13. Special Asthma Considerations for Inpatient

Patients who present with status asthmaticus that meet admission criteria are admitted to the General Pediatrics service. Both an Asthma Exacerbation clinical practice guideline and a powerplan are available for ordering inpatient.

• If patient is determined to fulfill the High Risk Asthma Program criteria, please order the High Risk asthma powerplan instead of Asthma CPG powerplan. 
  
  
• Patients followed in the AAIR clinic have severe refractory asthma and may have small airways dysfunction with airway obstruction at baseline. These patients may not manifest typical signs of respiratory distress; therefore, respiratory scores on the respiratory care plan may not be an accurate representation of level of distress.  It is recommended that beta-agonists should be ordered as scheduled treatments rather than per standard respiratory care plan protocol.  All patients with asthma followed by AAIR clinic should receive a pulmonary consultation.  It is recommended they remain on short acting beta - agonists every 2 hours until they are assessed by pulmonary medicine on call or discussed with pulmonary medicine on call/ AAIR clinic provider. Spacing for these patients should be decided through frequent reassessment by inpatient medical staff, respiratory therapist at bedside, and pulmonary consult.

Clinical Practice Guideline

The CPG for inpatient asthma exacerbation care recently has been updated and the recommendations remain current and exist as part of the Asthma Care Continuum Algorithm. In this section, we will discuss special considerations for inpatient management of asthma exacerbations. Discussion of appropriate considerations for PICU transfer are also discussed here. Finally, discharge processes and transition to home management has many pieces but can have implications for the patient’s asthma control going forward so the recommended pieces of an Asthma discharge are included. 

Bronchodilator Weaning Protocol

High Risk Asthma Program (HRAP)

HRAP criteria are as below:

• Patients who have had ≥ 4 encounters for asthma at the Urgent Care, ED, or inpatient admission (including the current encounter) within the past hospital year OR was admitted to the PICU, should have the High Risk Asthma Program power plan ordered. 
  
  
• HRAP requires an inpatient consult by either Allergy/Immunology or Pulmonology. If the patient is already established out-patient with one of these subspecialties or has been seen by them in the past 2 years, consult the respective service for continuity of care.
  
  
• If the patient has never been seen by Allergy/Immunology or Pulmonology, consider other disease processes when choosing the service to consult. For example, a child with severe food allergies and atopic asthma will likely benefit from long-term Allergy/Immunology follow up.
  
  
• Evidence: CMH created High Risk Asthma classification in 2015 to reduce high utilization of acute care visits for asthma. Identifying patients who are at risk for increased acute care visits was done based on 4 acute care visits in the preceding year and/or PICU admission. This was based on statistical analysis from over 28,000 visits over 3 years; it was found that patients with a history of higher numbers of acute care visits had an increased probability of future acute care visits and that a small group of patients disproportionately accounted for future acute care visits.¹ 
  
  
• It should be noted that the High Risk Asthma Pathway has been shown in our institution to decrease the total number of future ED, urgent care and hospitalizations². It has not been studied to identify decrease in readmission, mortality or near mortality due to asthma. It was unable to show impact on patient follow-up in outpatient clinic.³

Dexamethasone inpatient

Dexamethasone is a systemic steroid that can be given PO, IV or IM and has a 36-72 hour half-life. Because of these qualities, dexamethasone may be the preferred systemic steroid in patients who are not tolerating the daily to twice daily dosing of prednisone/prednisolone or may have barriers to attaining and taking oral medications at time of discharge but for whom an additional 2 days of steroid treatment is desired.

The inpatient CPG has been updated in 2022 with reevaluation of dexamethasone as an alternative to prednisolone and did not find sufficient evidence to recommend for or against the use of dexamethasone in these instances. Hence, the decision on systemic steroids is based on severity of asthma exacerbation, patient presentation, and physician preference. Dexamethasone is preferred as a one time dose in mild exacerbations throughout the care continuum in order to minimize the need for families to obtain prescriptions after discharge.  Moderate exacerbations can be treated with 1 or 2 days of dexamethasone or 3-5 days of prednisolone. Severe exacerbations should be treated with IV methylprednisolone as patients may not be able to take medications by mouth.

