Transcript Document

Inpatient Asthma
Sangeeta Schroeder, MD
Resident Noon Conference
Epidemiology
• According to the American Lung
Association (2006)
– Just about 7 million children have diagnosed
asthma
– 3rd leading cause of childhood hospitalization
– One of the most common causes of missed
school days (about 13 million missed
days/year)
Clinical Features
• Shortness of breath
• Wheezing
• Symptomatic with viral infections, allergens
or exercise
• Colds that last >10 days
• Frequent night-time coughing
Physiologic Features
Common Triggers
• Allergens
– Dust, mold, pollen, cats, dogs, etc
• Non-Allergens
–
–
–
–
–
Cigarette smoke/Smoke
Infections
Exercise
Temp Change
Stress
Initial Assessment
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•
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Respiratory Rate
Pulse Ox
Retractions
Dyspnea
Auscultation
LPCH Asthma Scoring Tool: Add Total Points
to Give Pediatric Asthma Score (PAS)
0 point
1 point
2 points
3 points
Respiratory rate
(breaths/min)
COUNT RESPIRATORY RATE FOR ONE FULL MINUTE
2-3 yr
18-26
27- 34
35-39
> 40
4-5 yr
16-24
25- 30
31-35
> 36
6-12 yr
14-20
21- 26
27-30
> 31
> 12 yr
12-18
19- 23
24-27
> 28
Pulse Ox
>95% on RA
90-94% on RA
87-89% on RA
<86% on RA
Retractions
None
Subcostal or
intercostal
2 of the following:
subcostal,
intercostal,
substernal, OR
nasal flaring
(infants)
3 of the following:
subcostal,
intercostal,
substernal,
suprasternal,
supraclavicular
OR nasal flaring
or head bobbing
(infants)
Dyspnea
2-4 years
Normal feeding,
vocalizations, and
play
1 of the following:
decreased
appetite,
increased
coughing after
play, hyperactivity
2 of the following:
decreased
appetite,
increased
coughing after
play, hyperactivity
Stops eating or
drinking, stops
playing, OR
drowsy or
confused and/or
grunting
Dyspena
> 5 years
Counts to > 10 in
one breath OR
speaks in
complete
sentences
Counts to 7-9 one
breath OR speaks
in short sentences
Counts to 4-6 in
one breath OR
speaks in partial
sentences
Counts to < 3 in
one breath OR
speaks in single
words OR Grunts.
Auscultation
(as it relates to
wheezing)
Normal breathing;
no wheezing
present
End-expiratory
wheeze only
Expiratory wheeze
only (greater than
end-expiratory
wheeze)
Inspiratory and
expiratory wheeze
OR diminished
breath sounds
Respiratory Rate
0 point
1 point
2 points
3 points
Respiratory COUNT RESPIRATORY RATE FOR ONE
FULL MINUTE
rate
(breaths/
min)
2-3 yr
18-26
27- 34
35-39
> 40
4-5 yr
16-24
25- 30
31-35
> 36
6-12 yr
14-20
21- 26
27-30
> 31
> 12 yr
12-18
19- 23
24-27
> 28
Pulse Ox
0 point
Pulse Ox >95% on
RA
1 point
2 points
3 points
90-94%
on RA
87-89%
on RA
<86% on
RA
Retractions
0 point
1 point
2 points
3 points
None
3 of the following:
Subcostal 2 of the
following:
or
subcostal,
Intercostal subcostal,
intercostal,
intercostal,
substernal,
substernal,
suprasternal,
OR nasal
supraclavicular,
flaring
nasal flaring or
(infants)
head bobbing
(infants)
Dyspnea 2-4 year olds
0 point
1 point
2 points
3 points
Normal
feeding,
vocalizations,
and play
1 of the
following:
decreased
appetite,
increased
coughing
after play,
hypoactivity
2 of the
following:
decreased
appetite,
increased
coughing
after play,
hypoactivity
Stops eating
or drinking,
stops playing,
OR drowsy or
confused
and/or
grunting
Dyspnea > 5 year olds
0 point
1 point
2 points
3 points
Counts to >
10 in one
breath OR
speaks in
complete
sentences
Counts to 7-9 Counts to 4-6 Counts to < 3
one breath
in one
in one
OR speaks
breath OR
breath OR
in short
speaks in
speaks in
sentences
partial
single
sentences
words OR
Grunts.
