13. Asthma Exacerbations for Inpatient Admission

Patients who present with status asthmaticus that meet admission criteria are admitted to the General Pediatrics service.

Inpatient Clinical Pathway and Order-set

Asthma Clinical Practice Guidelines

Please utilize the Inpatient Asthma Pathway order-set for asthma hospitalizations (except for High-Risk Asthma or AAIR Clinic patients – see below). This ensures that bronchodilator orders are implemented properly for Respiratory Therapy (RT) protocol. RTs will follow the Bronchodilator Weaning Protocol for spacing bronchodilators during admission.

High Risk Asthma Protocol (HRAP)

Children’s Mercy created the High-Risk Asthma classification in 2015 to reduce utilization of acute care visits for asthma. This was based on statistical analysis for >28k visits over 3 years which found that patients with a higher number of acute care visits had an increased probability of future acute care visits.¹ The High Risk Asthma Protocol has decreased the total number of ED, Urgent Care, and hospitalizations at our institute.² It has not been studied to identify decrease in readmission, mortality, or near mortality due to asthma. It did not show impact on patient follow-up in outpatient clinics.³

Patients qualify for HRAP if:

• ≥ 4 acute care visits (ED, Urgent Care, or admission) in the 12 months OR were admitted to the PICU for asthma

Identification of these patients prior to discharge allows for appropriate follow-up, but also helps providers know which patients are at greater risk to return for asthma care.

• Social Work Consult
• Environmental Health Home Assessment Referral
  
  

AAIR Clinic Patients

Patients followed in the AAIR Clinic have severe refractory asthma and may have small airways dysfunction at baseline. These patients may not manifest typical signs of respiratory distress. Therefore, the AAIR patient policy should be followed:

• Respiratory Care Scores may not be an accurate representation of the level of distress.
• Beta-agonists should be ordered as scheduled treatments rather than per standard Respiratory Care Plan protocol.
• AAIR Clinic patients should receive a Pulmonary consult.
• Beta-agonists should remain at least Q2 until the patient is assessed by pulmonary medicine or discussed with pulmonary medicine/AAIR clinic provider by phone.
• Beta-agonist spacing should be decided as a group through frequent reassessment by inpatient medical staff, RT, and pulmonary consult.
  
  

Systemic Corticosteroid Selection

In addition to short acting beta-agonists, all patients with asthma exacerbations should be receiving a course of systemic corticosteroids. Appropriate steroids include:

• Dexamethasone
• Prednisolone
• Prednisone
• Methylprednisolone

Selection of 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 to minimize the need for families to obtain prescriptions after discharge. Moderate exacerbations, including hospitalized children, can be treated with 1 or 2 days of dexamethasone (usually dosed 24-48 hours apart), or 3-5 days of prednisone/prednisolone. Severe exacerbations should be treated with IV methylprednisolone as patients may not be able to take medications by mouth.

Of note: Dexamethasone is a systemic steroid that can be given PO, IV or IM and has a 36–72-hour half-life, requiring fewer doses to complete exacerbation treatment than prednisone/prednisolone. 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 clinical pathway was updated in 2022 and includes dexamethasone as an alternative to prednisolone.

Criteria for PICU Admission

• Prolonged continuous albuterol for > 4 hours with worsening symptoms
• Inadequate ventilation with hypercapnia (pCO2 on capillary gas >45)
• Need for high flow nasal cannula (> 0.25L/kg/min or >10L or >40% FiO2) or non-invasive ventilation.
  • Of note, HFNC apparatus may be used on the floor at low flow and FiO2 (≤0.25 L/kg/min with max flow of 10 L/min, and <40% FiO2) for patients who require continuous albuterol but are not tolerating wearing the nebulizer mask for behavioral/comfort reasons.
• Persistent hypoxemia (SpO2 <90%) despite supplemental O2 (≥3L/min or >40% FiO2 with non-rebreather)
• Altered level of consciousness (drowsiness)

If your patient meets PICU transfer criteria or you are concerned your patient may be approaching these criteria, strongly consider a Situational Awareness Huddle for your patient. Situational Awareness Huddles promote collaboration amongst nursing staff, physicians, respiratory therapists and the patient/family and should be used when there are concerns for worsening clinical status or elevated Pediatric Early Warning Score (PEWS). Please ensure documentation of Situational Awareness events with clear objective goals.

