Management of acute exacerbation of ASTHMA in children

Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years Guideline 4 

Health Policy & Clinical Effectiveness Program 

Evidence-Based Care Guideline 

Management of 

acute exacerbation of 

ASTHMA 

in children 

Revision Publication Date: September 16, 2010 

Revision Publication Date: September 3, 2002 

Original Publication Date: July 20, 1998 

Please cite as: 

Acute Asthma Guideline, Cincinnati Children's Hospital 

Medical Center: Evidence-based care guideline for management of 

acute asthma exacerbation in children Asthma Exacerbation in 

Children Pediatric Evidence Based Care Guidelines, Cincinnati 

Children's Hospital Medical Center, Guideline 4, pages 1-35, 

September 16, 2010 

Target Population 

Inclusion: 

Children experiencing an acute asthma exacerbation: 

up to 18 years of age with diagnosed asthma or high 

probability of asthma presentation 

0 to 12 months: accurate diagnosis of asthma in 

this age range is difficult (see Attachment 1 Key 

Indicators and Attachment 2 Differential 

Diagnosis) 

Exclusion: Children: 

admitted to the intensive care unit (ICU) 

who require intubation, ventilator support or are in 

impending respiratory arrest 

with bronchiolitis or conditions characterized by non- 

bronchodilator-responsive wheezing 

Exercise caution in managing children with comorbid 

conditions such as: 

congenital or acquired cardiovascular disease 

cystic fibrosis 

chronic lung disease or bronchopulmonary dysplasia 

immunodeficiency syndromes 

Target Users 

Include, but are not limited to: 

Patient care staff, nurses, pharmacists, respiratory 

therapists 

Physicians, residents 

Primary care providers, physician assistants 

9BIntroduction 

10BReferences 

in parentheses ( ), Evidence strengths in [ ] (See last page for definitions) 

Asthma is a disease of the respiratory tract 

characterized by recurrent and/or chronic episodes of 

airway inflammation and obstruction (manifested by 

wheeze or cough, or demonstrated upon pulmonary 

function testing) and evidence of reversibility of 

obstruction. 

Despite advances in the understanding of asthma and 

development of effective medical interventions to 

prevent morbidity and improve quality of life, asthma 

remains a burden in prevalence, health care use and 

mortality. There are significant ethnic and racial 

disparities in asthma outcomes (Lai 2009 [4a], Ginde 2008 

[4a], Jones 2008 [4a], Ferris 2006 [4a], Gupta 2006 [4a], 

McDaniel 2006 [4a], Wilson 2005 [4a]) (see Section: 

Disparities in Quality Care). 

Prevalence in children continues to show an increasing 

trend with reported rates between 8.5% and 8.9% 

(Akinbami 2009 [4a], Kamble 2009 [4a], MMWR Moorman 2007 

[4a]). Asthma is most prevalent in children 5 to 14 years 

and in Puerto Rican and African-American children. 

Among children younger than 18 years of age, asthma 

is more prevalent in males (Akinbami 2009 [4a], MMWR 

Moorman 2007 [4a]). The rate of asthma deaths among 

children has declined from 1999 onward (Akinbami 2009 

[4a], WorldHealthOrganizationWritingGroup 2006 [5a]). 

Although this guideline is focused on the management 

of the acute exacerbation in the emergency department 

(ED) and inpatient settings (excluding the ICU), it is 

recognized that asthma is a chronic inflammatory 

disease and requires a safe transition of care to the 

chronic care provider upon discharge. 

The objectives of the guideline are to: 

resolve the acute episode providing appropriate 

therapies and decreasing the use of unnecessary 

therapies 

decrease risk of readmission to the ED or inpatient 

unit 

initiate or update chronic care management plan and 

provide a discharge patient management plan 

provide formal care transition to chronic care 

provider 

maintain and improve family satisfaction 

Copyright © 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 1 of 36


Guideline Recommendations 

Emergency Department Management 

Initial History and Physical 

1. It is recommended that before and as therapy is 

initiated, a brief, focused history and physical 

examination is obtained, including: (LocalConsensus [5], 

NAEPP 2007 [5a]) 

time of onset of current exacerbation 

current medications and allergies 

recent frequent use of beta2-agonists 

risk factors for severe, uncontrolled disease (e.g. 

ED visits, admissions to the hospital and ICU, 

and prior intubations) 

exposure to asthma triggers 

use of peak flow with home management 

respiratory score. 

Note 1: Indications of more severe exacerbation 

include increased anxiety, decreased level of 

consciousness, breathlessness, diffuse wheezing 

or absence of air movement, increased 

respiratory rate, and accessory muscle use or 

suprasternal retractions (see Attachment 3 

Formal Evaluation of Severity in the ED, 

Attachment 4 ED Management of Asthma 

Exacerbation Algorithm and Recommendation 

#13 for severe asthma with respiratory distress). 

Note 2: Perform a more detailed history and 

physical assessment only after therapy has begun 

(NAEPP 2007 [5a], Camargo 2009 [5b]). 

Note 3: Patient and parental reports of 

medication use, peak flow values and/or 

environmental irritant/allergen exposure often 

present a more favorable description of their 

disease management than is actual (Dell 2007 [2a], 

Kamps 2001 [2b], Bender 2000 [3b], Rich 2000 [3b], 

Dozier 2006 [4a], Halterman 2003 [4a], NAEPP 2007 

[5a]). 

2. It is recommended that repeat assessments of 

response to therapy be conducted, including clinical 

examination, asthma score, pulse oximetry, and lung 

function. In children with exacerbation, no single 

assessment tool appears to be best for assessing 

severity, treatment monitoring, or predicting 

admission; therefore, use of one tool may not be 

reliable (Sole 1999 [2a], Ribeiro de Andrade 2007 [3a], Keahey 

2002 [3a], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 

[5a]). 

3. It is recommended that forced expiratory volume in 1 

second (FEV1) or peak flow monitoring be attempted 

in children over 5 years with mild to moderate 

exacerbations and who currently perform peak flow 

with home management (NAEPP 2007 [5a], Camargo 2009 

[5b]). 

Note: Pulmonary function measurements, 

although often difficult to obtain in children, are 

useful in assessing the severity of an asthma 

exacerbation (Gorelick 2004 [3a]). If able to obtain, 

and measurement is < 40% of predicted (or 

personal best), consider adjunct therapies or 

admission (NAEPP 2007 [5a]). 

Initial Treatment 

Oxygen 

4. It is recommended that supplemental oxygen be 

started and monitored when the oxygen saturation is 

consistently less than 91% and to wean oxygen when 

saturation is higher than 94% (Geelhoed 1994 [3a], SIGN 

2008 [5a], NAEPP 2007 [5a]). 

Short-acting inhaled beta2-agonists 

5. It is recommended that racemic albuterol, an inhaled 

short-acting beta2-agonist (SABA) be administered as 

the drug of choice for rapid reversal of airflow 

obstruction (NAEPP 2007 [5a], Camargo 2009 [5b]). 

Modify therapy based on the early clinical response 

to treatments (SIGN 2008 [5a], NAEPP 2007 [5a], Camargo 

2009 [5b]) (see Table 1 Aerosolized Therapies –drugs 

and dosage recommendations). 

Note: Albuterol treatments given every 10 to 20 

minutes for a total of 3 doses can be given safely 

as initial therapy (LocalConsensus [5], SIGN 2008 [5a], 

NAEPP 2007 [5a]). 

6. It is recommended that levalbuterol not be routinely 

used in the treatment of acute exacerbation 

(LocalConsensus [5]). 

Confusion exists regarding the selection of albuterol 

versus levalbuterol in the treatment of acute asthma. 

Although levalbuterol may prove more efficacious 

for some individuals, there is currently no data on 

how to identify these patients (Jalba 2008 [1b]). The 

following information may assist in the decision to 

choose: 

Note 1: Efficacy 

Levalbuterol has demonstrated comparable 

efficacy to albuterol for treatment of acute 

exacerbations in the ED and inpatient settings 

(Gupta 2007 [1b], Ralston 2005 [2a], Carl 2003 [2a], 

Andrews 2009 [2b], Hardasmalani 2005 [2b], Qureshi 2005 

[3a]). A large double-blind prospective trial 

demonstrated a 10% reduction in hospital 

admissions with the use of levalbuterol (Carl 2003 

[2a]) and a retrospective review of consecutive 

cases demonstrated a 4.5% reduction (Schreck 2005 



[4a]). The numbers needed to treat (NNT) with 

levalbuterol to prevent one hospital admission in 

theses studies equals 11 and 10 respectively (Carl 

2003 [2a], Schreck 2005 [4a]). 

Note: 2: Side effect reduction 

Difference in the reduction of adverse events 

such as tachycardia, tremor, or increase in blood 

pressure has not been demonstrated when 

equivalent doses of levalbuterol and albuterol 

have been studied (Andrews 2009 [2b]). 

