The strength of the recommendation (strongly recommended, recommended, and no recommendation) and quality of the evidence (1a-5) are defined at the end of the "Major Recommendations" field.
Emergency Department Management
Initial History and Physical
- It is recommended that before and as therapy is initiated, a brief, focused history and physical examination is obtained, including: (Local Consensus ; National Asthma Education and Prevention Program [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., emergency department [ED] visits, admissions to the hospital and intensive care unit [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 Asthma Exacerbation Severity in the ED"; Attachment 4, "ED Management of Asthma Exacerbations - Algorithm" in the original guideline document and Recommendation #13 for severe asthma with respiratory distress below).
Note 2: Perform a more detailed history and physical assessment only after therapy has begun (NAEPP, 2007 [5a]; Camargo, Rachelefsky, & Schatz, 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 et al., 2007 [2a]; Kamps, Roorda, & Brand, 2001 [2b]; Bender et al., 2000 [3b]; Rich et al., 2000 [3b]; Dozier, Aligne, & Schlabach, 2006 [4a]; Halterman et al., 2003 [4a]; NAEPP, 2007 [5a]).
- 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 et al., 1999 [2a]; Ribeiro de Andrade, Duarte, & Camargos, 2007 [3a]; Keahey et al., 2002 [3a]; Local Consensus ; British Thoracic Society & Scottish Intercollegiate Guidelines Network [SIGN], 2008 [5a]; NAEPP, 2007 [5a]).
- 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, Rachelefsky, & Schatz, 2009 [5b]).
Note: Pulmonary function measurements, although often difficult to obtain in children, are useful in assessing the severity of an asthma exacerbation (Gorelick et al., 2004 [3a]). If able to obtain, and measurement is <40% of predicted (or personal best), consider adjunct therapies or admission (NAEPP, 2007 [5a]).
- 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, Landau, & Le Souef, 1994 [3a]; British Thoracic Society & SIGN, 2008 [5a]; NAEPP, 2007 [5a]).
Short-Acting Inhaled Beta2-Agonists
- 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, Rachelefsky, & Schatz, 2009 [5b]). Modify therapy based on the early clinical response to treatments (British Thoracic Society & SIGN, 2008 [5a]; NAEPP, 2007 [5a]; Camargo, Rachelefsky, & Schatz, 2009 [5b]) (see "Table 1: Aerosolized Therapies – Drugs and Dosage Recommendations" in the original guideline document).
Note: Albuterol treatments given every 10 to 20 minutes for a total of 3 doses can be given safely as initial therapy (Local Consensus ; British Thoracic Society & SIGN, 2008 [5a]; NAEPP, 2007 [5a]).
- It is recommended that levalbuterol not be routinely used in the treatment of acute exacerbation (Local Consensus ).
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 & Singh, 2007 [1b]; Ralston et al., 2005 [2a]; Carl et al., 2003 [2a]; Andrews et al., 2009 [2b]; Hardasmalani et al., 2005 [2b]; Qureshi et al., 2005 [3a]). A large double-blind prospective trial demonstrated a 10% reduction in hospital admissions with the use of levalbuterol (Carl et al., 2003 [2a]) and a retrospective review of consecutive cases demonstrated a 4.5% reduction (Schreck & Babin, 2005 [4a]). The numbers needed to treat (NNT) with levalbuterol to prevent one hospital admission in these studies equals 11 and 10 respectively (Carl et al., 2003 [2a]; Schreck & Babin, 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 et al., 2009 [2b]). The use of racemic albuterol with metered dose inhaler (MDI) has been shown to result in lower pulse rates when compared to nebulizer (Cates, Crilly, & Rowe, 2006 [1a]; Mathew & Singh, 2008 [1b]; Deerojanawong et al., 2005 [2b]; British Thoracic Society & SIGN, 2008 [5a]). This may be an important consideration for children at risk for tachycardia including children with congenital heart disease or known arrhythmias (Local Consensus ).
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 (Local Consensus ).
