,080 mcg >1,080 mcg

90 mcg/inhalation 1–2 inhs† 2x/day 3–4 inhs† 2x/day 1–3 inhs† 2x/day

180 mcg/ 2 inhs† 2x/day ≥3 inhs† 2x/day 1 inh† am, 2–3 inhs† 2x/day ≥4 inhs† 2x/day
inhalation 2 inhs† pm

Budesonide Nebules 0.25–0.5 mg >0.5–1.0 mg >1.0 mg 0.5 mg 1.0 mg 2.0 mg N/A N/A N/A

RETURN TO
THE BEGINNING
0.25 mg 1–2 nebs†/day 1 neb† 2x/day

0.5 mg 1 neb†/day 2 nebs†/day 3 nebs†/day 1 neb†/day 1 neb† 2x/day

1.0 mg 1 neb†/day 2 nebs†/day 1 neb†/day 1 neb† 2x/day

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Ciclesonide MDI† N/A N/A N/A 80–160 mcg >160–320 mcg >320 mcg 160–320 mcg >320–640 mcg >640 mcg
1 puff am,
80 mcg/puff 1–2 puffs/day 2 puffs pm– ≥3 puffs 2x/day 1–2 puffs 2x/day 3–4 puffs 2x/day
2 puffs 2x/day

160 mcg/puff 1 puff/day 1 puff 2x/day ≥2 puffs 2x/day 2 puffs 2x/day ≥3 puffs 2x/day

Flunisolide MDI† N/A N/A N/A 160 mcg 320–480 mcg ≥480 mcg 320 mcg >320–640 mcg >640 mcg

80 mcg/puff 1 puff 2x/day 2–3 puffs 2x/day ≥4 puffs 2x/day 2 puffs 2x/day 3–4 puffs 2x/day ≥5 puffs 2x/day

It is preferable to use a higher mcg/puff or mcg/inhalation formulation to achieve as low a number of puffs or inhalations as possible.
† Abbreviations: DPI, dry powder inhaler (requires deep, fast inhalation); inh, inhalation; MDI, metered dose inhaler (releases a puff of medication); neb, nebule.
JUDGMENT.
THIS PATHWAY

AND DOES NOT

REPLACE CLINICAL
SERVES AS A GUIDE
 LAST UPDATED: 11.11.19
ESTIMATED COMPARATIVE DAILY DOSAGES:
INHALED CORTICOSTEROIDS FOR LONG-TERM ASTHMA CONTROL (continued)
Inpatient Asthma

0–4 years of age 5–11 years of age ≥12 years of age

Daily Dose Low Low Low
CLINICAL PATHWAY:

Medium High Medium High Medium High

MEDICATION

©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004

Fluticasone MDI† 176 mcg >176–352 mcg >352 mcg 88–176 mcg >176–352 mcg >352 mcg 88–264 mcg >264–440 mcg >440 mcg

44 mcg/puff 2 puffs 2x/day 3–4 puffs 1–2 puffs 3–4 puffs 1–3 puffs
2x/day 2x/day 2x/day 2x/day

110 mcg/puff ≥2 puffs 2 puffs 2x/day 3 puffs 2x/day

1 puff 2x/day 1 puff 2x/day ≥2 puffs 2x/day
2x/day

220 mcg/puff 1 puffs 2x/day ≥2 puffs 2x/day

Appendix D: Comparative Daily Dosages

Fluticasone DPI† N/A N/A N/A 100–200 mcg >200–400 mcg >400 mcg 100–300 mcg >300–500 mcg >500 mcg

50 mcg/inhalation 1–2 inhs† 2x/day 3–4 inhs† 2x/day 1–3 inhs† 2x/day

100 mcg/inhalation 1 inh† 2x/day 2 inhs† 2x/day >2 inhs† 2x/day 2 inhs† 2x/day ≥3 inhs† 2x/day

250 mcg/inhalation 1 inh† 2x/day 1 inh† 2x/day ≥2 inhs† 2x/day

RETURN TO
Mometasone DPI† N/A N/A N/A 110 mcg 220–440 mcg >440 mcg 110–220 mcg >220–440 mcg >440 mcg

THE BEGINNING
110 mcg/inhalation 3–4 inhs† pm or
1 inh†/day 1–2 inhs† 2x/day ≥3 inhs† 2x/day 1–2 inhs† pm ≥3 inhs† 2x/day
2 inhs† 2x/day

220 mcg/inhalation 1–2 inhs†/day ≥3 inhs† divided 1 inh† pm 1 inh† 2x/day or ≥3 inhs† divided
in 2 doses 2 inhs† pm in 2 doses

CONTACTS: CHRISTINA GIUDICE, APRN | ALEX HOGAN, MD | ANAND SEKARAN, MD

It is preferable to use a higher mcg/puff or mcg/inhalation formulation to achieve as low a number of puffs or inhalations as possible.
† Abbreviations: DPI, dry powder inhaler (requires deep, fast inhalation); inh, inhalation; MDI, metered dose inhaler (releases a puff of medication); neb, nebule.