The use of racemic albuterol with MDI has been 

shown to result in lower pulse rates when 

compared to nebulizer (Cates 2006 [1a], Mathew 2008 

[1b ], Deerojanawong 2005 [2b], SIGN 2008 [5a]). This 

may be an important consideration for children at 

risk for tachycardia including children with 

congenital heart disease or known arrhythmias 

(LocalConsensus [5]). 

Note 3: Cost 

Given that there appears to be no safety 

advantage to the use of levalbuterol, and the 

ability to identify patients who have a differential 

treatment response, the greatly increased cost of 

the drug would argue against its use in the 

general population. Discussion of the safety and 

cost factors with parents may assist in the 

selection process (LocalConsensus [5]). 

Inhalation Delivery Device Selection 

Devices used for the delivery of bronchodilators and 

inhaled corticosteroids can be equally efficacious. 

7. It is recommended that when selecting an inhalation 

delivery device that consideration be given to the 

following: (Dolovich 2005 [1a], Scarfone 2002 [3b]) 

device/drug availability 

patient ability to use the selected device 

correctly 

device use with multiple medications 

cost and reimbursement 

drug administration time 

convenience in both outpatient and inpatient 

settings 

physician and patient preference. 

Note 1: In children and adolescents with acute 

asthma exacerbation, no significant difference 

exists for important clinical responses such as 

time to recovery of asthma symptoms, repeat 

visits, or hospital admissions when medications 

are delivered via MDI with Valved Holding 

Chamber (VHC) or nebulizer (Mathew 2008 [1b ], 

Delgado 2003 [2a], Jamalvi 2006 [3a], Benito-Fernandez 

2004 [3a], Yilmaz 2009 [4a]). Within this guideline, a 

spacer is defined as a VHC or ―delivery‖ device 

that has a one-way valve inside that prevents the 

medicine from escaping once you have pressed 

down on the MDI canister (LocalConsensus [5]). 

Spacers improve the clinical effect of inhaled 

medications, especially in patients unable to use 

an MDI properly (Lavorini 2009 [5b]). The use of 

large volume spacers has been recommended for 

any inhaled asthma drug in young children, and 

as a means of reducing systemic bioavailability 

of inhaled corticosteroids in adults and children 

alike (Newman 2004 [5a]). One study has 

demonstrated the percent difference of drug 

deposition into the lung as 4.9% to 10.9% with 

spacer use compared to no spacer. This 

represents a range of approximately 52% to 87% 

increase in drug deposition (Vidgren 1987 [4b]). 

Note 2: MDIs have been shown to shorten time 

to discharge from the ED, to improve pulmonary 

function measures, and to result in lower pulse 

rates when compared to nebulizer (Cates 2006 [1a], 

Castro-Rodriguez 2004 [1a], Mathew 2008 [1b ], 

Deerojanawong 2005 [2b], Boyd 2005 [3a], 

LocalConsensus [5], SIGN 2008 [5a]). 

Note 3: The inhalation route for SABA 

administration is considered optimal. 

Subcutaneous SABAs (epinephrine, terbutaline) 

provide no proven advantage over inhaled 

medication (NAEPP 2007 [5a]). Intravenous SABAs 

have not been shown to improve pulmonary 

physiology or outcomes compared to inhaled 

routes (Travers 2001 [1a], NAEPP 2007 [5a]). 

Inhaled ipratropium bromide 

8. It is recommended that inhaled ipratropium be added 

to SABA and corticosteroid therapies for children 

presenting with moderate or severe acute 

exacerbations or when the FEV1 is < 50% of 

predicted (Plotnick 2009 [1a], Rodrigo 2005 [1a], Dotson 2009 

[1b], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a], 

Hayday 2002 [5a]) (see Table 1 Aerosolized Therapies - 

drugs and dosage recommendations). 

Note 1 : Adding multiple doses (up to 3 doses) 

of anticholinergics to SABAs appears safe, 

improves lung function and avoids hospital 

admission in 1 of 12 school-aged children with 

severe exacerbation (number needed to treat 

[NNT] = 12) (Plotnick 2009 [1a]). 

Note 2: Although ipratropium has been shown to 

be efficacious in preventing hospitalizations for 

children with exacerbations where FEV1 is


Table 1: Aerosolized Therapies - Drugs and Dosage Recommendations 

Aerosolized Therapies 

Medication 

(formulation) 

Child Dose* Adolescent Dose Notes 

Inhaled Short-Acting Beta2-Agonists (SABA) 

Albuterol 

Nebulizer solution 

(2.5 mg/3mL, 

5 mg/mL) 

MDI 

(90 mcg/puff) 

Levalbuterol 

(R-albuterol) 

Nebulizer solution 

(0.31mg/3 mL, 

0.63 mg/3 mL, 

1.25 mg/0.5mL, 

1.25 mg/3 mL) 

2.5 to 5 mg every 20 minutes for 

3 doses, then 2.5 to 5 mg every 

1 to 4 hours as needed 

0.5 mg/kg/hour by continuous 

nebulization 

< 30 kg: 2.5 mg 

≥ 30 kg: 5 mg 

6 puffs (range: 4 to 8 puffs) 

every 20 minutes for 3 doses, 

then every 1 to 4 hours as needed 

0.075 mg/kg (minimum dose 

1.25 mg) every 20 minutes for 3 

doses, then 0.075 to 0.15 mg/kg 

(not to exceed 2.5 mg) every 1 to 

4 hours as needed 

2.5 to 5 mg every 20 

minutes for 3 doses, 

then 2.5 to 10 mg 

every 1 to 4 hours as 

needed, 

or 10 to 15 mg/hour 

continuously 

6 puffs (range: 4 to 8 puffs) 

every 20 minutes up to 4 

hours, then every 1 to 4 

hours as needed 

1.25 to 2.5 mg every 20 

minutes for 3 doses, then 

1.25 to 5 mg every 1 to 4 

hours as needed 

MDI See albuterol MDI dose above. See albuterol MDI dose 

(45 mcg/puff) Above. 

Anticholinergics in combination with Short-Acting Beta2-Agonist (SABA) 

Ipratropium 

bromide 

Nebulizer 

solution 

(500 mcg/2.5mL) 

MDI 

(18 mcg/puff) 

Ipratropium 

bromide with 

albuterol 

Nebulizer 

solution 

(Each 3 mL vial 

contains 0.5 mg 

ipratropium 

bromide and 2.5 

mg albuterol) 

500 mcg with first 3 doses of 

albuterol, (250 mcg may be used 

where available) 

not to exceed 1500 mcg in the 

first hour of treatment 

4 to 8 puffs every 20 minutes as 

needed up to 3 hours 

1.5 mL every 20 minutes for 3 

doses 

500 mcg with first 3 doses 

of albuterol, not to exceed 

1500 mcg in the first hour 

of treatment 

8 puffs every 20 minutes as 

needed up to 3 hours 

3 mL every 20 minutes for 

3 doses 

For optimal delivery, dilute aerosols to 

minimum of 3 mL at gas flow of 6 to 8 

L/min. Use large volume nebulizers for 

continuous administration. May mix 

with ipratropium nebulizer solution. 

In mild to moderate exacerbations, 

MDI plus VHC (see recommendation 

7) is as effective as nebulized therapy 

with appropriate administration 

technique. Add mask in children 

unable to manage an MDI device. 

See Recommendation 6 of this 

guideline regarding levalbuterol. 

Not necessary as first line therapy in 

children with mild exacerbations. 

Add to SABA therapy for children 

with moderate and severe 

exacerbations. 

Current formulation (HFA) is safe for 

persons with peanut allergy. 

May mix ipratropium bromide in same 

nebulizer with albuterol. 

Ipratropium is not necessary as first 

line therapy in children with mild 

exacerbations. 

Add ipratropium to SABA therapy for 

children with moderate and severe 

exacerbations. Once the child is 

hospitalized, further use of ipratropium 

has not been shown to provide 

significant benefit. 

*Children < 12 years of age 

Abbreviations: HFA = hydrofluoroalkane propellant; kg = kilogram; L/min = liter per minute; mcg = microgram; MDI = metered dose inhaler; 

mg = milligram; mL = milliliter; SABA = short-acting beta 2-agonist; VHC = valved holding chamber 

Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program 

Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a], Taketomo [5a]). 



Table 2: Corticosteroids - Drugs and Dosage Recommendations 

Systemic Corticosteroids 

Medication Dosage Notes 

Prednisone 

Prednisolone 

Methylprednisolone 

(sodium succinate) 

1 mg/kg once daily 

(maximum 60 mg/day) 

for a total of 5 days 

Dexamethasone Oral: 

0.6 mg/kg once daily 

(max 16 mg/dose) 

for 1 to 2 days (Qureshi 2001 [2a]) 

Dosages in excess of 1mg/kg of prednisone or 

prednisolone have been associated with adverse 

behavioral effects in children, whereas 1mg/kg 

provides equivalent pulmonary benefit with 

decreased adverse effects (Kayani 2002 [2b]). 

