1. STEP BY STEP MANAGEMENT OF STATUS ASTHMATICUS See details in the Asthma protocol guidelines Dr. D. Alvarez August 2008

2. INITIAL PROCES 1.Base-line patient’s chronic condition -If previous diagnosed with asthma, state Severity: Intermittent – Mild / Moderate / Severity Persistent (complete detail Asthma history later) -Has patient had previous PICU admissions? Intubations? -Last Hospitalization?; last intubation?. -Has patient been seen in the Asthma / Pulmonary clinic? date last visit

3. INITIAL PROCESS (continue) 2. Current event/exacerbation details: -Duration of symptoms of exacerbation -Triggering factors –Treatments / management at home. -Do they have an AAP?…. if yes ….Did they follow their AAP, including given steroids at home?. Time and dose given – did patient tolerated? or patient vomited.

4. ED Events. 3.- Review of ED-Events –Severity of Respiratory Distress /Assessment (See chart assessment)on presentation to ED and after therapies. –Studies / labs done (Start laboratory flow sheets record) CXR in patient’s with severe respiratory distress and/or fever. »Look for: significant atelectasis, air leaks, infiltrates? CBC with diff and Electrolytes in patient in moderate to Severe respiratory distress, receiving frequent bronchodilator treatments. »Look for signs of dehydration, HYPOKALEMIA, AND ACIDOSIS. 4.- Communicate with PICU Attending and inform on patient’s condition. 5.- Inform PICU Nurses that patient was accepted and up-date them on patient’s condition.

5. Asthma History Focus Has or Is patient being follow up in an asthma clinic? (give details) A. Asthma symptoms SINCE Or First wheezing episode –GIVE SOME DETAILS OF SEVERITY: (example: severe RSV infection) –this information is needed to phenotype patient in early onset ( 3 yo) B. RISK: will assess the severity of exacerbation. Frequency of subsequent symptoms / Seasonality –Note RISK: frequency and severity of exacerbations, requiring use of systemic steroids (#/yesr); ED/Hospitalization (#/year) – # PICU admissions - # Intubations –Note IMPARMENT: frequency of symptoms since last exacerbation, (as per guideline) –Medication used (at what level), / address modes of deliver, compliance and effect C. Course. –Level of control (See guide lines) –Overall improving, same, worse or up and down” _______________________________________________________________________________________ E. Asthma Risk Factors (Index) Positive Risk Factors if: - F amily hx of asthma / allergies.(parents), - Eczema - Allergies (Pt. and/or Fly), - Eosinophillia in CBC - Smoke exposure, etc. - Hx of RSV + bronchiolitis.

6. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 0–4 YEARS OF AGE Assessing severity and initiating therapy in children who are not currently taking long-term control medication

7. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 5–11 YEARS OF AGE Assessing severity and initiating therapy in children who are not currently taking long-term control medication

9. STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0–4 YEARS OF AGE

10. STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5–11 YEARS OF AGE

11. STEPWISE APPROACH FOR MANAGING ASTHMA I NYOUTHS ≥ 12 YEARS OF AGE AND ADULT S

12. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 0–4 YEARS OF AGE NIH 07 PG 309

13. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5–11 YEARS OF AGE

14. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN > YEARS OF AGE

15. Classifying severity asthma on follow up

16. ASSESSMENT

17. Physiological Problems that need to be Address / Assess. 1.Severity of Respiratory distress: (See chart criteria) Mild Moderate Severe

18. Severity of Respiratory Distress Mild Moderate Severe Mental StatusNormal -Alert Mild affected Irritable / Affected-Lethargy Tachypnea/ Dyspnea Normal / Mild Dysp - Speaks in full sentences - Normal cry 1 ½ x standard – Mod dyspnea - Speaks with pauses, normal cry 2 x standard -Severe dyspnea. - Can barely speaks - Weak cry Work of Breathing Mild SC retractionsSC-IT and Supra- clav Retrac- SC-IC-SC Retrac.& nasal flaring ? fatigue Air EntryNormalMild decreaseDecreased WheezingMild (+)Moderate (2-3+)(3- 4 +) OR None > imminent RF Hypoxia / O2 Sat in RA > 95 % 90 %< 90 % PCO2 / PEFR Norm/>75% 50% <75%> 45 / 50 %

19. 3. Assess cardiovascular compromise. Examples: –Mild Tachycardia / good perfusion –HR < than one standard deviation of normal for age. –Moderate Tachycardia /mild decrease perfusion. –HR > 1 < than 2 standard deviation of normal for age –Severe Tachycardic / poor perfusion. –HR > 2 standard deviation of normal for age 4. Assess Fluid-Electrolyte and AB Imbalance. Examples: (Look for sings of dehydration, hypokalemia, Metabolic acidosis and hyperglycemia) –Well hydrated / No electrolyte imbalance. –Mild dehydrated / mild acidosis, lowish K –Moderate dehydrated / moderate metabolic acidosis (Bic < 17), low K, hyperglycemia, high BUN and Creatitine.

