Pediatric Asthma Weaning Protocol - HUMCMD.net

Protocol for Weaning Inhalation Therapy for Patients in Status
Asthmaticus by Respiratory Therapists
Criteria for Entry into Respiratory Therapist (RT)-Directed Weaning Protocol:
All pediatric patients 2 years and older with an admitting diagnosis of status asthmaticus or
acute asthma exacerbation or reactive airway disease are eligible. The protocol will be initiated
only when ordered.
Severity of Illness Assessment:
The RT will use asthma severity scoring listed below as an objective measure of respiratory
status.
RESPIRATORY
RATE
2-3 YRS
4-5 YRS
6-12 YRS
> 12 YRS
1 point 2 points 3 points
34 OR LESS
30 OR LESS
26 OR LESS
23 OR LESS
35-39
31-35
27-30
24-27
40 OR GREATER
36 - 39
31 - 35
28 - 30
ROOM AIR SPO2 96% OR HIGHER 90 - 95% LESS THAN 90%
AUSCULTATION
RETRACTIONS
DYSPNEA
NONE TO MILD
END-
EXPIRATORY
WHEEZING
NONE OR
INTERCOSTAL
SPEAKS IN
COMPLETE
SENTENCES OR
COOS AND
BABBLES
EXPIRATORY
WHEEZING
INTERCOSTAL
+ SUBSTERNAL
SPEAKS IN
PARTIAL
SENTENCES
OR UTTERS
SHORT CRIES
Severity Scale (Mild = 5-7; Moderate = 8-11; Severe = 12-15)
* From Qureshi F, Pestian J, Davis P, et al. N Eng. J Med 1998;339:1030-5
Patients Admitted to the Pediatric Floor
Initial Therapy after Admission to the Pediatric Floor:
INSP + EXPIRATORY
WHEEZING, OR
DIMINISHED BREATH
SOUNDS
INTERCOSTAL,
SUBSTERNAL,
+ SUPRACLAVICULAR
SPEAKS IN SINGLE
WORDS, SHORT PHRASES
OR GRUNTS
1. When the protocol is ordered, the patient will receive at least 2 doses of 2.5 mg nebulized
albuterol separated by 2 hours before being weaned.
2. The RT will evaluate the patient before starting each albuterol treatment and within 10
minutes following completion of each albuterol treatment. The RT will evaluate and
document each component of the Pediatric Asthma Score.
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Schedule for weaning of patients who meet criteria
Patients on an initial therapy frequency of q2h after completing two treatments can be weaned
to q4h when they meet criteria.
Criteria for moving to the next lower level of care:
1. Albuterol dose must be no greater than 2.5 mg by nebulizer prior to starting the weaning
process.
2. To be weaned to the next lower level of therapy:
a. The patient must score 1 in every category, except oxygen requirement (may
score 2, but not 3 in this category) and
b. The total score must be ≤ 6.
3. The patient does not meet weaning criteria and should stay on current therapy if:
a. The total asthma score is 7 or 8
b. The patient scores > 1 in any category except oxygen requirement.
Criteria for increasing the intensity of care:
1. The RT must notify the physician for a total score of 9, or a score of 3 in any individual
category.
2. The PICU attending should be notified for a score > 11 for possible transfer. (See PICU
Consultation Section)
3. If the patient is on q4h frequency, therapy will be changed to q2h.
Response to increase in Asthma Severity Score:
Patients who have an increase in Asthma Severity Score of 2 or more points, or who have a
total score of greater than 6 but less than 11, will be returned to the last higher frequency of
treatment.
Preparation for discharge:
1. In preparation for discharge, the patient must meet all of the following 3 criteria:
a. Be in room air with oxygen saturation ≥93%
b. Be on q4h treatments for at least 2 consecutive treatments, and
c. Have an asthma score of 6 or less.
When all criteria are met, the attending will be notified to make the final determination
regarding further inpatient care and discharge.
2. If hypoxemia is noted only during sleep, SpO2 goals will be discussed with the attending
to determine criteria for discharge, home monitoring and/or home oxygen
3. RT or nursing will notify the resident after first q4h treatment in order to plan discharge
preparations. Discharge preparations will be initiated (i.e. medication reconciliation,
prescriptions, follow up care plan, etc.) only after discussion with the attending.
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PICU Consultation:
1. Resident physician or attending physician should be at the bedside to evaluate the
patient.
2. Consult PICU attending if the asthma severity score is ≥11.
3. Stat albuterol treatment(s) at 2.5 mg or higher should be initiated. Up to 3 stat treatments
of albuterol and/or continuous albuterol, not to exceed 1 hour, can be given to improve
patient’s respiratory status.
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