Introduction
Management of
acute exacerbation of
ASTHMA
in children
Revision Publication Date: September 16, 2010
Revision Publication Date: September 3, 2002
Original Publication Date: July 20, 1998
Please cite as:
Acute Asthma Guideline, Cincinnati Children's Hospital
Medical Center: Evidence-based care guideline for management of
acute asthma exacerbation in children Asthma Exacerbation in
Children Pediatric Evidence Based Care Guidelines, Cincinnati
Children's Hospital Medical Center, Guideline 4, pages 1-35,
September 16, 2010
Target Population
Inclusion:
Children experiencing an acute asthma exacerbation:
up to 18 years of age with diagnosed asthma or high
probability of asthma presentation
0 to 12 months: accurate diagnosis of asthma in
this age range is difficult (see Attachment 1 Key
Indicators and Attachment 2 Differential
Diagnosis)
Exclusion: Children:
admitted to the intensive care unit (ICU)
who require intubation, ventilator support or are in
impending respiratory arrest
with bronchiolitis or conditions characterized by nonbronchodilator-responsive wheezing
Exercise caution in managing children with comorbid
conditions such as:
congenital or acquired cardiovascular disease
cystic fibrosis
chronic lung disease or bronchopulmonary dysplasia
immunodeficiency syndromes
Target Users
Include, but are not limited to:
Patient care staff, nurses, pharmacists, respiratory
therapists
Physicians, residents
Primary care providers, physician assistants
Guideline 4
9B
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 1 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline Recommendations
Guideline 4
Initial Treatment
Oxygen
4. 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 1994 [3a], SIGN
2008 [5a], NAEPP 2007 [5a]).
Short-acting inhaled beta2-agonists
5. 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 2009 [5b]).
Modify therapy based on the early clinical response
to treatments (SIGN 2008 [5a], NAEPP 2007 [5a], Camargo
2009 [5b]) (see Table 1 Aerosolized Therapies drugs
and dosage recommendations).
Note: Albuterol treatments given every 10 to 20
minutes for a total of 3 doses can be given safely
as initial therapy (LocalConsensus [5], SIGN 2008 [5a],
NAEPP 2007 [5a]).
6. It is recommended that levalbuterol not be routinely
used in the treatment of acute exacerbation
(LocalConsensus [5]).
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
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 2 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
[4a]). The numbers needed to treat (NNT) with
Guideline 4
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 3 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
30 kg: 5 mg
6 puffs (range: 4 to 8 puffs)
every 20 minutes for 3 doses,
then every 1 to 4 hours as needed
Levalbuterol
Ipratropium
bromide with
albuterol
Nebulizer
solution
(Each 3 mL vial
contains 0.5 mg
ipratropium
bromide and 2.5
mg albuterol)
Notes
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 4 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Systemic Corticosteroids
Dosage
Oral:
0.6 mg/kg once daily
(max 16 mg/dose)
for 1 to 2 days (Qureshi 2001 [2a])
Notes
Dosages in excess of 1mg/kg of prednisone or
prednisolone have been associated with adverse
behavioral effects in children, whereas 1mg/kg
provides equivalent pulmonary benefit with
decreased adverse effects (Kayani 2002 [2b]).
Corticosteroids
9. It is recommended that oral corticosteroids be
administered to patients who do not respond
completely to initial inhaled SABAs (Edmonds 2009
[1a], NAEPP 2007 [5a], Camargo 2009 [5b]) (see Table 2
drugs and dosage recommendations).
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 2009a [1a], Edmonds 2009 [1a]).
Note 2: Oral prednisone has effects equivalent to
those of intravenous methylprednisolone
including tolerance by children (Rowe 2009a [1a],
SIGN 2008 [5a], NAEPP 2007 [5a], Camargo 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 2009 [1a], Schuh 2006 [2b], Nakanishi 2003
[2b], NAEPP 2007 [5a], Camargo 2009 [5b]).
