Pediatric Asthma Standardized Procedure

Dawn Sullivan, RCP Julian L. Gallegos, MS, RN, FNP-BC

Epidemiology
According to the American Lung Association (2006)
7 million children have been diagnosed asthma 3rd leading cause of childhood hospitalization One of the most common causes of missed school days (about 13 million missed days/year) In Solano County, approximately 66,000 children and adults have been diagnosed with asthma

Epidemiology

Epidemiology
Northbay Healthcare Hospital admissions NB ED Visits VVH ED Visits

NB/VV Emergency Department Asthma Discharges

Emergency Dept Pediatric Asthma DC 400 350 300
Discharges

350 321

372 300
NB

250 200 150 100 50 0 Aug 07 - Jul 08 Aug 08 - Jul 09 Year Aug 09 - Jul 10 Aug 10 - Jul 11

192

175

180 123

VV

NB Inpatient Asthma Discharges

Inpatient Pediatric Asthma Discharges 35 30 25
Discharges

33

20 15 10 5 0 Aug 07 - Jul 08

18

19 13 NB

Aug 08 - Jul 09 Year

Aug 09 - Jul 10

Aug 10 - Jul 11

 C/O Frequent night-time coughing shortness of breath Symptomatic with viral infections, allergens or exercise Colds that last >10 days Wheezing Tachypnea Retractions Often has eczema or rash

Clinical Presentation

Diagnosis of Asthma
Often times pediatric asthma is diagnosed as:
Bronchitis Pneumonia Reactive Airway Disease

Physiologic Features
Inflammatory process usually starts prior to bronchospasm

Physiological Effects
First to occur is the inflammatory process of the bronchiole Leads to bronchospasm Increased sputum production Often obstructs airway leading to infection

Common Triggers
Allergens
Dust, mold, pollen, cats, dogs, etc

Non-Allergens
Cigarette smoke/Smoke Respiratory Infections Exercise Temp Change (Cold Air) Stress GERD Sinus Infection

Reduction of Asthma Triggers

No smoking in home or car Avoid allergens Provide allergy free mattress and pillow case covers Maintain humidity within home Use a HEPA filter in the bedrooms Mold reduction measures

Aerosolized Albuterol Delivery Devices

Types of Aerosol Generators Three common types of aerosol generators are used for inhaled drug delivery: Small-volume Nebulizer: SVN is an aerosol generator that converts liquid drug solutions or suspensions into aerosol and is powered by compressed air, oxygen, a compressor, or an electrically powered device. Pressurized Metered-dose Inhaler: pMDI is a small, portable self-contained drug device combination that dispenses multiple doses by a metered value. Because of high medication loss in the oropharynx and hand-held coordination difficulty with pMDIs, holding chambers and spacers are often used as ancillary devices with the pMDI. Dry-powder Inhaler: The DPI is an aerosol device that delivers drug in a powdered form, typically with a breath-actuated dosing system.

Aerosolized Albuterol Delivery Devices

Equivalence of Aerosol Device Types Historically, nebulizers were thought to be more effective than pMDIs, especially for short-acting bronchodilators in acute exacerbations of airflow obstruction. Contrarily, evidence has shown equivalent clinical results whether a pMDI, a nebulizer, or a DPI is used,

Aerosolized Albuterol Delivery Devices

Aerosolized Albuterol Delivery Devices

Hazards of Aerosol Therapy
Hazards associated with aerosol drug therapy may occur as a result of inhaled medication, an aerosol generator being used, the aerosol administration technique, and the environment. Hazards of aerosol therapy can impact the patient receiving therapy, as well as care providers and bystanders.

Hazards for patients

Adverse Reaction: Most hazards associated with aerosol therapy are attributed to adverse reactions to the drug being used. Therefore, inhaled medications should be administered with caution. Types of adverse reactions include headache, insomnia, and nervousness with adrenergic agents. Bronchospasm: Administering a cold and high-density aerosol may induce bronchospasm in patients with asthma or other respiratory diseases. If bronchospasm occurs during aerosol therapy, the patient should be given a rest.

Drug Concentration: In both jet and ultrasonic nebulizers, drug concentrations may increase significantly during aerosol therapy. An increase in drug concentration may be due to evaporation, heating, or the inability to effectively nebulize suspensions. As a result of changes in drug concentration, the amount of the drug remaining in the nebulizer at the end of aerosol therapy is increased and the patient is exposed to higher concentrations of inhaled medications. This is a problem with continuous feed nebulization.
Infection: It has been well documented that aerosol generators were contaminated with bacteria and increase risk of infections in patients with respiratory disease. Proper practices of medication handling, device cleaning, and sterilization can greatly reduce the risk. Eye Irritation: Inhaled medication delivered with a face mask may inadvertently deposit in the eyes and result in eye irritation. Improving the interface between the face masks and patients may eliminate this problem and increase the amount of drug delivered to the distal airways. Therefore, caution should be exercised when using a face mask during aerosol drug administration.