Auscultation
0 point
1 point
2 points
3 points
Normal
breathing;
no
wheezing
present
Endexpiratory
wheeze
only
Expiratory
wheeze
only
(greater
than endexpiratory
wheeze)
Inspiratory
and
expiratory
wheeze OR
diminished
breath
sounds
Pediatric Asthma Score
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Add the Score for the 5 categories together
Mild: PAS < 6
Mild to Moderate: PAS of 7 or 8
Moderate to Severe: PAS of 9 or 10
Severe: PAS > 11
Initial Management
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Oxygen
Albuterol
Atrovent
Systemic Steriods
Magnesium Sulfate?
Initial Management
• Oxygen
Initial Management - Albuterol
Initial Assessment – Phase 1
Action
Weight <20kg and PAS <6
MDI 4 puffs Q20 min x3 OR
Alb neb 7.5mg/hr x1 hr
If wt >20kg and PAS <8
PAS 7-8, regardless of weight
MDI 6 puffs Q20 min X3 OR
Alb neb 10mg/hr x1 hr
PAS 9-10, regardless of weight
MDI 8 puffs Q20 min X 3 OR
Alb neb 15mg/hr x 1 hr
PAS >11/Intensification, regardless of
weight
MDI 10 puffs Q20 min x3 OR
Alb neb 20mg/hr x 1 hr
If PAS persistently >11, Consider
Magnesium at 50mg/kg and
NOTIFY ICU
Initial Management - Albuterol
• Assessment Q Hour
• A. If PAS has not improved by >2, or if it is not
<6, REPEAT phase 1 according to current PAS
score
• B. If PAS has improved by >2,OR PAS <6,
ADVANCE to Phase II
• C. If PAS has worsened by >2, OR PAS >11,
INTENSIFY
Initial Management
• Atrovent
– Found to decrease rate of admissions
– Only if given at least 2 doses
– Should be part of phase 1 treatment
Initial Management
• Systemic Steroids
– Decadron
• Can give in office/ER for mild asthma
• 0.6mg/kg x1 dose IM/IV/PO
– Prednisolone
• 1mg/kg/dose BID
• NEW GUIDELINES: MAX 60MG/DAY!!!!
– Solumedrol
• Use only if worried about respiratory
distress/aspiration
Initial Management
• Magnesium Sulfate
– 25-75 mg/kg/dose
– Usually give 50mg/kg/dose
– Give over 10-20 minutes!
When to Admit?
• Oxygen requirement
• After Phase 1 with Atrovent
– Child is still in resp distress
– Needs repeat albuterol dose within 4 hours
• Poor PO intake
• Poor Follow-up
Continued Management
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Albuterol
Systemic Steriods
Inhaled Corticosteroids
Asthma Education
Albuterol
• Repeat Phase 1 if child just got admitted
• Exception:
– If PAS is 1 or 2 on admit, start at Phase 2
Albuterol
Initial Assess. – Phase 2
Actions: Min of 4 hrs
Assessment Q 2 Hours
Weight <20kg and PAS <6 MDI 4 puffs Q 2 hrs x2
If wt >20kg and PAS <8
PAS 7-8, regardless of wt
PAS 9-10, regardless of
weight
PAS >11/Intensification,
regardless of weight
A. If PAS has not
improved by >2, or if it
is not <6, REPEAT
MDI 6 puffs Q 2 hrs x2
phase 2 according to
current PAS
B. If PAS has improved
MDI 8 puffs Q 2 hrs X1
by >2, OR PAS <6,
ADVANCE to Ph 3
Once PAS <8, CONTINUE
C. If PAS has worsened
in Phase 2 for a min of
by >2 or PAS >11,
4 hours per PAS
INTENSIFY
RETURN TO PHASE 1 INTENSIFICATION
If PAS persistently >11, CONSIDER Magnesium at
50mg/kg and NOTIFY ICU
Albuterol Continued
Initial Assess. – Phase 3 Actions: Min of 6 hrs
Assessment Q 3 Hours
Weight <20kg and PAS <6 MDI 4 puffs Q 3 hrs x2
PAS 9-10, regardless of
weight
A. If PAS has not improved
by >2, or if it is not <6,
REPEAT phase 3
according to current PAS
MDI 6 puffs Q 3 hrs x2
B. If PAS has improved by
>2, OR PAS <6,
ADVANCE to phase 4
C. If PAS has worsened by
>2 or PAS >11,
MDI 8 puffs Q 2 hrs and
INTENSIFY
return to Phase 2
PAS >11/Intensification,
regardless of weight
RETURN TO PHASE 1 --INTENSIFICATION
If wt >20kg and PAS <8
PAS 7-8, regardless of wt
Albuterol Continued
Initial Assess – Phase 4 Actions: Min of 4 hrs
Assessment Q 4 Hours
PAS <6, regardless of wt
MDI 4 puffs Q 4 hrs x1
PAS 7-8, regardless of
weight
MDI 6 puffs Q 4 hrs x 1
A. If PAS has not imp. by
>2, or if it is not <6,
REPEAT according to
current PAS score
Once PAS <6, CONTINUE
in Phase 4 with 4 puffs
Q 4 hrs x1 min
B. If PAS is <6, patient
is ready for
discharge.
