Inpatient Asthma Sangeeta Schroeder, MD Resident Noon Conference.

Inpatient Asthma

Sangeeta Schroeder, MD

Resident Noon Conference

Epidemiology

• According to the American Lung Association (2006)– Just about 7 million children have diagnosed

asthma – 3rd leading cause of childhood hospitalization– One of the most common causes of missed

school days (about 13 million missed days/year)

Clinical Features

• Shortness of breath

• Wheezing

• Symptomatic with viral infections, allergens or exercise

• Colds that last >10 days

• Frequent night-time coughing

Physiologic Features

Common Triggers

• Allergens– Dust, mold, pollen, cats, dogs, etc

• Non-Allergens– Cigarette smoke/Smoke– Infections– Exercise– Temp Change– Stress

Initial Assessment

• Respiratory Rate

• Pulse Ox

• Retractions

• Dyspnea

• Auscultation

LPCH Asthma Scoring Tool: Add Total Points to Give Pediatric Asthma Score (PAS)

0 point 1 point 2 points 3 points

Respiratory rate (breaths/min)

COUNT RESPIRATORY RATE FOR ONE FULL MINUTE

2-3 yr 18-26

27- 34 35-39 > 40

4-5 yr 16-24 25- 30 31-35 > 36

6-12 yr 14-20 21- 26 27-30 > 31

> 12 yr 12-18 19- 23 24-27 > 28

Pulse Ox >95% on RA 90-94% on RA 87-89% on RA <86% on RA

Retractions None Subcostal or intercostal

2 of the following:subcostal, intercostal, substernal, OR nasal flaring (infants)

3 of the following:subcostal, intercostal, substernal, suprasternal, supraclavicular OR nasal flaring or head bobbing (infants)

Dyspnea2-4 years

Normal feeding, vocalizations, and play

1 of the following:decreased appetite, increased coughing after play, hyperactivity

2 of the following: decreased appetite, increased coughing after play, hyperactivity

Stops eating or drinking, stops playing, OR drowsy or confused and/or grunting

Dyspena> 5 years

Counts to > 10 in one breath OR speaks in complete sentences

Counts to 7-9 one breath OR speaks in short sentences

Counts to 4-6 in one breath OR speaks in partial sentences

Counts to < 3 in one breath OR speaks in single words OR Grunts.

Auscultation(as it relates to wheezing)

Normal breathing; no wheezing present

End-expiratory wheeze only

Expiratory wheeze only (greater than end-expiratory wheeze)

Inspiratory and expiratory wheeze OR diminished breath sounds

Respiratory Rate0 point 1 point 2 points 3 points

Respiratory rate (breaths/min)

COUNT RESPIRATORY RATE FOR ONE FULL MINUTE

2-3 yr 18-26

27- 34 35-39 > 40

4-5 yr 16-24 25- 30 31-35 > 36

6-12 yr 14-20 21- 26 27-30 > 31

> 12 yr 12-18 19- 23 24-27 > 28

Pulse Ox


Pulse Ox >95% on RA

90-94% on RA

87-89% on RA

<86% on RA

Retractions0 point 1 point 2 points 3 points

None Subcostal or

Intercostal

2 of the following:

subcostal, intercostal, substernal, OR nasal flaring (infants)

3 of the following:subcostal,

intercostal, substernal, suprasternal, supraclavicular, nasal flaring or head bobbing (infants)

Dyspnea 2-4 year olds


Normal feeding, vocalizations, and play

1 of the following:decreased appetite, increased coughing after play, hypoactivity

2 of the following: decreased appetite, increased coughing after play, hypoactivity

Stops eating or drinking, stops playing, OR drowsy or confused and/or grunting

Dyspnea > 5 year olds


Counts to > 10 in one breath OR speaks in complete sentences

Counts to 7-9 one breath OR speaks in short sentences

Counts to 4-6 in one breath OR speaks in partial sentences

Counts to < 3 in one breath OR speaks in single words OR Grunts.