When should you consider transfer of a patient to the PICU? 

If a patient continues to worsen or does not improve clinically despite optimal treatment on the floor and/or the provider is unable to provide advanced treatments due to availability on the floor, transfer to the pediatric intensive care unit should be considered.

Any of the following would be indications for transfer to PICU:

• Prolonged continuous albuterol for >4 hrs with worsening symptoms
  
  
• Inadequate ventilation with hypercapnea (PCO2 on capillary blood gas >45)
  
  
• Need for high flow nasal cannula or non-invasive ventilation
  
  
• Persistent hypoxemia (SpO2 <90%) on supplemental O2 (>2 L/min or >50% FiO2 with non rebreather)

Other considerations include:

• It is important to note that V-Q mismatch when initiating therapy may result in temporary oxygen desaturation. 
  
  
• Personnel and staffing may not allow for frequency of care or medication administration required by patient acuity and thereby, necessitating transfer depending on the condition. 
  
  
• Respiratory Therapists are required to assess a patient hourly while on continuous inhaled albuterol. If staffing does not allow them to safely attend to all of their patients, it may necessitate a discussion with the Charge RT about additional resources or transferring to the PICU where there is more RT availability. 
  
  
• Clinical interventions which are unavailable on the inpatient wards include: (Please see Respiratory Support Section for further information) 
  
  
  • High Flow Nasal Cannula 
    
    
  • Positive pressure ventilation and CPAP 
    
    
  • Endotracheal intubation/ ECMO 
    
    
  • Aminophylline 
    
    
  • Heliox 
    

What are the essential parts of discharge preparation for patients admitted for status asthmaticus?

Generally, patients are considered clinically ready for discharge home when their asthma symptoms can be controlled with reasonable frequency of therapies at home and continued improvement. While this may vary from patient to patient, at a minimum they should be able to space bronchodilator therapy to 2-4 puffs at least 4 hours apart while maintaining normal oxyhemoglobin saturations on room air and without increased work of breathing or significant wheezing.

In addition, a discharge checklist for success at home is as follows: 

Asthma Action Plan

• Review and complete asthma action plan for each admission prior to asthma education class. Provide family with a printed version. Consider printing multiples for school or separate homes.
  
  

Asthma education

• Sign families up for Asthma Classes or refer to Asthma educator if family is unable to attend.
  

Medications in hand

• Prior to discharge patients should have prescribed medications with enough refills until follow up of inhalers, the full course of systemic steroids, and aerochamber spacer set up. Epi-Pen should be given to those with anaphylactic allergies.
  
  

Follow-up scheduled

• Team coordinator can assist with scheduling a follow-up visit with a provider within 1 week of discharge (often within 48 hours of completing steroid course)
  
  
• If needed (i.e. HRAP patient), follow up with subspecialist within 90 days
  
  

Influenza vaccine

• Influenza vaccine prior to discharge for patients who have not had one during the current flu season (two if first time influenza vaccine)
  
  

Primary asthma provider communication

• Communicate changes to AAP/medications prior to discharge
  
  
• It is also important to communicate complicated hospital courses including ICU admission or if any items need to be followed up on.

References:

1. Hanson, et al. Developing a risk stratification model for predicting future health care use in asthmatic children. Ann Allergy Asthma Immunol. 2016 Jan; 116(1): 26-30. Epub 2015 Nov 6.

2. Murphy, et al. Building a Targeted Asthma Education and Management Program. Mo Med. Sept -Oct 2016; 113 (5):409-414.

3. Nalin, et al. Does an Inpatient “High Risk Asthma Program” impact Outpatient Follow up? JACI. Volume 143, Number 2. Abstract