PAS 9-10, regardless of
weight
MDI 8 puffs Q 2 hrs and
return to Phase 2
C. If PAS has worsened
by >2 or PAS >11,
INTENSIFY
PAS >11/Intensification,
regardless of weight
RETURN TO PHASE 1
INTENSIFICATION
---
Systemic Steroids
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Continue for 3-10 days
Mild (no admission): 3 days
Most Admissions: 5 days
If still in hospital on day 4 or 5: 10 days
If use 60mg/day as MAX, no need to taper
Atrovent
• Has not been shown to decrease morbidity
of admission
• Has not been shown to decrease likelihood
of PICU transfer
• Has not been shown to decrease LOS
• NOT USED ON THE FLOOR
Inhaled Corticosteroids
• Start inpatient for education
• Flovent/QVAR
– MDI’s
• Pulmicort
– Neb
– Ensure child uses with mask that does not have
holes on top
– Risk of Corneal Ulceration
Asthma Education
• Review differences btwn preventive and
relief meds
• Demonstrate and teach proper MDI with
Spacer/mask use
• Educate on asthma signs and symptoms
• Review Home Management Plan of Care
MDI Education
Spacers
• All patients with
asthma
• Holds the “puff” in the
chamber
Spacer Use
• Insert the MDI into the
back end of the spacer
• SHAKE BEFORE
EACH USE
• Use a spacer with mask
in a young child
Spacer Use
• FIRST: Exhale
• SECOND: Create a
seal with your mouth
and the mouthpiece
• THIRD: Inhale slowly
as you push the inhaler
and hold breath for 10
seconds
• FOURTH: Breathe out
slowly
Spacer Use - Child
• FIRST: Exhale
• SECOND: Create a seal with your mouth
and the mouthpiece
• THIRD: Push the inhaler and keep the seal
with the mouthpiece for 8-10 breaths
• FOURTH: Breathe out slowly
Spacer Use – Infant/Toddler
• FIRST: Use a spacer
with mask
• SECOND: Create a
seal with the infant’s
mouth and the mask
• THIRD: Push the
inhaler and keep the
seal with the mask for
8-10 breaths
MDI/Spacer Use
• Make sure to repeat all the steps for each
puff: Including shaking the inhaler!!!
Discharge Guidelines
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Albuterol
System Steriods
ICS
F/U Appointment
Subspecialty Follow-up?
Discharge Guidelines
• Albuterol
– 4-6 puffs 4 times a day for 1 week
– Then per HMPC
• Systemic Steroids
– 3-10 day course at 60 mg/day max
– No need to taper the dose
• ICS
– Everyday for at least 1 year
Discharge Management
• Follow-up Appointment
– 1-2 days after hospital discharge
• Subspecialty Follow-up?
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Max doses of ICS
More than 1 controller
Strong Allergic Component
PCP is not comfortable with asthma
Parents are not comfortable with PCP
Home Management Plan of Care
• AKA: Asthma Action Plan
– New 4 tier system
– Emphasizes home asthma care
– Gives consent to school/daycare to administer
albuterol
HMPC
• Joint Commission Requirement
• All fields need to be filled out
– Triggers/avoidance
– All 4 tiers
– Follow-up Appointment
• Date/Time and PMD OR
• Time frame, PMD Name and Phone Number
– Parent’s Signature
– Discharging Attending Signature
HMPC
• Joint Commission Rates
– Quarter 2 of 2009: 64% Compliance
– 6/25 patients did not have an action plan in the
chart
• REMEMBER TO KEEP THE SIGNED COPY IN
THE CHART!!!
– 3/25 patients had incomplete fields