Intramuscular (dexamethasone sodium 

phosphate): 

0.6 mg/kg single dose 

(max 15 mg) (Gordon 2007 [2a]) 

No advantage has been found for higher dose corticosteroids in severe asthma exacerbations. 

There is no advantage for intravenous administration over oral therapy, provided gastrointestinal function is intact. 

Therapy following a hospitalization or ED visit is typically 5 days, but may last from 3 to 10 days. Studies indicate there is 

no need to taper the systemic corticosteroid dose when given up to 10 days. 

Any previous IV doses may be considered as part of the total steroid dose. 

Abbreviations: ED = emergency department; IV = intravenous; kg = kilogram; max = maximum; mg = milligram 


Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (Chang 2008 [2a], LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a], 

Taketomo [5a]). 

Corticosteroids 

9. It is recommended that oral corticosteroids be 

administered to patients who do not respond 

completely to initial inhaled SABAs (Edmonds 2009 

[1a], NAEPP 2007 [5a], Camargo 2009 [5b]) (see Table 2 

drugs and dosage recommendations). 

Note 1: Corticosteroids speed the resolution of 

airflow obstruction, reduce the rate of relapse, 

and may reduce hospitalizations, especially if 

administered within one hour of presentation to 

the ED (Rowe 2009a [1a], Edmonds 2009 [1a]). 

Note 2: Oral prednisone has effects equivalent to 

those of intravenous methylprednisolone 

including tolerance by children (Rowe 2009a [1a], 

SIGN 2008 [5a], NAEPP 2007 [5a], Camargo 2009 [5b]). 

Note 3: For treatment of acute exacerbation, 

insufficient evidence exists for inhaled 

corticosteroid therapy alone or as an additive 

benefit when used with systemic corticosteroids 

(Edmonds 2009 [1a], Schuh 2006 [2b], Nakanishi 2003 

[2b], NAEPP 2007 [5a], Camargo 2009 [5b]). 

Note 4: If the patient is on routine inhaled 

steroids for chronic control it is not necessary to 

stop their use during exacerbation. The inhaled 

corticosteroids can be started at anytime 

regardless of oral dosing for the exacerbation 

(LocalConsensus [5], SIGN 2008 [5a], NAEPP 2007 [5a]). 

Note 5: It is recognized that many children will 

have problems with treatment adherence due to 

an oral aversion to medicine, especially bittertasting 

corticosteroid preparations. In such cases, 

alternatives such as intramuscularly administered 

dexamethasone, oral dexamethasone, and orally 

administered intravenous versions of 

corticosteroids have been proven efficacious 

(Rowe 2009a [1a], Smith 2009 [1a], Gordon 2007 [2a], 

Altamimi 2006 [2a], Qureshi 2001 [2a], Greenberg 2008 

[2b], Huang 2007 [2b], Gries 2000 [2b]). 

Adjunctive Therapies 

Magnesium Sulfate 

10. It is recommended in children with moderate to 

severe exacerbations who are minimally responsive 

or unresponsive to initial treatment (SABA, oral 

corticosteroids, and ipratropium), that intravenous 

magnesium sulfate be administered (Rowe 2009b [1a], 

Mohammed 2007 [1a], Ciarallo 2000 [2b], SIGN 2008 [5a]) 

(see Table 3 Adjunctive Therapies - drugs and 

dosage recommendations). 

Note 1: In patients with acute exacerbation who 

have been maximized on standard therapy, 

intravenous magnesium sulfate has been shown 

to reduce hospitalizations and to improve lung 

function without significant side effects. Possible 

side effects to be aware of include hypotension, 

hypotonia, or abnormal reflexes when given 

doses above that recommended for asthma (Rowe 

2009b [1a], Mohammed 2007 [1a], Alter 2000 [1a]). 



Note 2: There is insufficient evidence regarding 

the use of nebulized magnesium sulfate in acute 

exacerbation (Blitz 2009 [1b]). 

Epinephrine and Terbutaline 

11. It is recommended for patients who are minimally 

responsive or responding poorly to SABA / 

ipratropium / systemic corticosteroid/magnesium 

sulfate therapies, or who are unable to tolerate 

aerosol treatments, that parenteral epinephrine or 

terbutaline be considered (NAEPP 2007 [5a]) see Table 

3 Adjunctive Therapies - drugs and dosage 

recommendations). 

Heliox 

12. There is insufficient evidence and lack of consensus 

regarding the effectiveness of heliox in acute 

exacerbation of asthma to make a recommendation 

for its routine use (Rivera 2006 [2b], SIGN 2008 [5a]). 

Note: Heliox-driven albuterol nebulization may 

be considered for patients who have life- 

threatening exacerbation or who remain in severe 

exacerbation after intensive conventional 

adjunctive therapy (Rodrigo 2006 [1a], Kim 2005 [2b], 

NAEPP 2007 [5a]). In one small study, 

improvement in respiratory score and shorter ED 

length of stay were seen when heliox was 

administered in moderate and severe 

exacerbation (Kim 2005 [2b]). 

Severe Asthma with Respiratory Distress and 

Normal Mental Status 

13. It is recommended that multiple therapies as 

described below be started simultaneously while 

either a consult from the Pediatric Intensive Care is 

requested or transport to a higher level of care is 

arranged (LocalConsensus [5]) (see Table 3 Adjunctive 

Therapies- drugs and dosage recommendations) 

Administer: 

continuous albuterol 

ipratropium bromide, up to 3 doses 

systemic coticosteroids 

(dexamethasone IM or 

methylprednisolone IV) 

epinephrine IM 

magnesium Sulfate IV 

consider terbutaline IV bolus, and infusion. 

Table 3: Adjunctive Therapies - Drugs and Dosage Recommendations 

Medication Child (< 12 years of age) Adolescent Notes 

Magnesium Bolus: 50 mg/kg/dose (25 to 100 mg/kg/dose; There is insufficient evidence regarding the benefit 

Sulfate 

max 2 gms) 

from continuous infusion of Magnesium Sulfate 

Intravenous (IV) Administer over 20 minutes 

(Mohammed 2007 [1a]). 

Systemic (injected) Beta2-Agonists 

Epinephrine 

Intramuscular (IM) 

1:1,000 

(1 mg/mL) 

Terbutaline 

Intravenous (IV) or 

Subcutaneous (SQ) 

(1 mg/mL) 

0.01 mg/kg 

(max 0.3 to 0.5 mg) 

every 20 minutes 

for 3 doses 

0.01 mg/kg bolus 

(max 0.4 mg ) 

Over 10 minutes 

0.01 mg/kg 

(max 0.25 mg) 

May repeat every 15 

minutes for 3 doses 

0.3 to 0.5 mg 

every 20 minutes 

for 3 doses 

0.01 mg/kg bolus 

(max 0.75 mg) 

Over 10 minutes 

0.01 mg/kg 

(max 0.25 mg) 

May repeat every 15 

minutes for 3 doses 

One small study demonstrated more rapid absorption 

and higher plasma levels of epinephrine when 

administered intramuscularly into the thigh compared 

to subcutaneously or intramuscularly into the arm (up 

to 4 times faster)(Simons 1998 [2b]). 

Starting continuous infusion dose in the ED or PICU 

settings: 1 mcg/kg/minute 

Abbreviations: ED = emergency department; gms = grams; kg = kilogram; max = maximum; mcg = microgram; mg = milligram; 

mL = milliliter; PICU = pediatric intensive care unit 


Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a], Taketomo [5a]). 



Timing of Disposition from the Emergency 

Department 

The response to initial treatment in the ED after a period 

of observation is a better predictor of the need for 

hospitalization than is the severity of an exacerbation 

(NAEPP 2007 [5a]). 

14. It is recommended that the current severity of the 

exacerbation be in the ―mild‖ range when evaluating 

a child for discharge from ED or hospital 

(LocalConsensus [5]) (see Attachment 3 Formal 

Evaluation of Severity in the ED, Attachment 4 ED 

Management of Asthma Exacerbation Algorithm) . 

Note 1: In the ED, if initial severity is moderate 

or severe, then the severity assessment 1 hour 

after treatment is better than initial severity 

assessment for determining the need for hospital 

admission as well as for predicting the need for 

ICU in patients initially assessed as severe (Kelly 

2004 [3a], LocalConsensus [5]). 