Inhalation Delivery Device Selection
Devices used for the delivery of bronchodilators and inhaled corticosteroids can be equally efficacious.
- It is recommended that when selecting an inhalation delivery device consideration be given to the following (Dolovich et al., 2005 [1a]; Scarfone et al., 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 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 & Singh, 2008 [1b]; Delgado et al., 2003 [2a]; Jamalvi et al., 2006 [3a]; Benito-Fernandez et al., 2004 [3a]; Yilmaz et al., 2009 [4a]). Within this guideline, a spacer is defined as a Valved Holding Chamber 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 (Local Consensus ). Spacers improve the clinical effect of inhaled medications, especially in patients unable to use an MDI properly (Lavorini & Fontana, 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 & Paronen, 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, Crilly, & Rowe, 2006 [1a]; Castro-Rodriguez & Rodrigo, 2004 [1a]; Mathew & Singh, 2008 [1b]; Deerojanawong et al., 2005 [2b]; Boyd & Stuart, 2005 [3a]; Local Consensus ; British Thoracic Society & 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 et al., 2001 [1a]; NAEPP, 2007 [5a]).
Inhaled Ipratropium Bromide
- 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 & Ducharme, 2009 [1a]; Rodrigo & Castro-Rodriquez, 2005 [1a]; Dotson et al., 2009 [1b]; Local Consensus ; British Thoracic Society & SIGN, 2008 [5a]; NAEPP, 2007 [5a]; Hayday & Stevermer, 2002 [5a]) (see "Table 1: Aerosolized Therapies – Drugs and Dosage Recommendations" in the original guideline document).
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 & Ducharme, 2009 [1a]).
Note 2: Although ipratropium has been shown to be efficacious in preventing hospitalizations for children with exacerbations where FEV1 is <50% of predicted, it has not been shown to provide significant benefit after the child is hospitalized; therefore, it is not a standard therapy to be considered in the inpatient management of acute exacerbations (Plotnick & Ducharme, 2009 [1a]; NAEPP, 2007 [5a]).
- It is recommended that oral corticosteroids be administered to patients who do not respond completely to initial inhaled SABAs (Edmonds et al., 2009 [1a]; NAEPP, 2007 [5a]; Camargo, Rachelefsky, & Schatz, 2009 [5b]) (see "Table 2: Corticosteroids – Drugs and Dosage Recommendations" in the original guideline document).
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 et al., "Early emergency," 2009 [1a]; Edmonds et al., 2009 [1a]).
Note 2: Oral prednisone has effects equivalent to those of intravenous methylprednisolone including tolerance by children (Rowe et al., "Early emergency," 2009 [1a]; British Thoracic Society & SIGN, 2008 [5a]; NAEPP, 2007 [5a]; Camargo, Rachelefsky, & Schatz, 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 et al., 2009 [1a]; Schuh et al., 2006 [2b]; Nakanishi, Klasner, & Rubin, 2003 [2b]; NAEPP, 2007 [5a]; Camargo, Rachelefsky, & Schatz, 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 any time regardless of oral dosing for the exacerbation (Local Consensus ; British Thoracic Society & 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 bitter-tasting 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 et al., "Early emergency," 2009 [1a]; Smith et al., 2009 [1a]; Gordon, Tompkins, & Dayan, 2007 [2a]; Altamimi et al., 2006 [2a]; Qureshi, Zaritsky, & Poirier, 2001 [2a]; Greenberg, Kerby, & Roosevelt, 2008 [2b]; Huang et al., 2007 [2b]; Gries et al., 2000 [2b]).
- 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 et al., "Magnesium sulfate," 2009 [1a]; Mohammed & Goodacre, 2007 [1a]; Ciarallo, Brousseau, & Reinert, 2000 [2b]; British Thoracic Society & SIGN, 2008 [5a]) (see "Table 3: Adjunctive Therapies – Drugs and Dosage Recommendations" in the original guideline document).
