Elsevier LogoAsthma

    English

    Careplan

    Asthma Exacerbation [Pediatric Inpatient]

    Jan.28.2022

    Asthma Exacerbation (Pediatric Inpatient)

    Clinical Description

    • Care of the hospitalized child experiencing symptoms related to airway inflammation and hyperresponsiveness.

    Key Information

    • Children may decompensate more quickly due to smaller airway size and the inability to describe symptoms of breathlessness.
    • Epinephrine (intramuscular) should be given in addition to standard therapy for symptoms associated with anaphylaxis or angioedema.
    • Holding-chamber spacers used with metered-dose inhalers are as effective as nebulized liquid medication. Use clinical judgment when choosing the delivery device appropriate for the situation.
    • Inhaled corticosteroid therapy should be standard care at discharge; however, it may be used in tandem with systemic corticosteroid therapy during hospitalization.
    • Antimicrobial therapy should only be used if a lung infection is clearly identified by fever, sputum or infiltrate on chest x-ray.
    • Sedation should be avoided due to respiratory depression effect.
    • Patients with asthma have a significantly increased risk of suicidal ideation, attempts and mortality. Suicide screening should be provided and appropriate mental health referrals when necessary.

    Clinical Goals

    By transition of care

    A. The patient will achieve the following goals:

    • Asthma Symptom Relief

    B. Patient, family or significant other will teach back or demonstrate education topics and points:
    • Education: Overview
    • Education: Self Management
    • Education: When to Seek Medical Attention

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity, congenital anomaly
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • child and family/caregiver:
        • health literacy
        • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Asthma Exacerbation

    Signs/Symptoms/Presentation

    • activity intolerance
    • anxiety
    • chest tightness
    • cough
    • fatigue
    • prolonged expiratory phase
    • restlessness
    • retractions
    • shortness of breath
    • wheezing
    • work of breathing increased

    Vital Signs

    • heart rate increased
    • respiratory rate increased
    • SpO2 (peripheral oxygen saturation) decreased

    Laboratory Values

    • ABG (arterial blood gas) abnormal
    • serum electrolytes abnormal
    • serum theophylline outside therapeutic range

    Problem Intervention

    Support Asthma Symptom Control

    • Provide inhaled short-acting beta2-agonist; consider inhaled anticholinergic.
    • Initiate oral or intravenous corticosteroid therapy.
    • Monitor response to treatment and peak expiratory flow rate.
    • Maintain optimal position to relieve discomfort, breathlessness and ventilation-perfusion mismatch.
    • Provide oxygen therapy judiciously to avoid hyperoxemia; adjust to achieve oxygenation goal.
    • Promote early mobility or ambulation; match activity to ability and tolerance.
    • Evaluate psychosocial factors that may contribute to the anxiety-breathlessness cycle; acknowledge, normalize and validate patient and support system response to patient’s breathlessness.
    • Utilize nonpharmacologic measures, such as parent/caregiver presence, controlled breathing, relaxation and mucus-clearance techniques to reduce breathlessness and anxiety.
    • Consider positive pressure ventilation to enhance oxygenation and ventilation, as well as reduce work of breathing.
    • Consider adjunctive therapy, such as magnesium sulfate, aminophyline and heliox gas mixture.
    • Evaluate self-management (asthma action plan) adherence and effectiveness of coping skills; encourage expression of feelings, expectations and concerns related to symptom management, quality of life and wellbeing.

    Associated Documentation

    • Airway/Ventilation Management
    • Breathing Techniques/Airway Clearance
    • Family/Support System Care
    • Medication Review/Management

    Education

    CPG-Specific Education Topics

    Overview

    • description

    • signs/symptoms

    Self Management

    • asthma action plan

    • asthma management

    • avoidance of triggers

    • environmental modification

    • immunizations

    • medication management

    • provider follow-up

    • rehabilitation therapy

    • safety

    When to Seek Medical Attention

    • unresolved/worsening symptoms

    General Education Topics

    General Education

    • admission, transition of care

    • orientation to care setting, routine

    • advance care planning

    • diagnostic tests/procedures

    • diet modification

    • opioid medication management

    • oral health

    • medication management

    • pain assessment process

    • safe medication disposal

    • tobacco use, smoke exposure

    • treatment plan

    Safety Education

    • call light use

    • equipment/home supplies

    • fall prevention

    • harm prevention

    • infection prevention

    • MDRO (multidrug-resistant organism) care

    • personal health information

    • resources for support

    Population-Specific Considerations

    General

    • Comorbidities, such as rhinosinusitis, obesity, gastroesophageal reflux disease and psychiatric disorders may contribute to poor symptom control and may require additional specialty services to manage treatment.
    • Youth may be at risk for developing anxiety disorders when chronic medical conditions, such as asthma, exists.

