Asthma

Asthma Inpatient Management

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Asthma Inpatient Management

  • See Also
  1. Pediatric Asthma Score
  2. Asthma Education
  3. Asthma Management
  4. Asthma Exacerbation Home Management
  5. Emergency Management of Asthma Exacerbation
  6. Status Asthmaticus
  7. Asthma-Related Death Risk Factors
  8. Asthma Differential Diagnosis
  1. See Pediatric Asthma Score
  2. Vital Signs: Temp, Pulse, Blood Pressure, Respirations
    1. Start with every 4 hours for 12 hours
    2. Space to every 6 hours
  3. Peak Expiratory Flow (PEFR)
    1. PEFR accurate age >7 years (may be helpful age > 5)
    2. Obtain at least twice daily Peak Flows at one hour following Bronchodilator
  4. Oxygen Saturation Monitor
    1. Oxygen to keep Oxygen Saturation adequate
      1. Adults: >93%
      2. Children: >95%
    2. Discontinuation Criteria
      1. Oxygen Saturation adequate for 4 hours
      2. Patient on general ward
    3. Continue spot check Oxygen Saturation
      1. Perform with Vital Signs
      2. As needed for respiratory distress
  5. Telemetry monitor (cardiac monitor) Indications
    1. Albuterol Nebulizer more than every 4 hours
    2. Infant or young child
      1. Corroborate Oxygen Saturation monitor (match pulse)
      2. Child movement makes Oxygen Saturation inaccurate
  • Management
  • Medications
  1. See Emergency Management of Asthma Exacerbation
  2. See Status Asthmaticus
  3. Bronchodilators
    1. See Albuterol
    2. Albuterol MDI or Albuterol Nebulizer every 4 to 6 hours as needed
    3. Consider adding Muscarinic Antagonist (Ipratropium Bromide, duonebs)
  4. Corticosteroids
    1. Methylprednisolone (Solu-Medrol)
      1. Dose: 1 mg/kg/dose q6 hours
      2. Maximum Dose: 60 mg IV q6 hour OR 80 mg IV q8 hours
    2. Oral Prednisone
      1. Indications to switch from Solu-Medrol
        1. Albuterol Nebulizer spaced to 4 hours or more
        2. Tolerating oral intake (No Nausea or Vomiting)
      2. Dose
        1. Prednisone 1-2 mg/kg/day qd-bid
        2. Maximum: 40-60 mg/day for 5-10 days
        3. No tapering needed if use less than 2 weeks
  • Evaluation
  • Monitoring
  1. Peak Expiratory Flow (PEF) or FEV1
    1. Obtain one hour after Bronchodilator doses
    2. Target improvement of >60% of predicted (or personal best)
  2. Venous Blood Gas or Arterial Blood Gas Indications (on admission)
    1. Pulmonary Function Test Criteria
      1. PEFR < 30%
      2. Prior history of pCO2 > 40
    2. Failure to improve in 4 hours of therapy
    3. Clinical Asthma score >7
  3. Indications to monitor serum Electrolytes
    1. Nausea or Vomiting
    2. Intravenous Fluids for more than 24 hours
    3. Beta Agonists more than every 4 hours for 24 hours
  4. Chest XRay Indications
    1. First episode Wheezing
    2. Marked Breath Sound asymmetry
    3. History or exam suggestive of Pneumonia
  • Findings
  1. Signs of Improvement
    1. Minimal or no Wheezing
      1. Caution that silent lungs also occurs in Status Asthmaticus prior to respiratory arrest
    2. Less than 2 night awakenings for Mild Asthma symptoms
    3. Good activity tolerance
    4. Peak Expiratory Flow (PEFR) or FEV1 > 60% of predicted or baseline
    5. Adequate Oxygen Saturation >93 to 94% (off Supplemental Oxygen)
    6. Pediatric Asthma Score (PAS): 5 to 7
  2. Signs of Worsening (consider ICU transfer)
    1. See Status Asthmaticus
    2. Altered Level of Consciousness (e.g. drowsiness or confusion)
    3. Decreased breath sounds (quiet lungs) with decreased work of breathing despite clinical worsening
    4. Persistent or progressive Hypoxia
    5. Failure to improve after first 6-12 hours of management (including Corticosteroids)
    6. Pediatric Asthma Score (PAS): >7 (and esp. >11)
  • Management
  • Discharge
  1. See Asthma-Related Death Risk Factors
  2. Indications
    1. Inhaled Beta Agonist no more then every 4 hours
    2. Parenteral Corticosteroids switched to Oral Corticosteroids
    3. Adequate Oxygen Saturation >93 to 94% (on room air)
    4. Peak Expiratory Flow (PEFR) or FEV1 > 60% of predicted or baseline
    5. Pediatric Asthma Score (PAS): 5 to 7
    6. Asthma Education: Medication use
      1. Inhaled Corticosteroid by bedside
      2. Respiratory Therapy or nurse to instruct use bid
      3. Peak Flow measurement at home
  3. Outpatient Management
    1. Continue short-acting Bronchodilator as needed (or advance SMART Asthma Management Protocol)
    2. Assess for proper Inhaler use with spacer
    3. Review Asthma Action Plan
    4. Start or step-up controller medication
    5. Continue oral Corticosteroids for 3 to 5 days in children (5 to 7 days in adults)
  4. Follow-up
    1. Clinic appointment within 7-10 days
  • References
  1. (1997) Management of Asthma, NIH 97-4053
  2. (1995) Global Strategy for Asthma, NIH 95-3659
  3. Dabbs (2024) Am Fam Physician 109(1): 43-50 [PubMed]
  4. Pollart (2011) Am Fam Physician 84(1): 40-7 [PubMed]