Acute Asthma Exacerbation Algo v1

Warning signs: RR > 45, Sat < 94% or AMS
  • Mild CRS < 3
    • Try
      • Albuterol MDI 6 puffs or Albuterol Neb x1
      • Atrovent MDI 4 puffs or Atrovent Neb x1
      • Oral Steroids
    • improved
      • Discharge Home
    • Worse
      • Try
        • Albuterol MDI 6 puffs x3 or ALbuterol Neb x3
        • Atrovent MDI 4 puffs x3 or Atrovent Neb x3
        • Oral Steroids
      • Improved
        • Discharge Home
      • Worse
        • Try
          • Albuterol Neb 1 hr continuous
          • Atrovent Neb x3
          • Oral or IV Steroids
          • Consider NS Bolus
          • Consider Magnesium
        • Improved
        • No change
          • Try
            • Continuous Albuterol Neb (2nd hour)
            • NS Bolus
            • Magnesium
          • No change
            • Try
              • Continuous Albuterol Neb (3rd hour)
              • Terbutlaine
              • High Flow Nasal Cannula
            • No change
              • PICU
            • Worse
              • Try
                • Bipap + Ketamine
                • Nitric Oxide 20 ppm
                • Heliox 70/30
              • No change
                • Intubation
          • Worse
            • Try
              • Terbutaline
              • Epinephrine
              • High Flow Nasal Cannula
            • No change
              • Try
                • Bipap + Ketamine
                • Nitric Oxide 20 ppm
                • Heliox 70/30
              • No change
                • Intubation
        • Worse
          • Try
            • Continuous Albuterol
            • Atrovent Neb x3
            • IV Steroids
            • NS bolus
            • Magnesium Sulfate
            • Prepare to Intubate
            • Notify PICU
          • No change
            • Try
              • Terbutaline
              • Epinephrine
              • High Flow Nasal Cannula
            • No change
              • Try
                • Bipap + Ketamine
                • Nitric Oxide 20 ppm
                • Heliox 70/30
              • No change
                • Intubation
  • Moderate CRS 3-5
    • Try
      • Albuterol MDI 6 puffs x3 or ALbuterol Neb x3
      • Atrovent MDI 4 puffs x3 or Atrovent Neb x3
      • Oral Steroids
    • Worse
      • Try
        • Albuterol Neb 1 hr continuous
        • Atrovent Neb x3
        • Oral or IV Steroids
        • Consider NS Bolus
        • Consider Magnesium
      • Improved
        • Dispo per Albuterol Requirement:
          • q3 = home
          • q2 = SDU
          • q1 or continuous = PICU
      • No change
        • Try
          • Continuous Albuterol Neb (2nd hour)
          • NS Bolus
          • Magnesium
        • Improved
          • Dispo per Albuterol Requirement:
            • q3 = home
            • q2 = SDU
            • q1 or continuous = PICU
        • No change
          • Try
            • Continuous Albuterol Neb (3rd hour)
            • Terbutlaine
            • High Flow Nasal Cannula
          • Worse
            • Try
              • Bipap + Ketamine
              • Nitric Oxide 20 ppm
              • Heliox 70/30
            • No change
              • Intubation
          • PICU
        • Worse
          • Try
            • Terbutaline
            • Epinephrine
            • High Flow Nasal Cannula
          • No change
            • Try
              • Bipap + Ketamine
              • Nitric Oxide 20 ppm
              • Heliox 70/30
            • No change
              • Intubation
      • Worse
        • Try
          • Continuous Albuterol
          • Atrovent Neb x3
          • IV Steroids
          • NS bolus
          • Magnesium Sulfate
          • Prepare to Intubate
          • Notify PICU
        • No change
          • Try
            • Terbutaline
            • Epinephrine
            • High Flow Nasal Cannula
          • No change
            • Try
              • Bipap + Ketamine
              • Nitric Oxide 20 ppm
              • Heliox 70/30
            • No change
              • Intubation
    • Improved
      • Discharge Home
  • Severe CRS > 6
    • Try
      • Albuterol Neb 1 hr continuous
      • Atrovent Neb x3
      • Oral or IV Steroids
      • Consider NS Bolus
      • Consider Magnesium
    • Improved
      • Dispo per Albuterol Requirement:
        • q3 = home
        • q2 = SDU
        • q1 or continuous = PICU
    • No change
        • Continuous Albuterol Neb (2nd hour)
        • NS Bolus
        • Magnesium
      • Improved
        • Dispo per Albuterol Requirement:
          • q3 = home
          • q2 = SDU
          • q1 or continuous = PICU
      • No change
        • Try
          • Continuous Albuterol Neb (3rd hour)
          • Terbutlaine
          • High Flow Nasal Cannula
        • Worse
          • Try
            • Bipap + Ketamine
            • Nitric Oxide 20 ppm
            • Heliox 70/30
          • No change
            • Intubation
        • PICU
      • Worse
        • Try
          • Terbutaline
          • Epinephrine
          • High Flow Nasal Cannula
        • No change
          • Try
            • Bipap + Ketamine
            • Nitric Oxide 20 ppm
            • Heliox 70/30
          • No change
            • Intubation
    • Worse
      • Try
        • Continuous Albuterol
        • Atrovent Neb x3
        • IV Steroids
        • NS bolus
        • Magnesium Sulfate
        • Prepare to Intubate
        • Notify PICU
      • No change
        • Try
          • Terbutaline
          • Epinephrine
          • High Flow Nasal Cannula
        • No change
          • Try
            • Bipap + Ketamine
            • Nitric Oxide 20 ppm
            • Heliox 70/30
          • No change
            • Intubation
  • CRASHING
    • Try
      • Continuous Albuterol
      • Atrovent Neb x3
      • IV Steroids
      • NS bolus
      • Magnesium Sulfate
      • Prepare to Intubate
      • Notify PICU
    • No change
      • Try
        • Terbutaline
        • Epinephrine
        • High Flow Nasal Cannula
      • No change
        • Try
          • Bipap + Ketamine
          • Nitric Oxide 20 ppm
          • Heliox 70/30
        • No change
          • Intubation
  • Clinical Respiratory Score (CRS) – click to view details
    • 0 points
      • Respiratory rate
        • <2m: <50
        • 2-12m: <40
        • 1-5y: <30
        • >5y: <20
      • Auscultation
        • Good air movement
        • Expiratory wheezing
      • Accessory Muscle Use
        • Nasal flaring
        • Mild to no retractions
      • Mental Status
        • Normal to irritable
      • Room Air Sat
        • >95%
      • Color
        • Normal
    • 1 point
      • Respiratory rate
        • <2m: 50-60
        • 2-12m: 40-50
        • 1-5y: 30-40
        • >5y: 20-30
      • Auscultation
        • Decreased air movement
        • Insp & exp wheezing
      • Accessory Muscle Use
        • Agitated/ Restless
      • Mental Status
        • 90-95%
      • Room Air Sat
        • 90-95%
      • Color
        • Pale
    • 2 points
      • Respiratory rate
        • <2m: >60
        • 2-12m: >50
        • 1-5y: >40
        • >5y: >30
      • Auscultation
        • Minimal air movement
        • Severe wheezing
      • Accessory Muscle Use
        • Severe intercostal and substernal retractions
      • Mental Status
        • Lethargic
      • Room Air Sat
        • <90%
      • Color
        • Cyanotic/Dusky

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