    Pregnancy

    • During pregnancy, asthma symptoms may worsen, improve or stay the same; exacerbations are most common in the second trimester due to hormonal changes or reduction in asthma medication. International guidelines can guide practitioners regarding medications that are safe during pregnancy.
    • A significant percentage of women who have asthma experience an exacerbation during labor and delivery. An exacerbation should be treated the same during labor as at any other time.

    Quality Measures

    • NQF 0728. Asthma Admission Rate (PDI 14)
      Admissions with a principal diagnosis of asthma per 100,000 population, ages 2 through 17 years. Excludes cases with a diagnosis code for cystic fibrosis and anomalies of the respiratory system, obstetric admissions and transfers from other institutions.
      Steward: Agency for Healthcare Research and Quality
      Care Setting: Hospital
      National Quality Forum-endorsed measure.
      Last Edited: 06/10/2016

    References

    • (2021). Rice Simpson, K.; Creehan, P. A.; O'Brien-Abel, N.; Roth, C. K.; Rohan, A. J. (Eds.), AWHONN's Perinatal Nursing. Philadelphia: Wolters Kluwer. [Core Curriculum]
    • (2021). Rice Simpson, K.; Creehan, P. A.; O'Brien-Abel, N.; Roth, C. K.; Rohan, A. J. (Eds.), AWHONN's Perinatal Nursing. Philadelphia: Wolters Kluwer. [Core Curriculum]
    • Abul, M. H.; Phipatanakul, W. Severe asthma in children: Evaluation and management. Allergology International. 2019;68(2), 150-157. doi:10.1016/j.alit.2018.11.007 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Al-Moamary, M. S.; Alhaider, S. A.; Alangari, A. A.; Al Ghobain, M. O.; Zeitouni, M. O.; Idrees, M. M. Alanazi, A. F.; Al-Harbi, A. S.; Yousef, A. A.; Alorainy, H. S.; Al-Hajjaj, M. S. The Saudi Initiative for Asthma-2019 Update: Guidelines for the diagnosis and management of asthma in adults and children. Annals of Thoracic Medicine. 2019, Jan;14(1), 3. doi:10.4103/atm.ATM_327_18 [Quality Measures,Clinical Practice Guidelines]
    • Amin, S.; Soliman, M.; McIvor, A.; Cave, A.; Cabrera, C. Understanding patient perspective on medication adherence in asthma: a targeted review of qualitative studies. Patient Preference and Adherence. 2020;14, 541-551. doi:10.2147/PPA.S234651 [Review Articles]
    • British Thoracic Society; Scottish Intercollegiate Guidelines Network (SIGN). (2016). BTS/SIGN British guideline on the management of asthma. Source[Quality Measures,Clinical Practice Guidelines]
    • British Thoracic Society; Scottish Intercollegiate Guidelines Network (SIGN). (2016). BTS/SIGN British guideline on the management of asthma. Source[Quality Measures,Clinical Practice Guidelines]
    • Cates, C. J.; Welsh, E. J.; Rowe, B. H. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database of Systematic Reviews. 2013;(9) doi:10.1002/14651858.CD000052.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
    • Cobham, V. E.; Hickling, A.; Kimball, H.; Thomas, H. J.; Scott, J. G.; Middeldorp, C. M. Systematic review: anxiety in children and adolescents with chronic medical conditions. Journal of the American Academy of Child & Adolescent Psychiatry. 2020;59(5), 595-618. doi:10.1016/j.jaac.2019.10.010 Source[Systematic Review]
    • Cobham, V. E.; Hickling, A.; Kimball, H.; Thomas, H. J.; Scott, J. G.; Middeldorp, C. M. Systematic review: anxiety in children and adolescents with chronic medical conditions. Journal of the American Academy of Child & Adolescent Psychiatry. 2020;59(5), 595-618. doi:10.1016/j.jaac.2019.10.010 Source[Systematic Review]
    • Craig, S. S.; Dalziel, S. R.; Powell, C. V. E.; Graudins, A.; Babl, F. E.; et al. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2020;(8) doi:10.1002/14651858.CD012977.pub2 [Systematic Review]
    • Dudeney, J.; Sharpe, L.; Jaffe, A.; Jones, E. B.; Hunt, C. Anxiety in youth with asthma: A meta-analysis. Pediatric Pulmonology. 2017;52(9), 1121-1129. doi:10.1002/ppul.23689 [Metasynthesis,Meta-analysis,Systematic Review]