Other considerations include:

• VQ mismatch when initiating bronchodilator therapy may result in temporary oxygen desaturation
• Additional conditions could contribute to worsening clinical status. Initiate these interventions early:
  • CXR for focal findings if patient has crackles or diminished breath sounds
  • IV placement for initiation of fluids therapy and/or IV medications including IV steroids
  • Antibiotics for treatment of super-imposed pneumonia
• Respiratory Therapists are required to reassess patients hourly while on continuous albuterol. If staffing does not allow them to safely attend to all their patients on multiple floors, it may necessitate a discussion with the Charge RT about additional resources or transfer to the PICU where there is a consistent RT presence.
• Clinical interventions which are unavailable on the inpatient floors include:
  • HFNC for impending respiratory failure, i.e., at flows of> 0.25L/kg/min or >10L, or >40% FiO2
  • Non-invasive positive pressure ventilation including
  • Endotracheal intubation
  • ECMO
  • Aminophylline
  • Heliox
    
    

Discharge Preparation

In general, patients admitted with asthma are ready for discharge when:

• Demonstrating clinical improvement
• Any ongoing symptoms can be managed safely with therapies at home
• Breathing comfortably and maintaining normal oxyhemoglobin saturations on room air
• Bronchodilator therapy spaced to 2-4 puffs every 4
  
  

Discharge Checklist

• Asthma Action Plan
• Asthma Education
• Medications in Hand
• Follow-up Scheduled
• Influenza Vaccine
• Communication with Primary Asthma Provider
  
  

Asthma Action Plan

• Create a new AAP with every encounter or AAP cannot be printed. Previous AAPs can be reviewed under documents.
• Two Types – Traditional AAP and SMART AAP (See below for information on SMART)
• Modify existing medications and/or doses on AAP if needed based on current symptoms, severity, and level of asthma control (See Stepwise Approach)
• Include AAP in discharge summary
• Provide family with several printed copies for home, school, and separate homes
  • Contact RT to ensure printed copies have been provided prior to discharge
• Patient should be instructed to use the yellow zone after discharge until seen by PCP for follow-up and/or symptoms fully resolve

• Single Maintenance and Reliever Therapy (SMART) Asthma Action Plan
  • ICS-formoterol combination inhalers can be prescribed for maintenance therapy and the same inhaler can also be used as need for symptom relief.
    • Symbicort® and Dulera® (and respective generics) are the only US approved medications for SMART
  • Formoterol has an onset of action within 3-5 minutes and lasts up to 12 hours.
  • Approved therapy for 4 years of age and up
  • Maximum dosing per 24 hours
    • Ages 4-11 = 8 puffs
    • Ages 12+ = 12 puffs
  • When compared to albuterol only, SMART resulted in fewer exacerbations and decrease in severity of reactions.
  • Considerations should be given to an emergency albuterol inhaler to be kept in home and/or school for when ICS-formoterol is unavailable.

Asthma Education

• Physician education at bedside
• RT to provide inhaler instruction and assess technique with every treatment
• RT or Asthma Coordinator education at bedside
• Asthma Class
  • Adele Hall in-person classes are held Monday-Friday from 11:15-12:15 in the Family Education Room on the ground floor.
    • In-person class in the preferred method for education
    • Please note that SMART is not taught in the in-person class currently. Bedside education should be completed prior to discharge for patients who follow SMART.
  • Inpatient TV Videos
    • Order “GWN CMH Asthma Class” or “GWN CMH SMART Asthma Class”
  • Asthma Class Video
  • SMART Asthma Class Video
• Asthma Education Website

Medications in Hand

• Patients should take home inhalers and spacers used in the hospital
• Prescribe inhaled medications with enough refills until follow-up appointment as well as a full course of systemic steroids if indicated
• Prescribe AeroChamber® spacer
• Consider whether multiple inhalers are needed for use in multiple homes and school or childcare settings
• Consider Epi-Pen for those with anaphylactic allergies

Follow-up Scheduled

• Team Coordinators can assist with scheduling a follow-up with a provider (ideally PCP) within 1 week of discharge (often within 48 hours of steroid course completion)
• HRAP follow-up with subspecialist within 90 days
• Consider referral to Pulmonology or Allergy/Immunology if specialty care desired by patient, family, or PCP

Influenza Vaccine

• Influenza vaccines are recommended for all asthma patients who have not had one in the current flu season. These should be given prior to discharge. Please note that two doses are necessary for first time influenza vaccine.

Primary Asthma Provider Communication

• Communicate changes to the AAP and/or medications prior to discharge
• Communicate complicated hospital courses including ICU admission and any items/issues that require follow-up
• Notify of any new specialty referrals

Asthma School Medication Form

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
4. Sudarmana A, Lawrence J, So N, et al. Discharge criteria for inpatient paediatric asthma: a systematic review. Arch Dis Child 2023; 108:839-845. 
5. Lo H, Messer A, Loveless J, et al. Discharging asthma patients on 3-hour B-Agonist treatments: a quality improvement project. Hosp Pediatr 2018;8:733-9.
6. Simmons J, Myers J, Martin L, et al. Ohio Pediatric Asthma Repository: Opportunities to Revise Care Practices to Decrease Time to Physiologic Readiness for Discharge. Hosp Pediatr 2018; 8:305-13.