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:
- 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

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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.