Therapeutic Issues Pertaining to Inhaled Corticosteroids (ICSs) for Long-Term Asthma Control
ƒƒ The most important determinant of appropriate dosing is the clinician’s judgment many European countries and in some scientific literature. Dry powder inhaler (DPI)
of the patient’s response to therapy. The clinician must monitor the patient’s doses are expressed as the amount of drug in the inhaler following activation.
response on several clinical parameters (e.g., symptoms; activity level; measures of
ƒƒ For children <4 years of age: The safety and efficacy of ICSs in children <1 year of
lung function) and adjust the dose accordingly. Once asthma control is achieved
age has not been established. Children <4 years of age generally require delivery of
and sustained at least 3 months, the dose should be carefully titrated down to the
ICS (budesonide and fluticasone MDI) through a face mask that fits snugly over nose
minimum dose necessary to maintain control.
and mouth to avoid nebulizing in the eyes. Face should be washed after treatment
ƒƒ Some doses may be outside package labeling, especially in the high-dose range. to prevent local corticosteroid side effects. For budesonide, the dose may be given
Budesonide nebulizer suspension is the only inhaled corticosteroid (ICS) with 1–3 times daily. Budesonide suspension is compatible with albuterol, ipratropium,
FDA-approved labeling for children <4 years of age. and levalbuterol nebulizer solutions in the same nebulizer. Use only jet nebulizers, as
ultrasonic nebulizers are ineffective for suspensions. For fluticasone MDI, the dose
ƒƒ Metered-dose inhaler (MDI) dosages are expressed as the actuator dose (amount
should be divided 2 times daily; the low dose for children <4 years of age is higher
leaving the actuator and delivered to the patient), which is the labeling required in the
Asthma Care Quick Reference

than for children 5–11 years of age because of lower dose delivered with face mask
United States. This is different from the dosage expressed as the valve dose (amount
and data on efficacy in young children.
of drug leaving the valve, not all of which is available to the patient), which is used in
9
JUDGMENT.
THIS PATHWAY

AND DOES NOT

REPLACE CLINICAL
SERVES AS A GUIDE
 CLINICAL PATHWAY: THIS PATHWAY
SERVES AS A GUIDE
Inpatient Asthma AND DOES NOT
Appendix D: Comparative Daily Dosages REPLACE CLINICAL
JUDGMENT.

10 Asthma Care Quick Reference

USUAL DOSAGES FOR OTHER LONG-TERM CONTROL MEDICATIONS*

Medication 0–4 years of age 5–11 years of age ≥12 years of age
Combined Medication (inhaled corticosteroid + long-acting beta2-agonist)
Fluticasone/Salmeterol — N/A† 1 inhalation 2x/day; dose 1 inhalation 2x/day; dose
DPI† 100 mcg/50 mcg, 250 mcg/50 mcg, or depends on level of depends on level of severity
500 mcg/50 mcg severity or control or control
MDI† 45 mcg/21 mcg, 115 mcg/21 mcg, or
230 mcg/21 mcg

Budesonide/Formoterol — N/A† 2 puffs 2x/day; dose 2 puffs 2x/day; dose depends

MDI† 80 mcg/4.5 mcg or 160 mcg/4.5 mcg depends on level of on level of severity or control
severity or control
Mometasone/Formoterol — N/A† N/A† 2 inhalations 2x/day; dose
MDI† 100 mcg/5 mcg depends on severity of asthma

Leukotriene Modifiers
Leukotriene Receptor Antagonists (LTRAs)
Montelukast — 4 mg or 5 mg chewable tablet, 4 mg every night at 5 mg every night at 10 mg every night at
4 mg granule packets, 10 mg tablet bedtime (1–5 years of age) bedtime (6–14 years of age) bedtime

Zafirlukast — 10 mg or 20 mg tablet N/A† 10 mg 2x/day 40 mg daily

Take at least 1 hour before or 2 hours after a meal. (7–11 years of age) (20 mg tablet 2x/day)
Monitor liver function.

5-Lipoxygenase Inhibitor
Zileuton — 600 mg tablet N/A† N/A† 2,400 mg daily
Monitor liver function. (give 1 tablet 4x/day)

Immunomodulators
Omalizumab (Anti IgE†) — N/A† N/A† 150–375 mg subcutaneous
Subcutaneous injection, 150 mg/1.2 mL following every 2–4 weeks, depending
reconstitution with 1.4 mL sterile water for injection on body weight and
Monitor patients after injections; be prepared to treat pretreatment serum IgE level
anaphylaxis that may occur.