Note 2: In acute childhood asthma, a repeat pulse 

oximetry of < 92 to 94 % at 1 hour after treatment 

better predicts need for hospitalization than the 

initial pulse oximetry (Kelly 2004 [3a], Wright 1997 

[3b], LocalConsensus [5]). 

Inpatient Management 

General Therapy 

15. It is recommended, with the exception of the use of 

anticholinergics such as ipratropium, that usual 

inpatient hospital management be viewed as a 

continuation of any therapies initiated in the ED 

including: (NAEPP 2007 [5a]) 

aerosolized bronchodilators 

oxygen 

corticosteroids 

initiation and continuation of controller (antiinflammatory) 

agents 

continued assessment 

intermittent assessment of oxygen saturation 

FEV1 or peak expiratory flow (PEF) on 

admission, 15 to 20 minutes after bronchodilator 

therapy during acute phase and daily until 

discharge (in children > 5 years of age if able to 

perform). 

Failure to Progress 

16. It is recommended that the following care be 

initiated for patients who fail to progress after 12 

hours of care: (LocalConsensus [5]) 

notify treating healthcare provider of any child 

that has not progressed after 12 hours of care 

assessment: 

physical examination and respiratory score 

explore reason/s for failure to progress (e.g. 

poor SABA responder, pneumonia or other 

diagnosis, suboptimal steroid dose or 

suboptimal frequency of administration) 

escalate plan based on assessment findings 

treatment considerations, as indicated: 

albuterol treatments every 10 to 20 minutes 

for 3 doses or continuous albuterol 

administered over 30 minutes, and reassess 

chest x-ray 

administer or re-administer IV steroid if 

greater than or equal to 12 hours since last 

dose (oral or IM if cannot acquire IV 

access) 

venous or capillary blood gas 

if status is improved after treatment escalation, 

then reassess hourly 

if status is not improved, discuss potential for 

transfer to PICU or higher level of care 

consider subspecialty consult. 

Decompensation 

17. It is recommended that the following care be 

initiated for the patient whose condition is assessed 

as decompensating from a prior stabilized state: (this 

is not for the patient in an obvious medical 

emergency for whom a medical code needs to be 

initiated): (LocalConsensus [5]) 

albuterol treatments every 10 to 20 minutes for a 

total of 3 doses or continuous albuterol over 30 

minutes, and reassess 

initiate the Medical Response Team (MRT) or the 

team responsible for immediate assessment of a 

child with a change in condition 

notify treating healthcare provider that child is 

decompensating 

assess for treatment escalation options: 

consider other adjunctive medications 

- epinephrine IM 

- ipratropium unless previously given 

- magnesium sulfate unless previously given 

administer or readminister steroid if indicated 

(oral, IM, or IV if available) 

insert IV 

portable chest x-ray 

prohibit eating or drinking (NPO) 

consider capillary or venous blood gas 

consider subspecialty consult 

reassess after treatment escalation 

if improved, resume hourly assessment 

if not improved, transfer to PICU or higher 

level of care. 



Consistency of Care 

18. It is recommended that available protocols such as 

clinical pathways or protocols be used, directing 

consistent provision of care for patients presenting 

with an acute asthma exacerbation (SIGN 2008 [5a], 

NAEPP 2007 [5a]). At Cincinnati Children’s Hospital 

Medical Center, such protocol usage includes: 

Asthma Clinical Order set 

Aerosol and Oxygen Protocol. 

Note: Use of a clinical pathway or designated 

care providers for inpatient management has 

been shown to decrease length of stay, use of 

SABA therapy, nursing and laboratory costs, 

and to improve quality of care with no increase 

in readmission rates (Johnson 2000 [2a], McDowell 

1998 [2a], Norton 2007 [4a], Wazeka 2001 [4a], 

Ebbinghaus 2003 [4b], Kelly 2000 [4b]). 

Complementary and Alternative Medicine 

19. It is recommended that the clinician ask 

patients/parents about all medications and treatments 

they are using for asthma (LocalConsensus [5], NAEPP 

2007 [5a]). 

Note 1: A high level of use of complementary 

and alternative medicine (CAM) has been 

reported in several studies: 45% of care providers 

reported using herbal products with their children 

(Lanski 2003 [3a]), 63% of adolescents reported the 

use of complementary medicine when surveyed 

(Reznik 2002 [3a]), and a review of literature of 

CAM use in asthma found the level ranged from 

33% to 89% in studies of children and adolescents 

(Mark 2007 [1b]). Currently there is insufficient 

evidence to support or refute the use of CAM 

therapies (Altunc 2007 [1a], Hondras 2005 [1a], Mark 

2007 [1b]). 

Note 2: Patients who use herbal treatments may 

need caution regarding the potential for harmful 

ingredients in herbal treatments and interactions 

with asthma medications (Lanski 2003 [3a], NAEPP 

2007 [5a]). 

20. It is recommended that acupuncture not be used for 

the treatment of asthma. No evidence of an effect of 

acupuncture in reducing asthma symptoms has been 

demonstrated (McCarney 2009 [1a], Martin 2002 [1a], 

NAEPP 2007 [5a]). 

ED or Inpatient Management 

Screening 

21. It is recommended that systematic screening be 

conducted using a broad assessment tool, such as 

Child Asthma Risk Assessment Tool (CARAT) for 

identification of risks including medical, 

environmental, adherence, financial, psychosocial or 

health literacy (LocalConsensus [5]). The CARAT may 

be accessed via the following URL: 

http://carat.asthmarisk.org 

Consultations 

22. It is recommended that the need for consultations be 

considered at the time of presentation or as early as 

possible in the acute course (LocalConsensus [5]). 

Medical consultation: Usual indications for medical 

consultation (usually, a fellowship-trained allergist or 

pulmonologist; occasionally, other physicians who 

have expertise in asthma management, developed 

through additional training and experience) in 

childhood asthma include: (LocalConsensus [5], NAEPP 

2007 [5a]) 

the diagnosis of asthma is in question 

current life-threatening or severe asthma 

exacerbation possibly requiring MRT (medical 

response team) 

poor-responder or requiring escalation in routine 

care or unexplained deterioration 

repeated life-threatening hospital admissions, 

history of intensive care admission, frequent ED 

visits for asthma 

patient has required more than two bursts of oral 

corticosteroids in the past 12 months 

any exacerbation requiring hospitalization in the 

last 12 months 

evaluation for addition or discontinuation of 

LABA therapy 

conditions complicating asthma or its diagnosis 

(e.g. sinusitis, nasal polyps, aspergillosis, severe 

rhinitis, vocal cord dysfunction, gastroesophageal 

reflux, and chronic obstructive pulmonary 

disease) 

need for extensive education and guidance on 

allergen avoidance, problems with adherence to 

therapy and poor control, or complications of 

therapy. 

Mental Health consultation: Patients who have 

significant psychiatric, psychosocial, or family 

problems that interfere with their asthma therapy may 

need referral to an appropriate mental health 

professional for counseling or treatment. 

Social Service Consultation: Indications for 

considering social service consultation include: 

family's social or financial difficulties might be 

impediments to adherence with the treatments and 

medical follow-up 

family resources are compromised or uncertain 



Interpreter Services Consultation: Indication for 

considering services: 

family in need of language interpretation 

Pharmacist Consultation: Indications for 

considering pharmacist consultation (where 

available) include review of the medication regimen 

of a patient admitted for asthma exacerbation 

Note: Medication regimen evaluation may 

include: screening for adverse drug reactions, 

screening for drug interactions, ensuring 

appropriate medication use and dosing, 

appropriate route of administration, appropriate 

dosing intervals and/or comparison of the 

medication reconciliation record with the 

current medication orders (Sanghera 2006 [1a], 

Kaushal 2008 [3a]). 

Therapies Generally NOT Recommended 

23. It is recommended that theophylline or 

aminophylline not be administered routinely in the 

ED or hospitalized patient because they do not appear 

to provide additional benefit to optimal SABA therapy 

(D'Avila 2008 [2b]) and may increase frequency of 

adverse effects in acute exacerbation (Mitra 2009 [1a], 

SIGN 2008 [5a], NAEPP 2007 [5a]). 

Note 3: Patients using theophylline as 

outpatients may continue on their usual doses in 

the hospital; obtaining a therapeutic level while 

the child is hospitalized may be considered, 

because illness can affect serum levels. 

Additionally, a pharmacist consult may be 

useful for review of drug interactions (NAEPP 

2007 [5a]). 

24. It is recommended that antibiotics not be used 

routinely for acute asthma exacerbations in the 

absence of an identified bacterial focus (Graham 2009 

[1a], SIGN 2008 [5a], NAEPP 2007 [5a], Blasi 2007 [5b]). 

25. It is recommended that aggressive rehydration not 

be used routinely for acute asthma exacerbation in 

the absence of clinical dehydration (NAEPP 2007 [5a]). 