Adjunctive Therapies
Magnesium Sulfate
10. 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 2009b [1a],
Mohammed 2007 [1a], Ciarallo 2000 [2b], SIGN 2008 [5a])
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 5 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Subcutaneous (SQ)
(1 mg/mL)
0.3 to 0.5 mg
every 20 minutes
for 3 doses
0.01 mg/kg
(max 0.25 mg)
May repeat every 15
minutes for 3 doses
0.01 mg/kg
(max 0.25 mg)
May repeat every 15
minutes for 3 doses
Notes
There is insufficient evidence regarding the benefit
from continuous infusion of Magnesium Sulfate
(Mohammed 2007 [1a]).
Abbreviations: ED = emergency department; gms = grams; kg = kilogram; max = maximum; mcg = microgram; mg = milligram;
mL = milliliter; PICU = pediatric intensive care unit
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (LocalConsensus [5], NAEPP 2007 [5a], Taketomo [5a]).
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 6 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Inpatient Management
General Therapy
15. 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
oxygen
corticosteroids
initiation and continuation of controller (antiinflammatory) 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
16. It is recommended that the following care be
initiated for patients who fail to progress after 12
hours of care: (LocalConsensus [5])
notify treating healthcare provider of any child
that has not progressed after 12 hours of care
assessment:
Guideline 4
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 7 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Consistency of Care
18. 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 (SIGN 2008 [5a],
NAEPP 2007 [5a]). At Cincinnati Childrens 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 2000 [2a], McDowell
1998 [2a], Norton 2007 [4a], Wazeka 2001 [4a],
Ebbinghaus 2003 [4b], Kelly 2000 [4b]).
Guideline 4
ED or Inpatient Management
Screening
21. 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,
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 8 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Therapy Cautions/Considerations
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Discharge/Transition Preparation
Guideline 4
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Discharge readiness
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 1
KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA
Consider a diagnosis of asthma and performing spirometry if any of these indicators is present.*
These indicators are not diagnostic by themselves, but the presence of multiple key indicators
increases the probability of a diagnosis of asthma. Spirometry is needed to establish a diagnosis of
asthma.
Wheezinghigh-pitched whistling sounds when breathing outespecially in children. (Lack
of wheezing and a normal chest examination do not exclude asthma.)
History of any of the following:
Cough, worse particularly at night
Recurrent wheeze
Recurrent difficulty in breathing
Recurrent chest tightness
Symptoms occur or worsen in the presence of:
Exercise
Viral infection
Animals with fur or hair
House-dust mites (in mattresses, pillows, upholstered furniture, carpets)
Mold
Smoke (tobacco, wood)
Pollen
Changes in weather
Strong emotional expression (laughing or crying hard)
Airborne chemicals or dusts
Menstrual cycles
Symptoms occur or worsen at night, awakening the patient.
*Eczema, hay fever or a family history of asthma or atopic diseases are often associated with asthma, but
they are not key indicators.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 2
DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA
Infants and Children
Upper airway diseases
Allergic rhinitis and sinusitis
Obstructions involving large airways
Foreign body in trachea or bronchus
Vocal cord dysfunction
Vascular rings or laryngeal webs
Laryngotracheomalacia, tracheal stenosis, or bronchostenosis
Enlarged lymph nodes or tumor
Obstructions involving small airways
Viral bronchiolitis or obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Heart disease
Other causes
Diagnosed recurrent cough not due to asthma
Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux
Adults
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Attachment 3
Symptoms
Guideline 4
Subset: Respiratory
Arrest Imminent
While walking
Prefers sitting
Sits upright
Talks in
Alertness
Sentences
Normal or may be
agitated
Phrases
Usually agitated
Words
Usually agitated
Cannot talk
Drowsy or confused