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 et al., "Magnesium sulfate," 2009 [1a]; Mohammed & Goodacre, 2007 [1a]; Alter, Koepsell, & Hilty, 2000 [1a]).
Note 2: There is insufficient evidence regarding the use of nebulized magnesium sulfate in acute exacerbation (Blitz et al., 2009 [1b]).
Epinephrine and Terbutaline
- 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" in the original guideline document).
- 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 et al., 2006 [2b]; British Thoracic Society & 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 et al., 2006 [1a]; Kim et al., 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 et al., 2005 [2b]).
Severe Asthma with Respiratory Distress and Normal Mental Status
- 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 (Local Consensus ) (see "Table 3: Adjunctive Therapies – Drugs and Dosage Recommendations" in the original guideline document).
- Continuous albuterol
- Ipratropium bromide, up to 3 doses
- Systemic corticosteroids (dexamethasone intramuscular [IM] or methylprednisolone [IV])
- Epinephrine IM
- Magnesium sulfate IV
- Consider terbutaline IV bolus, and infusion
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]).
- 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 (Local Consensus ) (see Attachment 3, "Formal Evaluation of Asthma Exacerbation Severity in ED or Urgent Care Setting", and Attachment 4, "ED Management of Asthma Exacerbations - Algorithm" in the original guideline document).
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 intensive care unit in patients initially assessed as severe (Kelly, Kerr, & Powell, 2004 [3a]; Local Consensus ).
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, Kerr, & Powell, 2004 [3a]; Wright et al., 1997 [3b]; Local Consensus ).
- 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
- Initiation and continuation of controller (anti-inflammatory) 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
- It is recommended that the following care be initiated for patients who fail to progress after 12 hours of care (Local Consensus ):
- Notify treating healthcare provider of any child that has not progressed after 12 hours of care
- 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 pediatric intensive care unit (PICU) or higher level of care
- Consider subspecialty consult
- 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) (Local Consensus ):
- 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; nothing by mouth (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
- 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 (British Thoracic Society & 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 et al., 2000 [2a]; McDowell et al., 1998 [2a]; Norton et al., 2007 [4a]; Wazeka et al., 2001 [4a]; Ebbinghaus & Bahrainwala, 2003 [4b]; Kelly et al., 2000 [4b]).
Complementary and Alternative Medicine
- It is recommended that the clinician ask patients/parents about all medications and treatments they are using for asthma (Local Consensus ; 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 et al., 2003 [3a]), 63% of adolescents reported the use of complementary medicine when surveyed (Reznik et al., 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, Pittler, & Ernst, 2007 [1a]; Hondras, Linde, & Jones, 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 et al., 2003 [3a]; NAEPP, 2007 [5a]).
- 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 et al., 2009 [1a]; Martin et al., 2002 [1a]; NAEPP, 2007 [5a]).
ED or Inpatient Management
- 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 (Local Consensus ). The CARAT may be accessed via the following URL: http://carat.asthmarisk.org
- It is recommended that the need for consultations be considered at the time of presentation or as early as possible in the acute course (Local Consensus ).
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 (Local Consensus ; NAEPP 2007 [5a]):
- The diagnosis of asthma is in question
- Current life-threatening or severe asthma exacerbation possibly requiring medical response team (MRT)
- 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 long-acting beta2-agonists (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 et al., 2006 [1a]; Kaushal et al., 2008 [3a]).
Therapies Generally NOT Recommended
- 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 et al., 2008 [2b]) and may increase frequency of adverse effects in acute exacerbation (Mitra et al., 2009 [1a]; British Thoracic Society & 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]).
- It is recommended that antibiotics not be used routinely for acute asthma exacerbations in the absence of an identified bacterial focus (Graham, Lasserson, & Rowe, 2009 [1a]; British Thoracic Society & SIGN, 2008 [5a]; NAEPP, 2007 [5a]; Blasi & Johnston, 2007 [5b]).