26. It is recommended that chest physiotherapy (CPT), 

incentive spirometry, and mucolytics not be used 

routinely for acute asthma exacerbations as they can 

trigger bronchospasm or worsen cough or air flow 

obstruction during an acute asthma attack (NAEPP 

2007 [5a]). 

27. It is recommended that anxiolytic and hypnotic 

drugs not be used routinely for acute asthma 

exacerbations outside of an intensive care setting, as 

they may cause respiratory depression (NAEPP 2007 

[5a]). 

28. It is recommended that oral albuterol not be used 

for acute exacerbation (LocalConsensus [5]). 

Therapy Cautions/Considerations 

29. It is recommended that for therapies outlined in this 

section, caution and consideration be used in 

treatment selections (LocalConsensus [5]). 

Ibuprofen: In children without known Aspirin Induced 

Asthma (AIA), ibuprofen may be a better choice than 

acetaminophen for the treatment of fever/pain in children 

presenting with acute asthma exacerbations. 

Acetaminophen has been associated with an increased risk 

of wheezing (Kanabar 2007 [1a], Karimi 2006 [4a]). 

In children with known AIA, it is prudent to counsel 

parents regarding the potential for cross-sensitivities to 

non-steroidal anti-inflammatory drugs (NSAIDs) (Debley 

2005 [1a]). This patient population demonstrates less crosssensitivity 

to acetaminophen. 

Cross-Sensitivities: (Jenkins 2004 [1a]) 

ibuprofen < 400mg 98% 

naproxen < 100mg 100% 

diclofenac < 40mg 93% 

acetaminophen > 500mg 7% 

Long-Acting Beta2-Agonists 

Epidemiological evidence suggests a link between longacting 

beta2-agonists (LABAs) and increases in asthma 

mortality. Concern remains that symptomatic benefit 

from treatment with LABAs might lead to 

underestimation of acute attack severity and long-term 

use could lead to tolerance to their bronchodilator 

effects (Cates 2009b [1a], Cates 2009a [1a]). In addition, 

recent analyses by the Food and Drug Administration 

(FDA) and others concluded that use of LABAs is 

associated with an increased risk of severe worsening of 

asthma symptoms, leading to hospitalization in both 

children and adults and death in some patients with 

asthma (Salpeter 2010 [1a], Walters 2007 [1a], Salpeter 2006 

[1a], FDA 2010 [5]). The FDA is requiring further studies 

for safety evaluation and has concluded that although 

these medicines play an important role in helping some 

patients control asthma symptoms, their use be limited 

to patients whose asthma cannot be controlled with 

inhaled corticosteroids alone (FDA 2010 [5]). There is no 

good evidence as to which subpopulation would benefit 

or be harmed with use of a LABA. One recent study, 

evaluating step-up therapy in children, concluded that 

response to LABA was more likely to provide a better 

response compared to ICS or leukotriene-receptor 

antagonist (LTRA). However many children had a best 

response to ICS or LTRA step-up, highlighting the need 

to regularly monitor and appropriately adjust each 



child’s asthma therapy within this level of care before 

further step-up (Lemanske 2010 [2a]). 

Until further studies are concluded, it is suggested 

that all patients treated with LABA be individually 

evaluated to ensure that this is the best option for 

asthma control (Cates 2009b [1a], Cates 2009a [1a]). 

Such evaluation may best be performed in 

conjunction with an Asthma Specialist 

(LocalConsensus [5]) (see Recommendation #35 for 

evaluation of LABA use). 

Disparities in quality of care: When treating children 

with asthma, it is important to consider the 

socioeconomic factors that might lead to avoidable 

hospitalizations and premature mortality (Cope 2008 [4a], 

Gupta 2006 [4a]). Special consideration of the following 

conditions assists in the provision of patient-centered, 

equitable care: 

Medicaid-covered, minority children have worse 

asthma status (parental report) and are less likely to 

be using preventive, anti-inflammatory agents than 

white children (Ferris 2006 [4a], Lieu 2002 [4a]). 

Children uninsured or on Medicaid have ranked 

significantly lower on seven quality measures 

including ED utilization, prescriptions from the ED, 

and access to and use of a primary care provider 

(Lara 2003 [2a], Knudson 2009 [4a], Wilson 2005 [4a], Ferris 

2001 [4a]). 

Black children demonstrate more likelihood to have 

asthma and to experience ED visits for asthma, 

compared with otherwise comparable white children 

(Flores 2005 [3a], Jones 2008 [4a]). 

The effect of comorbid conditions and mental illness 

in mothers of asthmatic children has recently been 

shown to impact asthma control and health services 

utilization related to asthma (Coughlan 2001 [1a], 

Bartlett 2001 [3a], Belamarich 2000 [3a], Rodriguez 2002 

[4a], Shalowitz 2001 [4a], NAEPP 2007 [5a]) (see 

Recommendation #22, Consultations, Social 

Services). 

Discharge/Transition Preparation 

Although this guideline is focused on the acute 

management of asthma exacerbations, it is recognized 

that asthma is a chronic disease. Discharge planning is 

intended to assist the transition from the acute 

exacerbation to chronic management, identifying factors 

within the chronic action plan that may need adjusting to 

prevent future exacerbations and improve long-term 

patient outcomes. The transition plan is expected to 

enhance the likelihood that the family, and ultimately 

the child, will become skilled in self-management of this 

chronic condition. Early planning is important to assure 

that problems with details associated with follow-up 

have been resolved prior to discharge. 

Recommendations for comprehensive management of 

chronic asthma can be found in the most recent update 

of the national asthma guideline (NAEPP 2007 [5a]). 

30. It is recommended that planning for discharge begin 

when the child first presents to the ED or hospital 

unit (LocalConsensus [5]). 

31. It is recommended that prior to discharge the patient 

undergo Severity Classification of chronic asthma (see 

Attachment 5 Severity Classification). This will 

support a patient-centered approach to therapy (NAEPP 

2007 [5a]). Also, Severity Classification may be useful 

to the primary care provider in identifying children 

with special health care needs and facilitating care 

coordination (LocalConsensus [5]). 

32. It is recommended that case or care management by 

trained health professionals be considered for 

patients who have poorly controlled asthma and have 

recurrent visits to the ED or hospital. Caremanagement 

processes are tools to improve the 

efficiency and quality of primary care delivery, self 

management, and have demonstrated a reduction in 

ED visits (Schulte 2004 [1b], Levy 2006 [2a], Walders 2006 

[2a], Griffiths 2004 [2a], Portnoy 2006 [4a], Rosen 2006 [4a], 

Spiegel 2006 [4a], Wood 2006 [4a], Allcock 2009 [4b], CMSA 

2010 [5]). 

33. It is recommended, before the patient is discharged 

from the ED or inpatient unit, that education be 

provided that is tailored to the identified needs, 

beliefs, and learning styles of the patient and family 

and addresses identified patient-desired outcomes 

(Zorc 2005 [2a], LocalConsensus [5], Mansour 2009 [5a], SIGN 

2008 [5a], NAEPP 2007 [5a]). 

Note 1: When usual care for asthma was 

compared to more intensive educational programs 

(provided in either the ED, hospital, home or 

clinic), reduction in subsequent ED visits and 

hospital admissions occurred in those receiving 

intensive education (Boyd 2009 [1a], Wolf 2008 [1a], 

Karnick 2007 [2a], Brown 2006 [2a], Ng 2006 [2a], 

Sockrider 2006 [2a]). The most effective type, 

duration or intensity of education has not been 

determined (Boyd 2009 [1a], Coffman 2008 [1a], Wolf 

2008 [1a], Zorc 2009 [2a]). Patient-centered, specific 

education efforts may be more effective than 

general or poorly targeted interventions (Canino 

2008 [2a], Forbis 2002 [2b], NAEPP 2007 [5a]). 

Note 2: Asthma education plans have been 

successfully implemented in busy EDs (Boychuk 

2006 [3a], NAEPP 2007 [5a]). 