Aerosolized Albuterol Delivery Devices

Hazards for Care Providers and Bystanders Exposure to Secondhand Aerosol Drugs: Care providers and bystanders have the risk of exposure to inhaled medications during routine monitoring and care of the patients. While workplace exposure to aerosol may be detectable in the plasma, it may also increase the risk of asthma-like symptoms and cause occupational asthma.

MDI propelled by CFC verses HFA

Dosing
How do we know the pMDI is Empty? Most pMDI are not packaged with dose counters to help

determine when an pMDI should be discarded. The only reliable method to determine the number of doses remaining in an pMDI is counting the doses manually or with a dose counter. Manual methods include reading the label to determine the total number of doses available in the pMDI and using a log to indicate every individual actuation given (including both priming and therapy doses).

Spacer with Valved Holding Chamber

A valved holding chamber (VHC) has a

low-resistance one-way valve that allow aerosol particles to be contained within the chamber for a short time until an inspiratory effort opens the valve. Time delays can significantly reduce the available dose for inhalation from a VHC. Children with low tidal volumes (less than device dead space) may need to take several breaths from a VHC through a face mask for a single pMDI actuation.

In the case for children the VHC should incorporate one-way valves for both inhalation and exhalation to decrease rebreathing and avoid blowing aerosol from the chamber.

Pediatric Asthma Scoring Tool (PAS)

Pediatric Asthma Scoring Tool

Assign score 0, 1, 2 for each of these items then ADD

SCORE
Oxygen* Requirements
Auscultation

0
SpO2 96% or greater on room air Normal breath sounds to endexpiratory wheeze only None or intercostal

1
SpO2 91%-95% on room air

2
SpO2 90% or less on room air or any supplemental oxygen Inspiratory and expiratory wheezing to diminished breath sounds Inter-costal, substernal and supraclavicular Severely prolonged _________ SCORE

* If SpO2 is
greater than 95% while receiving any supplemental oxygen, attempt to reduce (TITRATE) oxygen concentration (FiO2) and/or Liter Flow.

Expiratory wheezing

________ SCORE

Retractions

Inter-costal & Sub-sternal

________ SCORE

Expiratory Phase

Normal or mildly prolonged

Moderately prolonged

_________ SCORE

TOTAL SCORE =

Pediatric Asthma Score

Add the Score for the 4 categories together: Mild: PAS < 3 Mild to Moderate: PAS of 4-5 Severe: PAS > 6

 Oxygen requirements

Pediatric Asthma Assessment using PAS

Pulse Oximetry should be greater than or equal to 90% on room air

 Auscultation

Pediatric Asthma Assessment using PAS

Auscultate all anatomical lung points

Anterior Auscultation Points

Posterior Auscultation Points

Pediatric Asthma Assessment using PAS

Age 1-3 4-6 6-8 9-12 >13 Respiratory Rate 20-30 18-25 15-22 15-20 12-20 Heart Rate 80-110 75-110 70-110 70-100 60-100 Blood Pressure 95-105/55-65 95-110/60-70 95-115/60-75 110-125/60-80 100-120/60-80

Pediatric Asthma Assessment using PAS

Retractions
Indicative of increasing severity of asthma symptoms

Expiratory Phase
Associated with airway obstruction Indicative of increasing severity of asthma symptoms

Pediatric Asthma Assessment using PAS Retractions

Increased negative intrathoracic pressure causes the space between ribs to be pulled inward.

Intercostal, substernal or supraclavicular retractions are a sign of respiratory distress.

Retractions are usually due to stiff lungs because the patient must create a greater negative pressure to open the alveoli.

Pediatric Asthma Algorithm

ED TRIAGE
Initiate Pediatric Asthma Algorithm if Pediatric Score (PAS) 3-8 Notify Respiratory Therapy

ED Treatment

Step 1: 12 puffs every 2 hrs check PAS 1 hr after dose

12 puffs Albuterol* Wait 1 Hour

NOTES: A. PAS = Pediatric Asthma Score B. If PAS 6 or greater Have a second clinician confirm score, notify Physician and obtain on-going care orders until transfer to a higher level of care is accomplished. If PAS 6 or greater in any other step,return to Step 1. C. Notify MD Any time PAS 6 or greater When patient is ready for discharge.