Respiratory rate
Normal or increased
Increased
Increased, often
>30/minute
Guide to rates of breathing in awake children:
Age
Normal Rate
< 2 months
< 60/minute
2 to 12 months
< 50/minute
1 to 5 years
< 40/minute
6 to 8 years
< 30/minute
Usually not
Commonly
Usually
Normal or decreased
Loud; throughout
exhalation
Minimal or absent
< 100
100 to 120
Loud, throughout
inspiration and
exhalation or may be
absent
> 120
May be present
10 to 25 mmHg
Often present
> 25 mmHg (adult)
20 to 40 mmHg (child)
Absence suggests
respiratory muscle fatigue
> 70%
Approx. 40 to 69% or
Response to treatment
lasts < 2 hours
< 40%
< 25%
Note: PEF testing may not
be needed in very severe
attacks
Signs
Functional Assessment
While at rest
Paradoxical
thoracoabdominal
movement
Bradycardia
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Emergency Department Management of Asthma Exacerbations Algorithm
Guideline 4
Attachment 4
Initial Assessment: Brief History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, pulse
oximetry), PEF or FEV1 (if performed), or Asthma score, oxygen saturation, and other tests as indicated
Mild: see Attachment 3 for
details of signs and
symptoms:
Speaks in sentences
Wheeze mild to moderate
(end expiratory)
Mild
Oxygen to achieve SaO2 > 90%
Inhaled SABA by nebulizer or MDI
with valved holding chamber, up to 3
doses in 1st hour
Oral systemic corticosteroids if no
response or if patient recently took oral
systemic corticosteroids
Moderate / Severe
Oxygen to achieve SaO2 > 90%
High-dose inhaled SABA by nebulizer or
MDI with valved holding chamber, every
10 to 20 minutes or continuously for 1
hour PLUS ipratropium
Oral systemic corticosteroids
Repeat Assessment: Symptoms, physical examination, Asthma Score or PEF, FEV1 (if performed), oxygen saturation, other tests as
indicated
Moderate Exacerbation
Asthma Score, PEF or FEV1 (40 to 69%
predicted/personal best)
Inhaled SABA every 60 minutes
Oral systemic corticosteroids
Continue treatment 1 to 3 hours,
provided there is improvement; make
admit decision in < 4 hours
Good Response
Asthma Score, PEF or FEV1
(> 70%)
Response sustained at least 60
minutes after last treatment
No distress
Physical exam: normal
Discharge Home
Continue treatment with inhaled SABAs.
Continue course of oral systemic
corticosteroid.
Continue on ICS. For those not on long-term
control therapy, consider initiation of an ICS.
Patient education (e.g., review medications
including inhaler technique; review/initiate
action plan; recommend close medical followup and, whenever possible, environmental
control measures).
Before discharge, schedule follow-up
appointment with PCP and /or asthma
specialist in 1-5 days.
If unable to schedule from ED, notify PCP of
status
Severe Exacerbation
Asthma Score, PEF or FEV1 (<40% predicted/personal best)
History: high risk patient
No improvement after initial treatment
Oxygen
Nebulized SABA, hourly or continuous, plus ipratropium
Oral systemic corticosteroids (see Table 2)
Consider adjunct therapies (see Table 3)
Incomplete Response
Unchanging Asthma Score,
PEF or FEV1 (40 69%)
Symptoms persist
Poor Response
Unchanging or worsening
Asthma Score, PEF or FEV1
(< 40%)
Symptoms worsening
Improve
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Severity Classification
Guideline 4
Attachment 5
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 5
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 19 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 6
You can help prevent asthma episodes by staying away from things that make your asthma worse. This guide suggests
many ways to help you do this. You need to find out what makes your asthma worse. Some things that make asthma
worse for some people are not a problem for others. You do not need to do all of the things listed in this guide. Look
at the things listed below and put a check next to the ones that you know make your asthma worse, particularly if you
are allergic to those things. Then decide with your doctor what steps you will take. Start with the things in your
bedroom that bother your asthma. Try something simple first.
Tobacco Smoke
If you smoke, ask your doctor for ways to help you quit. Ask family members to quit smoking, too.
Do not allow smoking in your home, car, or around you.
Be sure no one smokes at a childs daycare center or school.
Smoke, Strong Odors, and Sprays
If possible, do not use a wood-burning stove, kerosene heater, fireplace, unvented gas stove, or heater.
