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Asthma Exacerbation [Pediatric Inpatient]

Nov.18.2020

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

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

Asthma Exacerbation

Signs/Symptoms/Presentation

  • activity intolerance
  • chest tightness
  • cough
  • fatigue
  • prolonged expiratory phase
  • 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 noninvasive or invasive positive pressure ventilation to enhance oxygenation, ventilation and 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

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.

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

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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.

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