20. 3. Assess > If associated overlapping infection Process. By History –Hx suggestive of Upper respiratory infection? Viral Vs Bacterial »Nasal symptoms: URI, Infected Rhinitis, Sinusitis »Pharyngeal symptoms: Pharingitis? Post Nasal drip. –Hx suggestive of Lower respiratory bacterial infection: »Prolonged productive cough with thick yellow sputum »Fever

21. 3. Assess > If associated overlapping infection Process. By Physical exam –Signs of Upper respiratory infection? Viral /Bacterial (See features of nose exam check list) »Examination of nose - Nasal crease/ allergic salute - Turbinate Normal size - Hypertrophy - Color- pale/red - Secretion-amount – scanty/copious. color- yellow/green/clear - Patency of nose- patent /blocked. –Signs of Lower respiratory bacterial infection: Signs of consolidation (decrease breath sounds, bronchophony, fine crackles – POSITIVE RACKLE DOES NOT MEANS PNEUMONIA)

22. 3. Assess If associated /overlapping infection Process. (Continue) By Studies: –CBC with diff (manual count) if clinically indicated –CRP if highly suspicious –CxR, looking for alveolar filling processes, NOT just atelectasis, although atelectasis can be infected. –DON’T FORGET TO CHECK PPD STATUS. 4.-Other associated pathology –Snoring? Obstructive sleep apnea?

23. MANAGEMENT

24. RESPIRATORY SUPPORT 1.OXYGEN Assess patient’s oxygen requirements and provide oxygen as needed to keep O2Sat’s > 95% in the acute processes. Provide Oxygen using the devices as per guidelines - Low Flow Oxygen: Nasal Canula < than 3 L/min (~ 35 %) - Moderate Flow Oxygen: USE AEROSOLIZE MASK, start with 40 % if switching from nasal canula OR as much as patient needs to keep saturation > 95 % - High Flow Oxygen: USE SAME AEROSOLIZE MASK. With this system flow can be adjusted from 28% to 100% just dialing up and down. Besides it delivers humidify oxygen. If patient’s is requiring > 55 % FiO2 to keep Saturation > 90 %, patient is in HYPOXIC RESPIRATORY FAILURE. NEED TO HAVE AND ABG. (Capillary blood gasses my suffice, NOT VENOUS)

25. RESPIRATORY SUPPORT (Continue) 2. Systemic Steroids Use IV Solumedrol for patient who are in moderate to Severe respiratory distress. Initial dose is 2 mg/kg/dose to a max of 125 mg. Follow up doses is 1 mg/kg/dose to a max of 60 mg Q6H PO steroids (Prednisone tablets or Prelone liquid). The dose is 2 mg /kg/day to a max of 60 mg if patient is in mild to moderate respiratory distress. IF SOLUMEDROL IS NOT AVAILABLE THIS CAN BE REPLACED BY DECADROM >> THE DOSE IS: 0.05 mg/kg/dose IM or IV Q 6 -12 hrs. (Max 10 mg/24 hrs) (0.08 -0.3 mg/kg/24 hr) Adult dose 10 mg Q 6 hrs

26. RESPIRATORY SUPPORT (Continue) 3. Bronchodilators A.Albuterol Nebulizer is the main brochodilator  Q2H in patient in Mild to Moderate respiratory distress.  If requiring more than Q2H, add Atrovent Neb and give it: “Back to Back” alternated (Alb & Atrovent) in patients with severe respiratory distress /Impending respiratory failure. Order x 4 Cycles and reassess. When improving, (usually expect it after ~ 6 hrs of the start of Steroids)Frequency can be spaced it gradually. Q1-2 H still alternated (Alb & Atrovent) >> if doing well, mild respiratory distress > d/c Atrovent Continue with Albuterol Q2-3 hours.

27. RESPIRATORY SUPPORT (Continue) 3. Bronchodilators (Continue) B. Terbutaline SC and / OR IV drip. To be use in patients who are not improving on back to back/continuous Nebulizer bronchodilators treatments to avoid intubation and/or pt. is already intubated and “very tight” (See drip chart) The initial dose is: C. MgSulfate: is a weaker bronchodilator than Albuterol or Atrovent. Recommended for its additional effect in the initial management in the ED. It should not be repeated at the risk to cause Hypermagnesemia.