    • Duse, M.; Santamaria, F.; Verga, M. C.; Bergamini, M.; Simeone, G.; Leonardi, L.; Tezza, G.; Bianchi, A.; Capuano, A.; Cardinale, F.; Cerimoniale, G. Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases. Italian Journal of Pediatrics. 2021;47(1), 1-24. doi:10.1186/s13052-021-01013-8 Source[Expert/Committee Opinion,Position Statements]
    • Fawcett, R.; Porritt, K.; Stern, C.; Carson-Chahhoud, K. Experiences of parents and carers in managing asthma in children: a qualitative systematic review. JBI Database of Systematic Reviews and Implementation Reports. 2019;17(5), 793-984. doi:10.11124/JBISRIR-2017-004019 [Systematic Review]
    • Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2021 update. 2021;Source[Policy/Practice Standards,Clinical Practice Guidelines]
    • Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2021 update. 2021;Source[Policy/Practice Standards,Clinical Practice Guidelines]
    • Hockenberry, M. J.; Wilson, D.; Rodgers, C. C. (2019). Wong's nursing care of infants and children. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Holguin, F.; Cardet, J. C.; Chung, K. F.; Diver, S.; Ferreira, D. S.; Fitzpatrick, A.; Gaga, M.; et al. Management of severe asthma: a European Respiratory Society/American Thoracic Society Guideline. European Respiratory Journal. 2020;55(1900588), 1-21. doi:10.1183/13993003.00588-2019 Source[Clinical Practice Guidelines]
    • Iannucci, J.; Nierenberg, B. Suicide and suicidality in children and adolescents with chronic illness: A systematic review. Aggression and Violent Behavior. 2021;101581, 1-13. doi:10.1016/j.avb.2021.101581 Source[Systematic Review]
    • Indinnimeo, L.; Chiappini, E.; del Giudice, M. M.; The Italian Panel for the management of acute asthma attack in children. Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics. Italian Journal of Pediatrics. 2018;44(46), 1-10. doi:10.1186/s13052-018-0481-1 Source[Clinical Practice Guidelines]
    • Knibb, R. C.; Alviani, C.; Garriga-Baraut, T.; Mortz, C. G.; Vazquez-Ortiz, M.; Angier, E.; et al. The effectiveness of interventions to improve self-management for adolescents and young adults with allergic conditions: a systematic review. Allergy. 2020; doi:10.1111/all.14269 [Systematic Review]
    • Knightly, R.; Milan, S. J.; Hughes, R.; Knopp-Sihota, J. A.; Rowe, B. H.; Normansell, R.; Powell, C. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database of Systematic Reviews. 2017;(11) doi:10.1002/14651858.CD003898.pub6. [Systematic Review]
    • Korang, S. K.; Feinberg, J.; Wetterslev, J.; Jakobsen, J. C. Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database of Systematic Reviews. 2016;(9) doi:10.1002/14651858.CD012067.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
    • Le Conte, P.; Terzi, N.; Mortamet, G.; Abroug, F.; Carteaux, G.; Charasse, C.; et al . Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d’Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies. Annals of Intensive Care. 2019;9(115), 1-16. doi:10.1186/s13613-019-0584-x [Clinical Practice Guidelines]
    • Le Conte, P.; Terzi, N.; Mortamet, G.; Abroug, F.; Carteaux, G.; Charasse, C.; et al . Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d’Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies. Annals of Intensive Care. 2019;9(115), 1-16. doi:10.1186/s13613-019-0584-x [Clinical Practice Guidelines]
    • Leas, B. F.; Tipton, K.; Bryant-Stephens, T.; Jackson-Ware, M.; Mull, N.; Tsou, A. Y. (2020, April). Characteristics of existing asthma self-management packages. Technical Brief No. 35 (Prepared by ECRI Institute - Penn Medicine EPC under Contract No. 290-2015-00005.) AHRQ Publication No. 20-EHC008. Rockville, MD: Agency for Healthcare Research and Quality. doi:10.23970/AHRQEPCTB35 Source[Practice Bulletins]
    • Maltby, S.; McDonald, V. M.; Upham, J. W.; Bowler, S. D.; Chung, L. P.; Denton, E. J.; et al. Severe Asthma Assessment, Management and the Organisation of Care in Australia and New Zealand: Expert Forum Roundtable Meetings. Internal Medicine Journal. 2020; doi:10.1111/imj.14806 [Expert/Committee Opinion]