Cromolyn
Cromolyn — Nebulizer: 20 mg/ampule 1 ampule 4x/day, N/A† 1 ampule 4x/day 1 ampule 4x/day
<2 years of age

Methylxanthines
Theophylline — Starting dose 10 mg/kg/ Starting dose 10 mg/ Starting dose 10 mg/kg/day
Liquids, sustained-release tablets, and capsules day; usual maximum: kg/day; usual maximum: up to 300 mg maximum;
Monitor serum concentration levels. ƒƒ <1 year of age: 0.2 (age in 16 mg/kg/day usual maximum:
weeks) + 5 = mg/kg/day 800 mg/day
ƒƒ ≥1 year of age:
16 mg/kg/day

Inhaled Long-Acting Beta2-Agonists (LABAs) – used in conjunction with ICS† for long-term control; LABA is NOT to be used as monotherapy
Salmeterol — DPI† 50 mcg/blister N/A† 1 blister every 12 hours 1 blister every 12 hours

Formoterol —DPI† 12 mcg/single-use capsule N/A† 1 capsule every 12 hours 1 capsule every 12 hours

Oral Systemic Corticosteroids

Methylprednisolone — 2, 4, 8, 16, 32 mg tablets ƒƒ 0.25–2 mg/kg daily
in single dose in a.m.
or every other day as
Prednisolone — 5 mg tablets; 5 mg/5 cc, 15 mg/5 cc needed for control
ƒƒ Short course “burst”:
1–2 mg/kg/day, max 60
Prednisone — 1, 2.5, 5, 10, 20, 50 mg tablets; mg/d for 3–10 days
5 mg/cc, 5 mg/5 cc
ƒƒ 0.25–2 mg/kg daily
in single dose in a.m.
or every other day as
needed for control
ƒƒ Short course “burst”:
1–2 mg/kg/day, max 60
mg/d for 3–10 days
ƒƒ 7.5–60 mg daily in single
dose in a.m. or every other
day as needed for control
ƒƒ 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.

RETURN TO
THE BEGINNING

CONTACTS: CHRISTINA GIUDICE, APRN | ALEX HOGAN, MD | ANAND SEKARAN, MD

LAST UPDATED: 11.11.19

©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004


CLINICAL PATHWAY:
Emergency Department Asthma
Exclusion Criteria: <1 yrs old, bronchiolitis or pneumonia as primary diagnosis, chronic cardiac or lung disease other than asthma
MPIS 6
Discharge Criteria/Instructions:
 MDI/spacer teach
 F/u with PCP in 2-3 days
 Medications: Albuterol PRN
*Consider Prednisolone/Prednisone for patients that
might benefit from longer steroids. Start 24 hours
after Dexamethasone dose.
MPIS 6
Observe for 1 hour
 Reassess
 Calculate MPIS
MPIS 6
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.
CONTACTS: ERIC HOPPA, MD | KRISTIN WELCH, MD
LAST UPDATED: 10.21.19
©2019 Connecticut Children’s Medical Center. All rights reserved. 19-004
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 5
Initial Assessment (MPIS 5):
Dexamethasone 0.6 mg/kg (max 16 mg) PO/IM
(Can substitute with prednisolone/prednisone/methylprednisolone 2 mg/kg at initial
provider s discretion. Can omit if already on oral steroids.)
MPIS 5-6 MPIS 7
 Albuterol 4 puffs MDI/spacer
Albuterol 5 mg/
(with teach) OR
MPIS 7 Ipratropium 500 mcg
Albuterol 2.5 mg neb
via nebulizer
 Calculate MPIS
 Reassess in 15-30 minutes
 Calculate MPIS
Albuterol 4 puffs
MDI/spacer
MPIS 6 MPIS 7
(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 7-8 MPIS 9-10 MPIS 11-12 MPIS 13
Medications: Medications: Medications: Medications:
 Albuterol 5 mg neb  Resume continuous  Resume continuous  Resume continuous
q2hr Albuterol at Albuterol at Albuterol at 20 mg/hr
 ED provider to place previous dose previous dose  Consider additional
order Initiate  ED provider to place  ED provider to place therapies per PICU
Albuterol wean order Initiate order Initiate consultation (e.g,
 RT will rescore MPIS Albuterol wean Albuterol wean methylprednisolone if
and speak with  RT will rescore MPIS  RT will rescore MPIS not done, MgSO4,
provider to place and speak with and speak with terbutaline)
MPIS 7
appropriate provider to place provider to place
Albuterol order appropriate appropriate Nursing:
Albuterol order Albuterol order  Place PIV (if not done)
Nursing:
 Place PIV if Nursing: Nursing: Consults:
inadequate oral  Place PIV if  Place PIV  Consult PICU attending
intake, or unable to inadequate oral in ED: observe in ED for
take oral steroids intake, or unable to further improvement
take oral steroids vs admission to PICU
Admission:
- Admit to MS floor or PICU
in discussion with IMT and
Admission:
PICU attending
 Admit to MS (PHM or Pulmonary if patient is known to them)
- If to be admitted to MS floor,
 See Inpatient Asthma Pathway
ED provider to place order
At time of transfer: Initiate Albuterol wean . RT
will rescore MPIS and speak
 Re-assess patient and calculate MPIS
with provider to place
 Inform attending and admitting team if MPIS is increasing
appropriate
 Hold transfer if MPIS 13 and consider PICU consult
Albuterol order.