Asthma Inpatient Management

Aka: Asthma Inpatient Management

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II. Evaluation: Vital Sign Monitoring

  1. Vital Signs: Temp, Pulse, Blood Pressure, Respirations
    1. Start with every 4 hours for 12 hours
    2. Space to every 6 hours
  2. Peak Expiratory Flow (PEFR)
    1. Hourly Nebs: hourly Peak Flow
    2. Regular Nebs: Bid Peak Flow pre and post Nebulizer
    3. PEFR accurate age >7 years (may be helpful age > 5)
  3. Oxygen Saturation Monitor
    1. Oxygen to keep Oxygen Saturation adequate
      1. Adults: >90%
      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
  4. 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

III. Management: Medications

  1. See Albuterol Nebulizer dose
  2. 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

IV. Evaluation: Monitoring

  1. 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
  2. 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
  3. Chest XRay Indications
    1. First episode Wheezing
    2. Marked Breath Sound asymmetry
    3. History or exam suggestive of Pneumonia

V. Evaluation: Signs of Improvement

  1. Minimal or no Wheezing
  2. Less than 2 night awakenings for Mild Asthma symptoms
  3. Good activity tolerance
  4. Pulmonary Function Test criteria
    1. PEFR or FEV1 >= 70% of baseline
  5. Adequate Oxygen Saturation off Supplemental Oxygen

VI. Management: More Intensive Treatment Options

  1. Intensive Care unit for no improvement in 6-12 hours
  2. See Status Asthmaticus

VII. Management: Preparation for Discharge

  1. Asthma-Related Death Risk Factors
  2. Inhaled Beta Agonist no more then q4 hours
  3. Parenteral steroids switched to Oral Corticosteroids
  4. Adequate Oxygen Saturation on room air
  5. Asthma Education: Medication use
    1. Inhaled Corticosteroid by bedside
    2. Respiratory Therapy or nurse to instruct use bid
    3. Peak Flow measurement at home
  6. Follow-up in clinic in 7-10 days

VIII. References

  1. (1997) Management of Asthma, NIH 97-4053
  2. (1995) Global Strategy for Asthma, NIH 95-3659
  3. Pollart (2011) Am Fam Physician 84(1): 40-7 [PubMed]

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