Try to stay away from strong odors and sprays, such as perfume, talcum powder, hair spray, paints, new
carpet, or particle board.
Dust Mites
Many people who have asthma are allergic to dust mites. Dust mites are like tiny bug
s you cannot see that live in
cloth or carpet. Things that will help the most:
Encase your mattress in a special dust mite proof cover.
Encase your pillow in a special dust mite-proof cover or wash the pillow each week in hot water. Water must
be hotter than 130 F to kill the mites. Cooler water used with detergent and bleach can also be effective.
Wash the sheets and blankets on your bed each week in hot water.
Cockroaches
Many people with asthma are allergic to the dried droppings and remains of cockroaches.
Keep all food out of your bedroom.
Keep food and garbage in closed containers (never leave food out).
Use poison baits, powders, gels, or paste (for example, boric acid) to eliminate cockroaches.
You can also use traps.
If a spray is used to kill roaches, stay out of the room until the odor goes away.
Other things that can help:
Reduce indoor humidity to or below 60 percent; ideally 3050 percent. Dehumidifiers or central air
conditioners can do this.
Try not to sleep or lie on cloth-covered cushions or furniture.
Remove carpets from your bedroom and those laid on concrete, if you can.
Keep stuffed toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and
bleach. Placing toys weekly in a dryer or freezer may help. Prolonged exposure to dry heat or freezing can kill
mites but does not remove allergen.
Animal Dander
Some people are allergic to the flakes of skin or dried saliva from animals.
The best thing to do:
Keep animals with fur or hair out of your home.
If you cant keep the pet outdoors, then:
Keep the pet out of your bedroom, and keep the bedroom door closed.
Remove carpets and furniture covered with cloth from your home. If that is not possible, keep the pet out
of the rooms where these are.
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (NAEPP 2007 [5a]).
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 20 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 6
You can help prevent asthma episodes by staying away from things that make your asthma worse. This guide suggests
many ways to help you do this. You need to find out what makes your asthma worse. Some things that make asthma
Indoor
worse
forMold
some people are not a problem for others. You do not need to do all of the things listed in this guide. Look
Fix
leaking
faucets,
othernext
sources
water.
at the things listed
below
andpipes
put a or
check
to theofones
that you know make your asthma worse, particularly if you
Clean
moldy
surfaces.
are allergic
to those
things.
Then decide with your doctor what steps you will take. Start with the things in your
basements,
possible.
bedroomDehumidify
that bother your
asthma.ifTry
something simple first.
VacuumSmoke
Cleaning
Tobacco
TrytoIfget
to vacuum
once
or twice
a week
yousomeone
smoke, else
ask your
doctorfor
foryou
ways
to help
you quit.
Ask family members to quit smoking, too.
If able:
Do not allow smoking in your home, car, or around you.
rooms
while
are being
vacuumed
for a short while afterward.
BeStay
sureout
no of
one
smokes
at athey
childs
daycare
center orand
school.
If unable:
Smoke, Strong Odors, and Sprays
Use a dust mask (from a hardware store), a central cleaner with a collecting bag outside the home, or a
If possible, do not use a wood-burning stove, kerosene heater, fireplace, unvented gas stove, or heater.
vacuum cleaner with a HEPA filter or a double-layered bag.
Try to stay away from strong odors and sprays, such as perfume, talcum powder, hair spray, paints, new
Pollen carpet,
and Outdoor
Mold
or particle
board.
During your allergy season (when pollen or mold spore counts are high)
Dust Mites
Try to keep your windows closed.
Many people who have asthma are allergic to dust mites. Dust mites are like tiny bug
s you cannot see that live in
If possible, stay indoors with windows closed during the midday and afternoon. Pollen and some mold spore
cloth or carpet. Things that will help the most:
counts are highest at that time.
Encase your mattress in a special dust mite proof cover.