Components of education programs have not been 

comparatively studied; however, programs that have 

demonstrated improvement have included the following 

components: (Boyd 2009 [1a], Coffman 2008 [1a], Wolf 2008 [1a]) 

etiology, prognosis, and risk factors emphasizing 

chronicity of condition 

medication purpose, and when and how to use 

medications (Smith 2008 [4a]) 

provision or updating of written asthma plan 

Note: Parental attitudes toward and knowledge of 

asthma (pathophysiology, medications, action 

plans, and environmental triggers) influenced 

adherence to prescribed asthma medications and 

action plans in several studies (Jones 2002 [2a], 

Douglas 2002 [2b], NAEPP 2007 [5a]). 

identification of environmental triggers for prevention 

of acute exacerbations (Lanphear 2001b [4a], Lanphear 

2001a [4a]) (see Attachment 6 How to Control what 

Makes Your Asthma Worse) 

Note: Multifaceted allergen education and control 

interventions delivered in the home setting have 

been shown to be effective in reducing exposures 

to cockroach, rodent, and dust-mite allergens and 

associated asthma morbidity (Arshad 2007 [2a], 

Morgan 2004 [2a], Schonberger 2004 [2a], Chan-Yeung 2002 

[2a], Custovic 2001 [2a], Finn 2000 [3a], NAEPP 2007 [5a]). 

demonstration of correct use of inhaler / spacer (Hussain- 

Rizvi 2009 [2b]) (see Attachment 7 MDI Use) 

demonstration of peak flow technique if sending home 

with peak flow meter – (for patients with moderate or 

severe persistent asthma or a history of severe 

exacerbations, or patients who are poor perceivers of 

airflow obstruction) (see Attachment 8 Peak Flow Use) 

Note: Peak flow measurement can be a useful 

addition for severity assessment of an asthma 

exacerbation and is most useful in patients with 

moderate to severe persistent asthma (McMullen 2002 

[2a], Yoos 2002 [2a]). It can be used in short-term 

monitoring, acute exacerbations, and daily chronic 

monitoring (Goldberg 2001 [4a], Brand 1999 [4a], NAEPP 

2007 [5a]). 

home management of exacerbation or relapse 

including evaluation of early clinical signs and 

symptoms of airway inflammation 

Note: Beginning treatment at home may avoid 

treatment delays, prevent exacerbations from 

becoming severe, and also adds to patients’ sense 

of control over their asthma. The degree of care 

provided in the home depends on the patients’ (or 

parents’) abilities and experience and on the 

availability of emergency care (NAEPP 2007 [5a]). 

Accurate evaluation of symptom severity by 

parents and children will assist to avoid delays 

in care and inappropriate home management 

(Garbutt 2009 [2a]). 

importance and purpose of follow-up appointment – 

explore action plan, evaluate patient goal attainment, 

identify barriers to meeting activity goals, identify 

potential treatment adjustments to help meet goals and 

prevent future exacerbations (Zorc 2005 [2a], Zorc 2003 

[2a], Flores 2005 [3a]): 

• schedule before discharge for hospitalized 

patient 1 to 5 days after discharge 

• contact primary care provider before discharge 

from ED 

importance of continual and consistent care in 

outpatient setting, partnering with primary care 

provider to tailor interventions toward the child’s 

goals for activity 

provision of Asthma Specialists resource information 

if indicated. 

34. It is recommended that SABAs be used at home on an 

as-needed basis after recovery from an acute asthma 

exacerbation (Walters 2002 [1a], NAEPP 2007 [5a]). If 

patient’s need is greater than 6 puffs every 3 to 4 

hours by 24 to 48 hours after discharge provide family 

with instruction to seek medical care (LocalConsensus 

[5]). 

35. It is recommended that if a LABA was in use before 

admission, it be suspended during hospitalization for 

exacerbation and the patient be evaluated for 

continuation of therapy after discharge: (LocalConsensus 

[5], SIGN 2008 [5a]). 

Note 1: There is no evidence that continuing a 

LABA during exacerbation is beneficial and 

concern remains regarding harm with its 

continued use. 

Note 2: The beneficial effects of LABA in 

combination therapy for the patients who require 

more therapy than low-dose ICS alone to control 

asthma need to be weighed against the potential 

increased risk of severe exacerbations, associated 

with the daily use of LABAs in some patients 

(Cates 2009b [1a], Cates 2009a [1a], Nelson 2006 [2a], 

NAEPP 2007 [5a]). 

Consider consultation with an Asthma Specialist 

for questions regarding continuation of LABA 

following hospital discharge (LocalConsensus [5]). 

Note 3: In February of 2010 the FDA announced 

new safety controls for LABAs as follows: 

―LABAs are contraindicated without the use 

of an asthma controller medication such as 

inhaled corticosteroid, and should not be 

used alone‖ (FDA 2010 [5], NAEPP 2007 [5a]). 



―LABAs ought to only be used long-term in 

patients whose asthma cannot be adequately 

controlled on other asthma controller 

medications‖ (FDA 2010 [5]). 

―LABAs ought to only be used for the 

shortest duration of time required to achieve 

control of asthma symptoms and 

discontinued, if possible, once asthma 

control is achieved‖ (FDA 2010 [5]). 

Note 4: Of the adjunctive therapies available, 

LABAs are the preferred therapy to combine with 

ICS in youths ≥ 12 years of age and adults (NAEPP 

2007 [5a]). 

Note 5: For patients ≥ 5 years of age who have 

moderate persistent asthma or asthma 

inadequately controlled on low-dose ICS, the 

option to increase the ICS dose may be given 

equal weight to the option of adding LABA 

(NAEPP 2007 [5a]). A recent study suggests that 

patients are most likely to have a differential 

response to the addition of LABA to low dose 

ICS compared to increasing ICS or adding a 

leukotriene receptor antagonist. However, the 

safety of long term use of LABA remains 

uncertain (Lemanske 2010 [2a]). 

Note 6: For patients ≥ 5 years of age who have 

severe persistent asthma or asthma inadequately 

controlled, the combination of LABA and ICS is 

the preferred therapy (NAEPP 2007 [5a]). 

Note 7: For patients < 4 years of age, there is 

insufficient evidence for use of a LABA. These 

drugs are not labeled for use in this age group. 

Consider consultation with an Asthma Specialist 

for questions regarding this subset of asthma 

patients before adding LABA therapy 

(LocalConsensus [5], NAEPP 2007 [5a]). 

36. It is recommended that patients already on ICS 

continue ICS therapy after discharge from ED or 

inpatient setting. Consider initiating ICS for patients 

with persistent asthma if not already receiving (SIGN 

2008 [5a], NAEPP 2007 [5a]). 

Note: Initiating ICS at discharge for patients not 

already on ICS has demonstrated a decreased risk 

of subsequent ED visits for patients with persistent 

asthma (Sin 2002 [4a], NAEPP 2007 [5a]). 

37. It is recommended, when possible, that long term 

controller medications and medicines to complete 

exacerbation therapy are provided to the patient prior 

to discharge (Qureshi 2001 [2a], Cooper 2001 [4a]). 

Note: Prescriptions are not always filled after 

discharge (Qureshi 2001 [2a], Cooper 2001 [4a]). 

Outcomes demonstrated from prescriptions not 

filled have been an increase in missed school and 

work days (Qureshi 2001 [2a]). It is also believed 

that providing medicines will result in decrease 

readmission rates (LocalConsensus [5], NAEPP 2007 

[5a]). 

38. It is recommended that patients have a written plan 

that reflects adjustments necessary due to the current 

exacerbation and includes a stepwise approach 

coordinating with the child’s plan for chronic 

management (Zemek 2008 [1a], Bhogal 2006 [1a], NAEPP 

2007 [5a]) (see Attachment 9, Stepwise Management). 

39. It is recommended that every attempt be made to 

schedule the follow-up appointment before the 

child is discharged from the facility. When this is 

not possible, attempt to notify the primary care 

provider of the current exacerbation event (Zorc 2005 

[2a], Zorc 2003 [2a], LocalConsensus [5], NAEPP 2007 

[5a]). 

Note: A significant number of patients from the 

Cincinnati population consider the ED their 

regular source of care, and a commonly held 

health belief is that the ED is the appropriate place 

to seek care for a breathing problem (Mansour 2000 

[2b]). Having fewer general practice contacts in 

the previous year has been independently 

associated with an increased risk of fatal asthma, 

increasing the importance of the follow-up visit 

either with the primary care provider or asthma 

specialist (LocalConsensus [5], NAEPP 2007 [5a]). 

Discharge readiness 

Ongoing assessment will provide the needed information 

of the patient progression to determine the readiness for 

discharge. Discharge readiness usually includes the 

following: 

child stable on therapies that can be administered at 

home 

home environment is able to safely fulfill discharge 

plan 

sufficient knowledge of asthma to manage care at 

home or seek help if symptoms worsen 

arrangements for any special medications or 

equipment required for home therapies are complete 

transition plan based on admission screening is 

complete and reflects the patients continuum of care 

needs 

follow-up care is arranged, coordinating with 

primary care provider or asthma specialist if 

indicated, and providers agree with plans. 



Future Research Agenda 

Clinical questions of potential interest to CCHMC 

investigators related to the population of children 12 

months to 18 years of age with acute asthma: 

1. Does the discontinuation of LABA upon 

exacerbation compared to continuation of LABA: 

decrease the length of exacerbation? 

decrease the number of treatment failures (e.g. 

decompensation, admission)? 

2. Does the use of same dose Levalbuterol compared 

to Albuterol: 

decrease admissions? 

decrease costs? 

decrease cardiac adverse events (e.g. 

tachycardia, arrhythmia)? 