Auscultation


Normal breathing; no wheezing present

End-expiratory wheeze only

Expiratory wheeze only (greater than end-expiratory wheeze)

Inspiratory and expiratory wheeze OR diminished breath sounds

Pediatric Asthma Score

• Add the Score for the 5 categories together

• Mild: PAS < 6

• Mild to Moderate: PAS of 7 or 8

• Moderate to Severe: PAS of 9 or 10

• Severe: PAS > 11

Initial Management

• Oxygen

• Albuterol

• Atrovent

• Systemic Steriods

• Magnesium Sulfate?

Initial Management

• Oxygen

Initial Management - AlbuterolInitial Assessment – Phase 1 Action

Weight <20kg and PAS <6 MDI 4 puffs Q20 min x3 ORAlb neb 7.5mg/hr x1 hr

If wt >20kg and PAS <8PAS 7-8, regardless of weight

MDI 6 puffs Q20 min X3 ORAlb neb 10mg/hr x1 hr

PAS 9-10, regardless of weight MDI 8 puffs Q20 min X 3 ORAlb neb 15mg/hr x 1 hr

PAS >11/Intensification, regardless of weight

MDI 10 puffs Q20 min x3 ORAlb neb 20mg/hr x 1 hr

If PAS persistently >11, Consider Magnesium at 50mg/kg and NOTIFY ICU

Initial Management - Albuterol

• Assessment Q Hour • A. If PAS has not improved by >2, or if it is not

<6, REPEAT phase 1 according to current PAS score

• B. If PAS has improved by >2,OR PAS <6, ADVANCE to Phase II

• C. If PAS has worsened by >2, OR PAS >11, INTENSIFY

Initial Management

• Atrovent– Found to decrease rate of admissions – Only if given at least 2 doses– Should be part of phase 1 treatment

Initial Management

• Systemic Steroids– Decadron

• Can give in office/ER for mild asthma• 0.6mg/kg x1 dose IM/IV/PO

– Prednisolone• 1mg/kg/dose BID• NEW GUIDELINES: MAX 60MG/DAY!!!!

– Solumedrol• Use only if worried about respiratory distress/aspiration

Initial Management

• Magnesium Sulfate– 25-75 mg/kg/dose– Usually give 50mg/kg/dose– Give over 10-20 minutes!

When to Admit?

• Oxygen requirement

• After Phase 1 with Atrovent– Child is still in resp distress– Needs repeat albuterol dose within 4 hours

• Poor PO intake

• Poor Follow-up

Continued Management

• Albuterol

• Systemic Steriods

• Inhaled Corticosteroids

• Asthma Education

Albuterol

• Repeat Phase 1 if child just got admitted

• Exception: – If PAS is 1 or 2 on admit, start at Phase 2

AlbuterolInitial Assess. – Phase 2 Actions: Min of 4 hrs Assessment Q 2 Hours

Weight <20kg and PAS <6 MDI 4 puffs Q 2 hrs x2 A. If PAS has not improved by >2, or if it is not <6, REPEAT phase 2 according to current PAS

B. If PAS has improved by >2, OR PAS <6, ADVANCE to Ph 3

C. If PAS has worsened by >2 or PAS >11, INTENSIFY

If wt >20kg and PAS <8PAS 7-8, regardless of wt

MDI 6 puffs Q 2 hrs x2

PAS 9-10, regardless of weight

MDI 8 puffs Q 2 hrs X1

Once PAS <8, CONTINUE in Phase 2 for a min of 4 hours per PAS


RETURN TO PHASE 1 INTENSIFICATIONIf PAS persistently >11, CONSIDER Magnesium at

50mg/kg and NOTIFY ICU

Albuterol ContinuedInitial Assess. – Phase 3 Actions: Min of 6 hrs Assessment Q 3 Hours

Weight <20kg and PAS <6 MDI 4 puffs Q 3 hrs x2 A. If PAS has not improved by >2, or if it is not <6, REPEAT phase 3 according to current PAS