    • Murphy, K. R.; Hong, J. G.; Wandalsen, G.; Larenas-Linnemann, D.; El Beleidy, A.; Zaytseva, O. V.; Pedersen, S. E. Nebulized inhaled corticosteroids in asthma treatment in children 5 years or younger: a systematic review and global expert analysis. The Journal of Allergy and Clinical Immunology: In Practice. 2020;8(6), 1815-1827. doi:10.1016/j.jaip.2020.01.042 Source[Expert/Committee Opinion,Systematic Review]
    • Napolitano, N.; Berlinski, A.; Walsh, B. K.; Ginier, E.; Strickland, S. L. AARC Clinical Practice Guideline Management of pediatric patients with oxygen in the acute care setting. Respiratory Care. 2021; doi:10.4187/respcare.09006 [Systematic Review,Clinical Practice Guidelines]
    • National Asthma Council Australia. (2021). Australian Asthma Handbook, Version 2.1. Melbourne, Australia: National Asthma Council Australia. Source[Clinical Practice Guidelines]
    • National Asthma Council Australia. (2021). Australian Asthma Handbook, Version 2.1. Melbourne, Australia: National Asthma Council Australia. Source[Clinical Practice Guidelines]
    • National Institute for Health and Care Excellence (NICE). (2021). Asthma: diagnosis, monitoring and chronic asthma management [NG80]. Source[Clinical Practice Guidelines]
    • Pateraki, E.; Morris, P. G. Effectiveness of cognitive behavioural therapy in reducing anxiety in adults and children with asthma: A systematic review. Journal of Asthma. 2018;55(5), 532-554. doi:10.1080/02770903.2017.1350967 [Metasynthesis,Meta-analysis,Systematic Review]
    • Pizzichini, M. M. M.; de Charvalho-Pinto, R. M.; Cancado, J. E. D.; Rubin, A. S.; Neto, A. C.; Cardoso, A. P.; et al. 2020 Brazilian Thoracic Association recommendations for the management of asthma. Jornal Brasileiro de Pneumologia. 2020;46(1), e20190307. doi:10.1590/1806-3713/e20190307 [Expert/Committee Opinion,Position Statements]
    • Roncada, C.; Madeiros, T. M.; Strassburger, M. J.; Strassburger, S. Z.; Pitrez, P. M. Comparison between the health-related quality of life of children/adolescents with asthma and that of their caregivers: a systematic review and meta-analysis. Jornal Brasileiro de Pneumologia. 2020;46(3), 1-10. doi:10.36416/1806-3756/e20190095 Source[Meta-analysis,Systematic Review]
    • Schuers, M.; Chapron, A.; Guihard, H.; Bouchez, T.; Darmon, D. Impact of non-drug therapies on asthma control: A systematic review of the literature. European Journal of General Practice. 2019;25(2), 65-76. doi:10.1080/13814788.2019.1574742 Source[Systematic Review]
    • Slota, M. C. (2019). AACN Core Curriculum for Pediatric High Acuity, Progressive, and Critical Care Nursing. New York: Springer Publishing Company. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Vazquez-Ortiz, M.; Angier, E.; Blumchen, K.; Comberiati, P.; Duca, B.; DunnGalvin, A.; Gore, C.; Hox, V.; Jensen, B.; Pite, H.; Santos, A. F. Understanding the challenges faced by adolescents and young adults with allergic conditions: a systematic review. Allergy. 2020;75(8), 1850-1880. doi:10.1111/all.14258 Source[Position Statements,Systematic Review]
    • Zhang, W.; Wang, Q.; Liu, L.; Yang,W.; Liu, H. Effects of physical therapy on lung function in children with asthma: a systematic review and meta-analysis. Pediatric Research. 2020;, 1-9. doi:10.1038/s41390-020-0874-x Source[Meta-analysis,Systematic Review]
    • Zhang, Y.; Cheng, J.; Li, Y.; He, R.; Choudhry, A. A.; Jiang, J.; et al. Suicidality among patients with asthma: a systematic review and meta-analysis. Journal of Affective Disorders. 2019;256, 594-603. doi:10.1016/j.jad.2019.06.031 [Metasynthesis,Systematic Review]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

    ;
    Small Elsevier Logo

    Cookies are used by this site. To decline or learn more, visit our cookie notice.

    Small Elsevier Logo
    RELX Group