3. Does the use of a respiratory score compared to no 

score: 

decrease length of stay? 

CCHMC Guideline Implementation Tools 

Any available implementation tools are available online 

and may be distributed by any organization for the 

global purpose of improving child health outcomes. 

Website address: 

http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/evbased/default.htm 



KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA 

Consider a diagnosis of asthma and performing spirometry if any of these indicators is present.* 

These indicators are not diagnostic by themselves, but the presence of multiple key indicators 

increases the probability of a diagnosis of asthma. Spirometry is needed to establish a diagnosis of 

asthma. 

Wheezing—high-pitched whistling sounds when breathing out—especially in children. (Lack 

of wheezing and a normal chest examination do not exclude asthma.) 

History of any of the following: 

Cough, worse particularly at night 

Recurrent wheeze 

Recurrent difficulty in breathing 

Recurrent chest tightness 

Symptoms occur or worsen in the presence of: 

Exercise 

Viral infection 

Animals with fur or hair 

House-dust mites (in mattresses, pillows, upholstered furniture, carpets) 

Mold 

Smoke (tobacco, wood) 

Pollen 

Changes in weather 

Strong emotional expression (laughing or crying hard) 

Airborne chemicals or dusts 

Menstrual cycles 

Symptoms occur or worsen at night, awakening the patient. 

Attachment 1 

*Eczema, hay fever or a family history of asthma or atopic diseases are often associated with asthma, but 

they are not key indicators. 

(NAEPP 2007 [5a]) 



DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA 

Infants and Children 

Upper airway diseases 

Allergic rhinitis and sinusitis 

Adults 

Obstructions involving large airways 

Foreign body in trachea or bronchus 

Vocal cord dysfunction 

Vascular rings or laryngeal webs 

Laryngotracheomalacia, tracheal stenosis, or bronchostenosis 

Enlarged lymph nodes or tumor 

Obstructions involving small airways 

Viral bronchiolitis or obliterative bronchiolitis 

Cystic fibrosis 

Bronchopulmonary dysplasia 

Heart disease 

Attachment 2 

Other causes 

Diagnosed recurrent cough not due to asthma 

Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux 

COPD (e.g., chronic bronchitis or emphysema) 

Congestive heart failure 

Pulmonary embolism 

Mechanical obstruction of the airways (benign and malignant tumors) 

Pulmonary infiltration with eosinophilia 

Cough secondary to drugs (e.g., angiotensin-converting enzyme (ACE) inhibitors) 

Vocal cord dysfunction 

(NAEPP 2007 [5a]) 



Attachment 3 

Formal Evaluation of Asthma Exacerbation Severity in ED or Urgent Care Setting 

Mild Moderate 

Symptoms 

Severe Subset: Respiratory 

Arrest Imminent 

Breathlessness While walking 

Can lie down 

While at rest (infant: 

softer, shorter cry, 

difficulty feeding) 

Prefers sitting 

While at rest (infant: 

stops feeding) 

Sits upright 

While at rest 

Talks in Sentences Phrases Words Cannot talk 

Alertness Normal or may be 

agitated 

Usually agitated 

Signs 

Usually agitated Drowsy or confused 

Respiratory rate Normal or increased Increased Increased, often 

>30/minute 

Normal or decreased 

Guide to rates of breathing in awake children: 

Age Normal Rate 

< 2 months < 60/minute 

2 to 12 months < 50/minute 

1 to 5 years < 40/minute 

6 to 8 years < 30/minute 

Use of accessory muscles; Usually not Commonly Usually Paradoxical 

suprasternal retractions; 

thoracoabdominal 

nasal flaring; abdominal 

breathing 

movement 

Wheeze Moderate, often only Loud; throughout Loud, throughout Minimal or absent 

end expiratory exhalation 

inspiration and 

exhalation or may be 

absent 

Pulse/minute (at initial 

presentation) 

< 100 100 to 120 > 120 Bradycardia 

Pulsus paradoxus Absent 25 mmHg (adult) 

20 to 40 mmHg (child) 

respiratory muscle fatigue 

Functional Assessment 

PEF (peak expiratory > 70% Approx. 40 to 69% or < 40% < 25% 

flow) 

Response to treatment 

Note: PEF testing may not 

Percent predicted or 

lasts < 2 hours 

be needed in very severe 

percent personal best 

attacks 

PaO2 (arterial oxygen Normal (test not > 60 mmHg (test not < 60 mmHg: possible 

pressure, on room air) 

and/or 

usually necessary) usually necessary) cyanosis 

PCO2 (partial pressure of < 42 mmHg (test not < 42 mmHg (test not > 42 mmHg: possible 

carbon dioxide) 

usually necessary) usually necessary) respiratory failure 

SaO2 (oxygen saturation) 

(on room air) 

> 95% 90 to 95% < 90% 

at sea level Hypercapnia (hypoventilation) develops more easily in young children than 

in adolescents and adults. 

The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation 

Many of these parameters have not been systematically studied, especially as they correlate with each other and thus serve only as 

general guides 


Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a]). 



Emergency Department Management of Asthma Exacerbations – Algorithm Attachment 4 

Initial Assessment: Brief History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, pulse 

oximetry), PEF or FEV 1 (if performed), or Asthma score, oxygen saturation, and other tests as indicated 

Mild: see Attachment 3 for 

details of signs and 

symptoms: 

Speaks in sentences 

Wheeze mild to moderate 

(end expiratory) 

Mild 

Oxygen to achieve SaO 2 > 90% 

Inhaled SABA by nebulizer or MDI 

with valved holding chamber, up to 3 

doses in 1 st hour 

Oral systemic corticosteroids if no 

response or if patient recently took oral 

systemic corticosteroids 

Moderate Exacerbation 

Asthma Score, PEF or FEV 1 (40 to 69% 

predicted/personal best) 

Inhaled SABA every 60 minutes 

Oral systemic corticosteroids 

Continue treatment 1 to 3 hours, 

provided there is improvement; make 

admit decision in < 4 hours 

Good Response 

Asthma Score, PEF or FEV 1 

(> 70%) 

Response sustained at least 60 

minutes after last treatment 

No distress 

Physical exam: normal 

Moderate: see Attachment 3 

for details of signs and 

symptoms: 

Speaks in words 

Wheeze loud (throughout 

exhalation) 

Repeat Assessment: Symptoms, physical examination, Asthma Score or PEF, FEV 1 (if performed), oxygen saturation, other tests as 

indicated 

Discharge Home 

Continue treatment with inhaled SABAs. 

Continue course of oral systemic 

corticosteroid. 

Continue on ICS. For those not on long-term 

control therapy, consider initiation of an ICS. 

Patient education (e.g., review medications 

including inhaler technique; review/initiate 

action plan; recommend close medical followup 

and, whenever possible, environmental 

control measures). 

Before discharge, schedule follow-up 

appointment with PCP and /or asthma 

specialist in 1-5 days. 

If unable to schedule from ED, notify PCP of 

status 

Moderate / Severe 

Oxygen to achieve SaO 2 > 90% 

High-dose inhaled SABA by nebulizer or 

MDI with valved holding chamber, every 

10 to 20 minutes or continuously for 1 

hour PLUS ipratropium 

Oral systemic corticosteroids 

Incomplete Response 

Unchanging Asthma Score, 

PEF or FEV 1 (40 – 69%) 

Symptoms persist 

Decide patient’s disposition 

Severe: see Attachment 3 for 

details of signs and symptoms: 

Speaks in phrases 

Wheeze loud (throughout 

inhalation or exhalation) or 

absent 

Severe Exacerbation 

Asthma Score, PEF or FEV 1 (


Severity Classification 

(NAEPP 2007 [5a]) 

Attachment 5 



Severity Classification (continued) 

(NAEPP 2007 [5a]) 

Attachment 5 



How to Use Your Metered-Dose Inhaler 

Attachment 7 

Using an inhaler seems simple, but most people do not use it the right way. When an inhaler is used the wrong 

way, less medicine gets to the lungs. Use of a holding chamber/spacer increases reliability of drug effectiveness, 

especially when inhalers are not used correctly. 

For the next few days, read these steps aloud as you do them or ask someone to read them to you. Ask your 

primary care provider to check how well you/your child are using the inhaler. 

Use the inhaler in the way pictured below. 

Steps for using your inhaler: 

Getting ready 1. Take off the cap, shake the inhaler and attach spacer 

2. Breathe out all the way. 

3. Hold the inhaler the way instructed by your primary care provider (see picture). 

4. Press down on the inhaler, within 5 seconds, begin to breathe in slowly through your 

mouth. 

