Pediatric Asthma Protocol

Published: March 12th, 2015

Category: Teaching Cases

EMS called to house for shortness of breath

5 year old African American male with history of asthma who has been short of breath for last few hours. Mother has tried a couple albuterol treatments but has not really helped this morning.

EMS assessment and management

Vitals:             HR 150                       RR 40             BP 95/55       Sats 88% on RA         Wt: white

2 L via NC Oxygen applied

Transferred to EMS vehicle

Albuterol 2.5 mg and atrovent 500 mcg initiated

IV placed

In the ED:

Upon arrival, albuterol 5 mg and atrovent 500mcg initiated as well as Solumedrol 34 mg IV

Asthma Management per EMS protocol Date 9/02          Reviewed 12/2012

Consider specific treatment situations:

  • Reactive Airway Disease/Asthma (wheezing)
    • Albuterol 2.5 mg and Atrovent 0.5 mg. Subsequent nebulizer treatments will contain only Albuterol 2.5 to 5 mg
    • Solu-Medrol 2 mg/kg IV/IO maximum dose 125 mg
      • When multiple nebulizer treatments are required
      • When patient presents with severe respiratory distress
    • If patient’s condition does not improve administer Epinephrine 1:1000 0.01 mg/kg IM/SQ, with maximum dose of 0.3 mg
    • If patient’s condition does not improve administer Magnesium Sulfate 25 to 50 mg/kg IV/IO infusion (diluted in100 mL NS infused over 15 min)

Questions

Why is there one standardized dose of albuterol?

Why are pediatric patients only being given 1 dose of atrovent?

 

Evidence

According to local practice, the ED uses albuterol 5 mg for patients 10 kg or more and 2.5 mg for those less 10 kg. High dose albuterol (5mg) has been shown to be more effective than the dose of 2.5 mg. There are studies which have shown that it decreases hospitalization rates, ED length of stay and decreased hospital rate of admission.

There have been multiple different studies that have shown a benefit with the use of multidose atrovent. The benefits include decrease hospitalization rates and reduction in the duration of ED stay. The benefits are substantial enough that the in the 2007 Guidelines for the Diagnosis and Management of Asthma released by the National Heart, Lung, and Blood Institute promotes multidose use in moderate to severe asthma.

 

New Suggested Protocol

Reactive Airway Disease/Asthma (wheezing) –

  • In patients with broslow of Gray, Pink, and Red: Albuterol 2.5 mg and Atrovent 0.25 mg. Subsequent nebulizer treatments will contain Albuterol 2.5 mg and atrovent 0.25mg
  • In patients with broslow of Purple or higher Albuterol 5 mg and Atrovent 0.5 mg. Subsequent nebulizer treatments will contain Albuterol 5 mg and atrovent 0.5 mg
    • Solu-Medrol 2 mg/kg IV/IO maximum dose 125 mg
      • When multiple nebulizer treatments are required
      • When patient presents with severe respiratory distress
    • If patient’s condition does not improve administer Epinephrine 1:1000 0.01 mg/kg IM/SQ, with maximum dose of 0.3 mg

 

References

  1. E.R McFadden Jr, MD, Louise Strauss, RN, BSN, Rana Hejal, MD, Gale Galan, MD, Lisa Dixon, RN. Comparison of two dosage regimens of albuterol in acute asthma

E.R . The American Journal of Medicine. Volume 105, Issue 1 , Pages 12-17, July 1998

  1. Qureshi F, Pestian J, Davis P, Zaritsky A: Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med 339: 1030, 1998. [PMID: 9761804]
  1. Scarfone, Richard J.MD, Friedlaender, Eron Y. [beta]2-Agonists in acute asthma: The evolving state of the art. Pediatric Emergency Care: December 2002 – Volume 18 – Issue 6 – pp 442-447
  1. Schuh S, Reider MJ, Canny G, et al. Nebulized albuterol in acute childhood asthma: comparison of two doses. Pediatrics. 1990;86:509 –513
  2. Arnold DH, Moore PE, Abramo TJ, Hartert TV. The dilemma of albuterol dosing for acute asthma exacerbations in pediatric patients. Chest. 2011 Feb;139(2):472. doi: 10.1378/chest.10-2163.
  3. Artemis System. http://artemis.ppag.org/php/static/home.php