Ask your doctor whether you need to take or increase anti-inflammatory medicine before your allergy season
Encase your pillow in a special dust mite-proof cover or wash the pillow each week in hot water. Water must
starts.
be hotter than 130 F to kill the mites. Cooler water used with detergent and bleach can also be effective.
Exercise or Sports
(NAEPP 2007 [5a])
Wash the sheets and blankets on your bed each week in hot water.
You should be able to be active without symptoms. See your doctor if you have asthma symptoms when you
are activesuch as when you exercise, do sports, play, or work hard.
Cockroaches
Ask with
your asthma
doctor about
takingtomedicine
you exercise
to prevent
symptoms.
Many people
are allergic
the driedbefore
droppings
and remains
of cockroaches.
Warm
forout
a period
before
you exercise.
Keep
all up
food
of your
bedroom.
Check
theand
air garbage
quality index
and containers
try not to work
orleave
play hard
Keep
food
in closed
(never
food outside
out). when the air pollution or pollen levels (if
allergic
to powders,
the pollen)
are or
high.
you
Useare
poison
baits,
gels,
paste (for example, boric acid) to eliminate cockroaches.
You can also use traps.
Seasonal Exposures
If a spray is used to kill roaches, stay out of the room until the odor goes away.
Maintain good hand-washing habits
Avoid
exposure
to crowds during high viral seasons, as much as is possible
Other things
that
can help:
Discuss
with your
healthcare
provide
benefits
of a 3050
seasonal
influenza
vaccine
Reduce
indoor
humidity
to or below
60 the
percent;
ideally
percent.
Dehumidifiers
or central air
conditioners can do this.
Things
Try not That
to sleep
or Make
lie on cloth-covered
cushions or furniture.
Other
Can
Asthma Worse
Sulfitescarpets
in foods:
Doyour
not drink
beerand
or wine
eaton
shrimp,
driedif fruit,
or processed potatoes if they cause
Remove
from
bedroom
thoseorlaid
concrete,
you can.
symptoms.
asthma
Keep stuffed
toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and
bleach.
Cold air:
Covertoys
your
nose and
with
a scarf
onhelp.
cold Prolonged
or windy days.
Placing
weekly
in amouth
dryer or
freezer
may
exposure to dry heat or freezing can kill
mites
Otherbut
medicines:
Tell
your
doctor
about
all
the
medicines
you
may
take.
Include cold medicines, aspirin,
does not remove allergen.
herbal or alternative medicines, and even eye drops.
Animal Dander
Some people are allergic to the flakes of skin or dried saliva from animals.
The best thing to do:
Keep animals with fur or hair out of your home.
If you cant keep the pet outdoors, then:
Keep the pet out of your bedroom, and keep the bedroom door closed.
Remove carpets and furniture covered with cloth from your home. If that is not possible, keep the pet out
of the rooms where these are.
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (NAEPP 2007 [5a]).
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 7
Using an inhaler seems simple, but most people do not use it the right way. When an inhaler is used the wrong
way, less medicine gets to the lungs. Use of a holding chamber/spacer increases reliability of drug effectiveness,
especially when inhalers are not used correctly.
For the next few days, read these steps aloud as you do them or ask someone to read them to you. Ask your
primary care provider to check how well you/your child are using the inhaler.
Use the inhaler in the way pictured below.
Steps for using your inhaler:
Getting ready 1. Take off the cap, shake the inhaler and attach spacer
2. Breathe out all the way.
3. Hold the inhaler the way instructed by your primary care provider (see picture).
4. Press down on the inhaler, within 5 seconds, begin to breathe in slowly through your
mouth.
5. Keep breathing in slowly, as deeply as possible.
6. Hold your breath and count to 10 slowly, if possible.
7. Remove the inhaler and breathe out through pursed lips (like blowing out a candle)
8. For inhaled quick-relief medicine (beta2-agonists), wait about 1 minute between puffs.
There is no need to wait between puffs for other medicines.
Clean your inhaler as needed, and know when to replace your inhaler. For instructions, read the package insert or
talk to your primary care provider or pharmacist. It is important to refill your prescription before the medicine
runs out or the inhaler expires to ensure medicine is available when needed.
