Hamad Medical Corporation

Department of Pediatrics
Pediatric Emergency Centers Protocol

TITLE : Practice Guidelines for Bronchial Asthma/Reactive

Airway Disease (RAD)

PURPOSE : To provide PEC Physicians the essential guidelines for

management of acute asthma and RAD

PROTOCOL :

Subjective:
Important points to document at each visit.
1. Frequency of and/or last exacerbation
2. Hospitalizations-last admit, ICU, intubations
3. Last course of steroids
4. Triggers – smoke, pollen, infections
5. Current medications in detail, recent use history and
compliance
6. Duration of current attack

Objective:
1. Overall appearance, speech, cyanosis
2. Vital signs
3. Work of breathing, lung exam, mental status

Assessment:
1. Severity of acute episode (mild, moderate or severe)
2. Pulse oximetry
3. Peak flow (when applicable & feasible)
4. Chest x-ray – indications

New onset wheezing (Gershel’s criteria – HR >160,
RR>60, focal finding)

Clinical suspicion of pneumonia, pneumothorax,
atelectasis, FB

No improvement after treatment

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History suggestive of a secondary cause of wheezing,
congestive heart failure etc or signs of systemic
disease or onset of wheezing in newborn period

5. Sinus x-ray – if h/o persistent cough

Plan:

1. Therapy
a. Bronchodilators
- Ventolin – MD1, Nebulizer
- Ipratroprium Bromide (Atrovent)
- Terbutaline

b. Steroids
- Oral vs parenteral (for loading)

c. Chronic/Prophylactic
- Pulmicort Nebulizations
- Inhaled steroids

d. Ventolin
- In severe cases Ventolin at a dose of 0.1 to
0.3mg/Kg should be nebulized on back to back
basis for 3-4 doses per hour for the first 2 hours,
provided that patient gets proper clinical evaluation
after each dose with proper documentation.
- Continuous Ventolin dose = 4 cc / 14 cc NS x 1-2
hours starting dose. Can increase up to 8 cc/ 20 cc
NS. Oxygen 8-10 LPM.

e. Ipratroprium Bromide (Atrovent)

- Sicker children should get nebulized atrovent mixed
with ventolin
- Useful for children already using inhaled albuterol at
home
- Upper dosage limit: 500 Mcg (250Mcg if wt <40 Kg)
three times, 20 - minutes apart then Q 4-6 hrs

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 - Maximum effect in 30 – 60 minutes
- Not a routine at home medication

f. Mg Sulphate:
- Dose 20-50mg/Kg IV slowly over 20 minutes with
target serum Mg++ level of 3-4mg/dl 1-4 hours after
infusion g. Terbultaline:
- Should only be used in severe exacerbations not
responding to the usual measures.
- Dose: initial bolus 10meq/kg over 5-15 minutes, then
infusion 0.4meq/kg/min, increase by o.2meq/kg/min
up to maximum of 3-6 meq/kg/min

2. Assessment & Monitoring:

During patient stay in PEC, regular clinical assessment of

patient’s response to treatment should be kept and
documented.

3. Hospitalization
a. Hypoxia – pulse ox <92
b. Respiratory distress despite therapy
c. h/o severe asthma exacerbations
d. underlying lung disease
e. poor compliance at home or difficult home conditions.
f. Inadequate response to PEC measures in 12 hours.
g. Incomplete resolution of symptoms within 24 hours.
h. Frequent visits to PEC for this exacerbration within 48
hours (3 or more visits)
i. PICU transfer if no response to initial aggressive
measures at PEC and or rapid detoriation of asthma,
presence of mental status changes or signs of
impending respiratory arrest.
4. Follow-up
Must document plan including home care instructions

5. Pediatric Allergy-Immunology (PAIC) or Pulmonary Clinics

(PPC) referrals
- Up to discretion of PEC Physician

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Critical Components:

1. Is there documentation of any past history of

wheezing/asthma?

2. Are current asthma medications documented?

3. Is there documentation of the initial respiratory exam to

include the
respiratory effort and the lung exam?

4. Is the respiratory exam documented after aerosol treatments

by the provider – to include the time, respiratory effort, and
lung exam – after each treatment?

References:

1. Textbook of Pediatric Emergency Medicine, Gary R.

Fleisher, Stephen Ludwig.

2. Guidelines on Asthma Treatment at PEC Prepared by

Mohammad Ehlayel, MD and Ibrahim Janahi, MD

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 Management Outline Of Asthma Exacerbation
Initial assessment:
• History, PE, O2 saturation.
• Other tests as indicated.

Initial Treatment:
• Nebulized short Inhaled β2-agonists
• O2 to achieve O2sat > 95 % in children
• Systemic steroids.

Repeat Assessment
• PE, O2 saturation
• Other tests indicated

Moderate Episode: Severe Episode:

• PEFR: 60-80% of predicted • PEFR: <60% of predicted
• PE: moderate symptoms • PE: severe symptomsat rest.
• Inhaled β 2-agonists Q 60 minutes • History : high-risk patients.
• Consider corticosteroids • No improvement after initial treatment.
• Continue Rx 1-3 hours, provided there is • Inhaled B2-agonist, Q 1 hour or continuous, + inhaled
improvement. anticholinergic
• Oxygen.
• Systemic steroids.
Good Response: Incomplete Response within 1-2 hrs: Poor Response within 1-2 hrs:
• Response sustained 60 min • Hx: high-risk patient • Hx: high-risk patient.
after last Rx • PE: mild to moderate • PE: severe symptoms,
• PE: normal. symptoms drowsiness confusion.
• PEFR>70% • PEFR: 50-70% O2 • PEFR <30%.
• No distress saturation: Not improving • PO2 <60mm Hg.
• O2 Saturation >95% • PCO2 >45mm Hg.

Discharge Home: Admit to Hospital: Admit to ICU:

• Continue treatment with
Inhaled β2-agonists.
• Consider Oral steroids
• Medical follow-up
• Inhaled β2-agonists ± inhaled • Inhaled β2-agonists ±
anticholinergic. inhaled anticholinergic.
• Systemic steroids. • IV steroids
• Oxygen. • Consider SQ, IM or IV 2-
• Monitor PEF, O2 saturation, agonists.
HR • Oxygen
• Possible intubation & AV.

Improve Not Improve

Discharge Home: Admit to PICU:

If PEFR>70% • If no improvement within 6-12
Sustained improvement on Oral +/ hours.
Inhaled Medications

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 Hamad Medical Corporation
Department of Pediatrics
Pediatric Emergency Centers Protocol

TITLE: Bronchial Asthma/Reactive Airways Disease

Prepared By:
PEC clinical protocols team.

Dr. Ali Memon,

Dr. Sameer Azzam

Reviewed By:

PEC Consultant. Dr. Ali Memon

Approved by:

Dr. Ibrahim Janahi

Director of PEC

Hospital Administrator