- It is recommended that aggressive rehydration not be used routinely for acute asthma exacerbation in the absence of clinical dehydration (NAEPP, 2007 [5a]).
- 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]).
- 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]).
- It is recommended that oral albuterol not be used for acute exacerbation (Local Consensus ).
- It is recommended that for therapies outlined in this section, caution and consideration be used in treatment selections (Local Consensus ).
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, Mirzaei, & Ahmadieh, 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 et al., 2005 [1a]). This patient population demonstrates less cross-sensitivity to acetaminophen.
Cross-Sensitivities (Jenkins, Costello, & Hodge, 2004 [1a]):
- Ibuprofen ≤400mg, 98%
- Naproxen ≤100mg, 100%
- Diclofenac ≤40mg, 93%
- Acetaminophen ≥500mg, 7%
Epidemiological evidence suggests a link between long-acting 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, Lasserson, & Jaeschke, "Regular treatment with salmeterol," 2009 [1a], Cates, Lasserson, & Jaeschke, "Regular treatment with formoterol," 2009 [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, Wall, & Buckley, 2010 [1a]; Walters et al., 2007 [1a]; Salpeter et al., 2006 [1a]; FDA, 2010 ). 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 ). 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 inhaled corticosteroid (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 et al., 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, Lasserson, & Jaeschke, "Regular treatment with salmeterol," 2009 [1a], Cates, Lasserson, & Jaeschke, "Regular treatment with formoterol," 2009 [1a]). Such evaluation may best be performed in conjunction with an asthma specialist (Local Consensus ) (see Recommendation #35 below 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, Unger, & Glazier, 2008 [4a]; Gupta, Carrion-Carire, & Weiss, 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 et al., 2006 [4a]; Lieu et al., 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 et al., 2003 [2a]; Knudson et al., 2009 [4a]; Wilson et al., 2005 [4a]; Ferris et al., 2001 [4a]).
- Black children demonstrate more likelihood to have asthma and to experience ED visits for asthma, compared with otherwise comparable white children (Flores et al., 2005 [3a]; Jones et al., 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, Gibson, & Henry, 2001 [1a]; Bartlett et al., 2001 [3a]; Belamarich, 2000 [3a]; Rodriguez et al., 2002 [4a]; Shalowitz et al., 2001 [4a]; NAEPP, 2007 [5a]) (see Recommendation #22 above, Consultations, Social Services).
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]).
- It is recommended that planning for discharge begin when the child first presents to the ED or hospital unit (Local Consensus ).
- It is recommended that prior to discharge the patient undergo Severity Classification of chronic asthma (see Attachment 5, "Severity Classification" in the original guideline document). 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 (Local Consensus ).
- 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. Care-management processes are tools to improve the efficiency and quality of primary care delivery, self management, and have demonstrated a reduction in ED visits (Schulte et al., 2004 [1b]; Levy et al., 2006 [2a]; Walders et al., 2006 [2a]; Griffiths et al., 2004 [2a]; Portnoy & Jennings, 2006 [4a]; Rosen & Rodriguez, 2006 [4a]; Spiegel et al., 2006 [4a]; Wood et al., 2006 [4a]; Allcock, 2009 [4b]; Case Management Society of America [CMSA], 2010 ).
- 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, Scarfone, & Li, 2005 [2a]; Local Consensus ; Mansour, 2009 [5a]; British Thoracic Society & 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 et al., 2009 [1a]; Wolf et al., 2008 [1a]; Karnick et al., 2007 [2a]; Brown et al., 2006 [2a]; Ng et al., 2006 [2a]; Sockrider et al., 2006 [2a]). The most effective type, duration or intensity of education has not been determined (Boyd et al., 2009 [1a]; Coffman et al., 2008 [1a]; Wolf et al., 2008 [1a]; Zorc et al., 2009 [2a]). Patient-centered, specific education efforts may be more effective than general or poorly targeted interventions (Canino et al., 2008 [2a]; Forbis & Aligne, 2002 [2b]; NAEPP, 2007 [5a]).