B. If PAS has improved by >2, OR PAS <6, ADVANCE to phase 4


If wt >20kg and PAS <8PAS 7-8, regardless of wt

MDI 6 puffs Q 3 hrs x2


MDI 8 puffs Q 2 hrs and return to Phase 2


RETURN TO PHASE 1 INTENSIFICATION

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Albuterol ContinuedInitial Assess – Phase 4 Actions: Min of 4 hrs Assessment Q 4 Hours

PAS <6, regardless of wt MDI 4 puffs Q 4 hrs x1 A. If PAS has not imp. by >2, or if it is not <6, REPEAT according to current PAS score

B. If PAS is <6, patient is ready for discharge.



MDI 6 puffs Q 4 hrs x 1

Once PAS <6, CONTINUE in Phase 4 with 4 puffs Q 4 hrs x1 min


MDI 8 puffs Q 2 hrs and return to Phase 2


RETURN TO PHASE 1 INTENSIFICATION

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Systemic Steroids

• Continue for 3-10 days

• Mild (no admission): 3 days

• Most Admissions: 5 days

• If still in hospital on day 4 or 5: 10 days

• If use 60mg/day as MAX, no need to taper

Atrovent

• Has not been shown to decrease morbidity of admission

• Has not been shown to decrease likelihood of PICU transfer

• Has not been shown to decrease LOS

• NOT USED ON THE FLOOR

Inhaled Corticosteroids

• Start inpatient for education

• Flovent/QVAR – MDI’s

• Pulmicort– Neb – Ensure child uses with mask that does not have

holes on top– Risk of Corneal Ulceration

Asthma Education

• Review differences btwn preventive and relief meds

• Demonstrate and teach proper MDI with Spacer/mask use

• Educate on asthma signs and symptoms

• Review Home Management Plan of Care

MDI Education

Spacers

• All patients with asthma

• Holds the “puff” in the chamber

Spacer Use

• Insert the MDI into the back end of the spacer

• SHAKE BEFORE EACH USE

• Use a spacer with mask in a young child

Spacer Use

• FIRST: Exhale

• SECOND: Create a seal with your mouth and the mouthpiece

• THIRD: Inhale slowly as you push the inhaler and hold breath for 10 seconds

• FOURTH: Breathe out slowly

Spacer Use - Child

• FIRST: Exhale

• SECOND: Create a seal with your mouth and the mouthpiece

• THIRD: Push the inhaler and keep the seal with the mouthpiece for 8-10 breaths

• FOURTH: Breathe out slowly

Spacer Use – Infant/Toddler

• FIRST: Use a spacer with mask

• SECOND: Create a seal with the infant’s mouth and the mask

• THIRD: Push the inhaler and keep the seal with the mask for 8-10 breaths

MDI/Spacer Use

• Make sure to repeat all the steps for each puff: Including shaking the inhaler!!!

Discharge Guidelines

• Albuterol

• System Steriods

• ICS

• F/U Appointment

• Subspecialty Follow-up?

Discharge Guidelines

• Albuterol– 4-6 puffs 4 times a day for 1 week– Then per HMPC

• Systemic Steroids– 3-10 day course at 60 mg/day max– No need to taper the dose

• ICS– Everyday for at least 1 year

Discharge Management

• Follow-up Appointment– 1-2 days after hospital discharge

• Subspecialty Follow-up?– Max doses of ICS– More than 1 controller– Strong Allergic Component– PCP is not comfortable with asthma– Parents are not comfortable with PCP

Home Management Plan of Care

• AKA: Asthma Action Plan– New 4 tier system– Emphasizes home asthma care– Gives consent to school/daycare to administer

albuterol

• Joint Commission Requirement

• All fields need to be filled out– Triggers/avoidance– All 4 tiers– Follow-up Appointment

• Date/Time and PMD OR

• Time frame, PMD Name and Phone Number

– Parent’s Signature– Discharging Attending Signature

HMPC

• Joint Commission Rates– Quarter 2 of 2009: 64% Compliance– 6/25 patients did not have an action plan in the

chart• REMEMBER TO KEEP THE SIGNED COPY IN

THE CHART!!!

– 3/25 patients had incomplete fields

HMPC

Inpatient Asthma Sangeeta Schroeder, MD Resident Noon Conference.

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