D. Discharge Criteria Step 4 PAS <3 O2 sat > 90% on room air Completion of education program Adequate oral intake for hydration Overall condition improving E. Discharge with Script for controller medication (if appropriate) Albuterol MDI and spacer device Remainder of corticosteroid burst Plan for follow-up

PAS Less than 6

Step 2: 12 puffs every 3hrs check

PAS 2hrs after dose

Step 3: 12 puffs every 4 hours

check PAS 3 hrs after dose

Step 4: 6 puffs every 4 hours

check PAS 3 hours after dose 6 puffs Albuterol*

Yes Wait 1 Hour Wait 2 Hours

PAS Less than 3 NO (PAS 3, 4, 5)

12 puffs Albuterol*

Wait 3 Hours

Yes
Wait 1 Hour

PAS Less than 6 Yes Wait 1 Hour

Wait 3 Hours
12 puffs Albuterol*

PAS Less than 6 Yes

PAS Less than 6 Yes NO (PAS 3, 4, 5)

Wait 1 Hour

PAS Less than 3

NO (PAS 3, 4, 5) 12 puffs Albuterol *

NO

Yes
Meets Discharge Criteria

PAS Less than 3

Wait 1 Hour

PAS Less than 3 Yes

NO (PAS 3, 4, 5)

Yes
Wait 1 Hour PAS Less than 3 Yes No Waiting NO (PAS 3, 4, 5) Meet NO Dischar (PAS 3, 4, 5) ge Criteria Yes 6 puffs Albuterol* Q4H until Discharge
DISCHARGE

Yes
12 Puffs Albuterol* Discharge to home with: Script for controller medication (if appropriate) Albuterol MDI and spacer device Remainder of corticosteroid burst Plan for follow-up

May admit to Unit 1800 if stable and Improving

*For Albuterol: If infant/child does not tolerate MDI with spacer, RCP may substitute 5 mg nebulizer for 12 puffs and 2.5 mg nebulizer for 6 puffs. Nebulized treatments must be given with a mask. Reassess the ability to tolerate MDI with spacer at each step.

ED Management of Pediatric Asthma utilizing the PAS tool and Pediatric Asthma Algorithm

ED Management
ED Management of the pediatric patient with asthma will start at triage RN will perform initial triage assessment utilizing the PAS
If PAS greater than or equal to 3, patient meets inclusion criteria for the Pediatric Asthma Algorithm

The RN will collaborate with physician and contact RCP for treatment based on the Pediatric Asthma Algorithm or physician order

ED Management
Oxygen
Supplemental oxygen to maintain SpO2 9095%

Albuterol via Metered Dose Inhaler and Spacer

Dilates the airways rapidly by relaxing smooth muscle

Systemic steroids as ordered by physician

Prevent swelling of the airway lining and/or reduce existing swelling

Common Side Effects

Oxygen
Mucosal drying
Utilize humidification for all pediatric inpatients

Notify physician for any patient with FIO2 greater than .60

Albuterol
Tremors Nausea Tachycardia Potential for blood potassium washout

Common Side Effects

Systemic Steroids
Short term
Oral steroids not tolerated well May cause nausea/vomiting

Long term
Reduction in long bone growth Weight gain Mood changes Effect on blood glucose and sodium

ED Discharge Criteria
Oxygen Saturation > 90% RA Adequate oral intake for hydration Improving with a PAS < 3 Asthma Education provided and understood by parents Discharge Instructions
Script for controller medication (if appropriate) Albuterol MDI and spacer device Remainder of corticosteroid burst Plan for follow-up

Criteria for Admission to Unit 1800

The patient must be stable and at Step 2 of the pathway with a Pediatric Asthma Score (PAS) 3-5 showing signs of improvement. The patient should be able to maintain oxygen saturation with FIO2 less than 0.50 (50%).The patient should not require beta-agonist therapy more than every 2 hours. The patient should not require nursing reassessment of condition more than q 1h x 4 and or q 3 hours as per Nursing policy 403 (Continuum of Care: Admisson, Discharge,Transfer of Patients). If the patient condition dictates more frequent nursing assessments the patient should be evaluated for transfer to a higher level of care. managed by the ED physician in collaboration with the on-call pediatrician.

Criteria for Admission to Unit 1800

If continuous nebulized albuterol is used to stabilize the patient in the ED, patients need to be monitored for a minimum of 2 hours in the ED after stopping continuous inhaled therapy before transfer to the 1800 Medical/Surgical Unit. Patients requiring more than 1 hour of continuous albuterol, albuterol more frequently than every 2 hours, or multiple continuous albuterol treatments in the ED should be considered for transfer to a higher level of care.