28. Fluid Therapy NPO if patient is in moderate to Severe distress. 1.Calculate patient’s maintenance fluids (requirements); Wt. base OR per SA(m2) A. Basic Requiremente Wt base: 100 ml/kg for the first 10 kg 50 ml/kg for the next 10 kg 20 ml/kg for the rest…. kg. Per SA (m2) 1500 mL/M2 B.Add Insensitive extra loses given by: Tachypnea Fever 2.Replace deficit: take in account: Duration of symptoms PO intake, vomiting. Fluid Requirement for patients in moderate to severe respiratory distress may be estimated as 1 ½ maintenance.

29. Fluid Therapy ( CONTINUES ) 3. Follow up studies: –Electrolytes abnormalities Hypo, hypernatremia / dehydration Hypokalemia –May need to increase KCL concentration in IV solution –DO NOT HOLD KCL IN IV SOLUTION WAITING FOR URINE OUTPUT, AS LONG AS THE SERUN K AND BUN AND CREATININE ARE NORMAL IN INITIAL LYTES. Hyperglycemia: –Check > F/U FS and UA till normalize –D/C glucose from IV if necessary –ABB (Acid – Base – Balance) Check and follow up metabolic acidoses than can be a sign of fatigue to be use as indication for respiratory support (intubation).

30. Indication for intubation (Impending / Respiratory Failure) 1.Altered Sensorium /coma 2.Fatigue Inhability to speak Diaphoresis in the recumbent position Lactic acidosis 3.Silent chest despite respiratory effort 4.Refractory hypoxemia (PaO2 < 60 mmHg /O2 Sat < 90 % on Max O2) 5.Increasing PCO2 (50 mmHg and rising > 5 mmHg/hr) 6.Acute Barotrauma /Tension Pneumothorax (Pneumomediastinum in a patient in no distress is not an indication for intubation ) 7.Respiratory or cardiac arrest

31. Intubation Process 1.Call anesthesia (Emergency Beeper in the board) if PICU attending not in house. 2.Calculate / Order / Prepare Sedation Medication RSI INTUBATION MEDICATIONS  Penthobarbital OR  Midazolan and Ketamine  Lidocaine  Vecuronium 3.Call Respiratory therapy (Emergency Beeper in the board 4.Order initial Mechanical Ventilator setting according to guidelines after discussion with PICU attending

32. Principles of Mechanical Ventilation in patients with Status Asthmaticus. There is and increase resistence and decrease compliance therefore be aware of checking PIP if you are ventilating with volume control (SIMV or CMV) –High risk for barotrauma If patient is started on Volume control and the reached PIP is > 30, consider changing to Pressure control Because the high resistance and decrease compliance, the time Constance is increase (need more time to fill up the alveoli) therefore need to use lower rates to decrease airtraping/AutoPEEP and barotrauma.

33. Principles of Mechanical Ventilation in patients with Status Asthmaticus. (CONTINUE) REMEMBER THE VENTILADOR WILL NOT RESOLVE THE IMFLAMATORY PROCESS NOR THE BRONCHOSPASM; ON THE CONTRARY IT MAY MAKE IT WORSE. BE READY TO DEAL WITH CIRCULATORY COMPROMISE IMMEDIATELY AFTER INTUBATION. THIS SHOULD BE TREATED WITH FLUIDS. NEED GENTLE VENTILATORY SUPPORT WAITING FOR THE MEDICATIONS (Steroids and bronchodilators) TO WORK The main goals of respiratory support are: Ensure oxygenation Decrease work load of a fatigue patient, reverse lactic acidosis. Prevent cardio-respiratory arrest Avoid barotrauma using “permisive hypercarbia”. DO NOT AIM TO NORMALIZE ABG

34. Intubation Process (Continue) 5. Connect and read ETCO2 and O2 Sats. 6. Order Chest x Rays. DO NOT FORGET TO REMOVE CHEST C-R LEADS BEFORE X RAYS TAKEN. 7. DO ABG and correlate ETCO2 with PaCO2

35. TREATMENTS DURING MECHANICAL VENTILATION 1.Bronchodilators: a.Continue frequent albuterol and atrovent given by MDI alternated every 30 > 60 minutes. 4 puffs for younger child 6 puffs for older child > 5 yo b.Continue Or start terbutaline drip (as per protocol) 2.Continue IV steroids. 3.Sedation: Deep sedation, avoid paralysing agent after the initial use for intubation and stabilization. a)Ketamine drip is the drug of choice plus midazonal PRN or drip.