Note 2: Asthma education plans have been successfully implemented in busy EDs (Boychuk et al., 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 et al., 2009 [1a]; Coffman et al., 2008 [1a]; Wolf et al., 2008 [1a])
- Etiology, prognosis, and risk factors emphasizing chronicity of condition
- Medication purpose, and when and how to use medications (Smith et al., 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 et al., 2002 [2a]; Douglass et al., 2002 [2b]; NAEPP, 2007 [5a]).
- Identification of environmental triggers for prevention of acute exacerbations (Lanphear et al., "Residential Exposure," 2001 [4a], Lanphear et al., "Contribution," 2001 [4a]) (see Attachment 6, "How to Control What Makes Your Asthma Worse" in the original guideline document).
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 et al., 2007 [2a]; Morgan et al., 2004 [2a]; Schonberger et al., 2004 [2a]; Moira et al., 2002 [2a]; Custovic et al., 2001 [2a]; Finn et al., 2000 [3a]; NAEPP, 2007 [5a]).
- Demonstration of correct use of inhaler/spacer (Hussain-Rizvi, Kunkov, & Crain, 2009 [2b]) (see Attachment 7, "How to Use Your MDI" in the original guideline document)
- 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" in the original guideline document)
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, Yoos, & Kitzman, 2002 [2a]; Yoos et al., 2002 [2a]). It can be used in short-term monitoring, acute exacerbations, and daily chronic monitoring (Goldberg et al., 2001 [4a]; Brand et al., 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 et al., 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, Scarfone, & Li, 2005 [2a]; Zorc et al., 2003 [2a]; Flores et al., 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
- It is recommended that SABAs be used at home on an as-needed basis after recovery from an acute asthma exacerbation (Walters & 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 (Local Consensus ).
- 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 (Local Consensus ; British Thoracic Society & 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, Lasserson, & Jaeschke, "Regular treatment with salmeterol," 2009 [1a], Cates, Lasserson, & Jaeschke, "Regular treatment with formoterol," 2009 [1a]; Nelson et al., 2006 [2a]; NAEPP, 2007 [5a]).
Consider consultation with an asthma specialist for questions regarding continuation of LABA following hospital discharge (Local Consensus ).
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 ; 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 ).
- "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 ).
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 et al., 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 (Local Consensus ; NAEPP, 2007 [5a]).
- 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 (British Thoracic Society & 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 & Man, 2002 [4a]; NAEPP, 2007 [5a]).
- 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, Zaritsky, & Poirier, 2001 [2a]; Cooper & Hickson, 2001 [4a]).
Note: Prescriptions are not always filled after discharge (Qureshi, Zaritsky, & Poirier, 2001 [2a]; Cooper & Hickson, 2001 [4a]). Outcomes demonstrated from prescriptions not filled have been an increase in missed school and work days (Qureshi, Zaritsky, & Poirier, 2001 [2a]). It is also believed that providing medicines will result in decrease readmission rates (Local Consensus ; NAEPP, 2007 [5a]).
- 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, Bhogal, & Ducharme, 2008 [1a]; Bhogal, Zemek, & Ducharme, 2006 [1a]; NAEPP, 2007 [5a]) (see Attachment 9, "Stepwise Approaching to Managing Asthma in Children" in the original guideline document).
- 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, Scarfone, & Li, 2005 [2a]; Zorc et al., 2003 [2a]; Local Consensus ; 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, Lanphear, & DeWitt, 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 (Local Consensus ; NAEPP, 2007 [5a]).
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.
Table of Evidence Levels
|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
†a = good quality study; b = lesser quality study
Table of Recommendation Strength
||There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
||There is consensus that benefits are closely balanced with risks and burdens.
|No recommendation made
||There is a 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.
- Grade of the Body of Evidence
- Health benefit to the patients (direct benefit)
- Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
- Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
- Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
- Impact on morbidity/mortality or quality of life
A clinical algorithm is provided for emergency department management of asthma exacerbations.