Adapted from the National Heart Blood and Lung Institute, National Education and Prevention Program
Expert Panel Report 3: Diagnosis and Management of Asthma, 2007 (Roller 2007 [4a], LocalConsensus [5], NAEPP 2007 [5a]).
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 8
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 8
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 9
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Attachment 9
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 26 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Development Process
The process by which this guideline was developed is documented in
the Guideline Development Process Manual; relevant development
materials are kept electronically. The recommendations contained in
this guideline were formulated by an interdisciplinary working group
which performed systematic search and critical appraisal of the
literature, using the Table of Evidence Levels described following the
references, and examined current local clinical practices.
To select evidence for critical appraisal for this guideline, the
Medline, EmBase and the Cochrane databases were searched for
dates of January, 2002 to November, 2009 to generate an unrefined,
Guideline 4
the title, abstract, and indexing terms. The citations were reduced
by: eliminating duplicates, review articles, non-English articles,
and adult articles. The resulting abstracts were reviewed by a
methodologist to eliminate low quality and irrelevant citations.
During the course of the guideline development, additional clinical
questions were generated and subjected to the search process, and
some relevant review articles were identified. September, 2002 was
the last date for which literature was reviewed for the previous
version of this guideline. The details of that review strategy are
documented and maintained in an asthma literature binder.
However, all previous citations were reviewed for appropriateness
to this revision. Any new literature encountered for this October,
2010 version was reviewed by two or more team members and then
discussed as a team.
Experience with the implementation of earlier publications of this
guideline has provided learnings which have been incorporated into
this revision.
Once the guideline has been in place for five years, a team
reconvenes to explore the continued validity of the guideline. This
phase can be initiated at any point that evidence indicates a critical
change is needed.
The guideline was externally appraised by three reviewers using the
AGREE instrument and the results by domain are:
Rigor of Development
92%
Applicability
74%
Editorial Independence
72%
Recommendations have been formulated by a consensus process
directed by best evidence, patient and family preference and
clinical expertise. During formulation of these recommendations,
the team members have remained cognizant of controversies and
disagreements over the management of these patients. They have
tried to resolve controversial issues by consensus where possible
and, when not possible, to offer optional approaches to care in the
form of information that includes best supporting evidence of
efficacy for alternative choices.
The guideline has been reviewed and approved by clinical experts
not involved in the development process, distributed to senior
management, and other parties as appropriate to their intended
purposes.
The guideline was developed without external funding. All Team
Members and AC Support staff listed, have declared whether they
have any conflict of interest and none were identified.
Copies of this Evidence-based Care Guideline (EBCG) and any
available implementation tools are available online and may be
distributed by any organization for the global purpose of improving
child health outcomes. Website address:
http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/evbased/default.htm
Examples of approved uses of the EBCG include the following:
copies may be provided to anyone involved in the organizations
process for developing and implementing evidence-based care
guidelines;
hyperlinks to the CCHMC website may be placed on the
organizations website;
the EBCG may be adopted or adapted for use within the
organization, provided that CCHMC receives appropriate
attribution on all written or electronic documents; and
copies may be provided to patients and the clinicians who manage
their care.
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 27 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 28 of 36
Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
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Guideline 4
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Evidence-Based Care Guideline for Management of Acute Exacerbation of Asthma in children aged 0 to 18 years
Guideline 4
Strongly recommended
There is consensus that benefits clearly outweigh risks and burdens
(or visa-versa for negative recommendations).
Recommended
There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made
There is 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.
1. Grade of the Body of Evidence (see note above)
2. Safety / Harm
3. Health benefit to patient (direct benefit)
4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
5. Cost-effectiveness to healthcare system (balance of cost / savings of resources, staff time, and supplies based on published studies or
onsite analysis)
6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention,
comparison, outcome])
7. Impact on morbidity/mortality or quality of life
Copyright 1998, 1999, 2002, 2010 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 36 of 36