5. Keep breathing in slowly, as deeply as possible. 

6. Hold your breath and count to 10 slowly, if possible. 

7. Remove the inhaler and breathe out through pursed lips (like blowing out a candle) 

8. For inhaled quick-relief medicine (beta2-agonists), wait about 1 minute between puffs. 

There is no need to wait between puffs for other medicines. 

Clean your inhaler as needed, and know when to replace your inhaler. For instructions, read the package insert or 

talk to your primary care provider or pharmacist. It is important to refill your prescription before the medicine 

runs out or the inhaler expires to ensure medicine is available when needed. 


Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (Roller 2007 [4a], LocalConsensus [5], NAEPP 2007 [5a]). 



Peak Flow Use 

(NAEPP 2007 [5a]) 

Attachment 8 



Peak Flow Use (continued) 

(NAEPP 2007 [5a]) 

Attachment 8 



Stepwise Approaching to Managing Asthma in Children 0 to 4 years of age 

Attachment 9 

(NAEPP 2007 [5a]) 



Stepwise Approaching to Managing Asthma in Children 5 to 11 years of age 

Attachment 9 

(NAEPP 2007 [5a]) 



Members of Asthma Team 2010 

Community Physicians 

Scott Callahan, MD, Co-Chair (General Pediatrics) 

William DeBuys, MD (General Pediatrics) 

CCHMC Physicians 

Carolyn Kercsmar, MD, Co-Chair (Allergy and Pulmonary 

Medicine) 

Jeffrey Simmons, MD, Methodologist (General Pediatrics) 

*Michele Lierl, MD (Allergy and Pulmonary Medicine) 

Craig Gosdin, MD (General Pediatrics) 

Laurie Johnson, MD (Emergency Medicine) 

Sue Poynter, MD (Critical Care Medicine) 

Rajit Basu, MD (Critical Care Medicine) 

Residents 

Angela Statile, MD (Chief Resident) 

Corrine Bria, MD (Chief Resident) 

Nursing 

Sue Wieser, RN 

Lisa Crosby, RN 

Pharmacy 

Bradley McCrory, PharmD 

Michelle Caruso, PharmD, BCPS 

Respiratory Therapy 

Edward Conway, RRT (Certified Asthma Educator) 

Lisa Devoto, RN, RT, CPN (Certified Asthma Educator) 

Rachel Keller, RRT, RPFT (Certified Asthma Educator) 

James M. Anderson Center (AC) - Support 

*Eloise Clark, MPH, MBA (Lead Program Administrator) 

*Wendy Gerhardt, MSN, RN-BC (Program Administrator) 

Danette Stanko-Lopp, MA, MPH (Epidemiologist) 

Karen Vonderhaar, RN, MSN (Program Administrator) 

Ad hoc Advisors 

Lorie Ferenzi, (Allergy and Pulmonary Medicine) 

*Richard Ruddy, MD (Director, Emergency Medicine) 

*Amal Assa'ad, MD (Allergy) 

Karen McDowell, MD (Pulmonary Medicine) 

Christopher J Cates, Division of Population Hlth Sci and Educ, St. 

George’s, U of London, UK 

Annie Lintzenich, MD, Gen Peds, Med U of SC 

Ronald J Teufel II, MD, MSCR, Pediatrics/Internal Medicine, Gen 

Peds Hospital Section, Med U of SC 

*Member of 2002 Development Team 

Development Process 

The process by which this guideline was developed is documented in 

the Guideline Development Process Manual; relevant development 

materials are kept electronically. The recommendations contained in 

this guideline were formulated by an interdisciplinary working group 

which performed systematic search and critical appraisal of the 

literature, using the Table of Evidence Levels described following the 

references, and examined current local clinical practices. 

To select evidence for critical appraisal for this guideline, the 

Medline, EmBase and the Cochrane databases were searched for 

dates of January, 2002 to November, 2009 to generate an unrefined, 

―combined evidence‖ database using a search strategy focused on 

answering clinical questions relevant to acute exacerbation of 

asthma and employing a combination of Boolean searching on 

human-indexed thesaurus terms (MeSH headings using an OVID 

Medline interface) and ―natural language‖ searching on words in 

the title, abstract, and indexing terms. The citations were reduced 

by: eliminating duplicates, review articles, non-English articles, 

and adult articles. The resulting abstracts were reviewed by a 

methodologist to eliminate low quality and irrelevant citations. 

During the course of the guideline development, additional clinical 

questions were generated and subjected to the search process, and 

some relevant review articles were identified. September, 2002 was 

the last date for which literature was reviewed for the previous 

version of this guideline. The details of that review strategy are 

documented and maintained in an asthma literature binder. 

However, all previous citations were reviewed for appropriateness 

to this revision. Any new literature encountered for this October, 

2010 version was reviewed by two or more team members and then 

discussed as a team. 

Experience with the implementation of earlier publications of this 

guideline has provided learnings which have been incorporated into 

this revision. 

Once the guideline has been in place for five years, a team 

reconvenes to explore the continued validity of the guideline. This 

phase can be initiated at any point that evidence indicates a critical 

change is needed. 

The guideline was externally appraised by three reviewers using the 

AGREE instrument and the results by domain are: 

• Scope and Purpose 100% 

• Stakeholder Involvement 86% 

• Rigor of Development 92% 

• Clarity and Presentation 97% 

• Applicability 74% 

• Editorial Independence 72% 

Recommendations have been formulated by a consensus process 

directed by best evidence, patient and family preference and 

clinical expertise. During formulation of these recommendations, 

the team members have remained cognizant of controversies and 

disagreements over the management of these patients. They have 

tried to resolve controversial issues by consensus where possible 

and, when not possible, to offer optional approaches to care in the 

form of information that includes best supporting evidence of 

efficacy for alternative choices. 

The guideline has been reviewed and approved by clinical experts 

not involved in the development process, distributed to senior 

management, and other parties as appropriate to their intended 

purposes. 

The guideline was developed without external funding. All Team 

Members and AC Support staff listed, have declared whether they 

have any conflict of interest and none were identified. 

Copies of this Evidence-based Care Guideline (EBCG) and any 

available implementation tools are available online and may be 

distributed by any organization for the global purpose of improving 

child health outcomes. Website address: 

http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/evbased/default.htm 

Examples of approved uses of the EBCG include the following: 

• copies may be provided to anyone involved in the organization’s 

process for developing and implementing evidence-based care 

guidelines; 

• hyperlinks to the CCHMC website may be placed on the 

organization’s website; 

• the EBCG may be adopted or adapted for use within the 

organization, provided that CCHMC receives appropriate 

attribution on all written or electronic documents; and 

• copies may be provided to patients and the clinicians who manage 

their care. 



Notification of CCHMC at HPCEInfo@cchmc.org for any EBCG, or 

its companion documents, adopted, adapted, implemented or 

hyperlinked by the organization is appreciated. 

NOTE: These recommendations result from review of 

literature and practices current at the time of their 

formulations. This guideline does not preclude using care 

modalities proven efficacious in studies published subsequent to 

the current revision of this document. This document is not 

intended to impose standards of care preventing selective 

variances from the recommendations to meet the specific and 

unique requirements of individual patients. Adherence to this 

guideline is voluntary. The clinician in light of the individual 

circumstances presented by the patient must make the ultimate 

judgment regarding the priority of any specific procedure. 

For more information about this guideline, its supporting 

evidences and the guideline development process, contact the AC 

office at: 513-636-2501 or HPCEInfo@cchmc.org . 



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Note: Full tables of evidence grading system available in separate document: 

Table of Evidence Levels of Individual Studies by Domain, Study Design, & Quality (abbreviated table below) 

Grading a Body of Evidence to Answer a Clinical Question 

Judging the Strength of a Recommendation (abbreviated table below) 

Table of Evidence Levels (see note above) 

Quality level Definition 

1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies 

2a or 2b Best study design for domain 

3a or 3b Fair study design for domain 

4a or 4b Weak study design for domain 

5a or 5b Other: General review, expert opinion, case report, consensus report, or guideline 

5 Local Consensus 

†a = good quality study; b = lesser quality study 

Table of Recommendation Strength (see note above) 

Strength Definition 

―Strongly recommended‖ There is consensus that benefits clearly outweigh risks and burdens 

(or visa-versa for negative recommendations). 

―Recommended‖ There is consensus that benefits are closely balanced with risks and burdens. 

No recommendation made There is lack of consensus to direct development of a recommendation. 

Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus 

process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below. 

1. Grade of the Body of Evidence (see note above) 

2. Safety / Harm 

3. Health benefit to patient (direct benefit) 

4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time) 

5. Cost-effectiveness to healthcare system (balance of cost / savings of resources, staff time, and supplies based on published studies or 

onsite analysis) 

6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, 

comparison, outcome]) 

7. Impact on morbidity/mortality or quality of life

Management of acute exacerbation of ASTHMA in children

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