# Initial Management of Pediatric Asthma
In Emergent/Urgent Care Settings
This document outlines the methodology used to develop recommendations to support early identification and initial management of children and youth with asthma who present to emergent/urgent care settings across British Columbia. This provincial work was led by Child Heath BC (CHBC) in partnership with clinical and content experts, representing rural and urban centers within the various provincial health authorities. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument provided the methodological strategy for the development of this guideline. The following document reviews each component of the AGREE II instrument 23 . The resulting work consists of a package of clinical support documents and educational tools that used together assist the emergency clinician to screen, rapidly assess and begin implementation of interventions in the emergent/urgent care setting. They are not intended for inpatient use.
The provincial resource package includes: 
Guideline

# Background Pediatric Asthma
Pediatric asthma has been identified as a significant health issue in British Columbia (BC). It is the most common chronic disease impacting children and is a leading cause of missed school days and hospital visits 12 . As there is no known cure for asthma; efforts are focused on the delivery of timely and appropriate management strategies to minimize the individual and community level impacts. Children and families can be supported to control their asthma and improve their overall quality of life 13 .
Asthma is a chronic health condition characterized by inflammation of the airway walls and narrowing of the air passages leading to the lungs 13 . Symptoms can be episodic or persistent and present in a variety of ways that include: chest tightness, coughing, wheezing and shortness of breath. These symptoms and episodes of severe shortness of breath can be triggered by exposures such as allergens, environmental irritants, viral infections, exercise and strong emotions 8,12,14 . Poor asthma control can negatively impact a child's overall quality of life, impacting their ability to participate in sports, school and other recreational activities 14 .

# Asthma Diagnosis and Management
The majority of children with asthma present with symptom onset in their preschool years. Preschool aged children have the highest rates of emergency department visits and hospitalizations for asthma symptoms when compared to other age groups. There continues to be uncertainty regarding the diagnosis of asthma in this young age group. This uncertainty can result in delayed treatment and contribute to morbidity in both the short and long term; highlighting the need for early diagnosis and treatment 8 .  8,14 . Management strategies include medications, education and environmental controls 15 . "Asthma education is an essential component of asthma management for all patients. Guided self-management, combining asthma education, regular medical review, self-assessment and a written action plan have been shown to reduce hospitalizations, emergency visits, urgent physician visits, missed days at work or school, days of restricted activity, and improved pulmonary function in children" (Canadian Thoracic Society Asthma Committee, 2010, p.18).
Evidence-based management of pediatric patients experiencing acute asthma symptoms includes repeated doses of Salbutamol and Ipratropium, along with oral corticosteroids within the first sixty minutes of care 3 . Lower rates of hospitalization and the improved use of evidence-based medications are associated with the use of a validated and standardized clinical score. The PRAM is a validated scoring tool used to classify the severity of a pediatric patient's respiratory distress and subsequent response to treatment 1, 2, 3 .

# Scope and Purpose
Child Health BC Provincial Asthma Guideline: Initial Management of Pediatric Asthma in Emergent/Urgent Care Settings

# Scope
This guideline is for use with Children ages 1 year of age to 17 years of age less 1 day- presenting with wheezing, or respiratory distress, AND  Diagnosed to have asthma, or  Treated 2 times prior with a bronchodilator for wheezing *While children less than 1 year of age with their first known episode of wheeze should not be routinely treated as a part of the PRAM pathway, treating physicians may choose to include these children on a case by case basis following their assessment.

# Target User of this Guideline
PRAM scoring is performed in the Emergency Department or Urgent Care Centre by members of the health care team including: Physicians, Nurse Practitioners, Registered Nurses and Respiratory Therapists.

# Purpose
This provincial guideline and related tools outline the recommendations for the initial management of pediatric patients presenting to emergent/urgent care settings across British Columbia (BC) with acute asthma exacerbations. The guideline provides recommended actions based on the use of the Pediatric Respiratory Assessment Measure (PRAM) 1,2 .
The Translating Emergency Knowledge for Kids (TREKK) Bottom Line Recommendations: Asthma (2017) were used as the foundation for building this guideline 3 . 

# Methodology
The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument provided the methodological strategy for the development of this guideline 23 .

# Literature Search Strategy
The provincial working group was aware that TREKK had completed a comprehensive literature review and had developed updated Bottom Line Recommendations for Asthma (2017). The TREKK review included:
- 4 systematic reviews - 2 meta-analysis - 3 key studies - Review of existing guidelines
The TREKK Bottom Line Recommendations were reviewed by the working group and it was determined that these recommendations would be used as the basis for the provincial guideline and care algorithm. As a part of this determination the provincial working group reviewed original papers that were included in the systematic review and other literature as relevant. An additional scoping review was completed to gather and review existing guidelines and explore specific components within the guideline. Specifically additional information was sought to inform medication dosing and teaching recommendations.

# Methods for Formulating Recommendations
Based on the information listed above, pediatric recommendations were accepted by the provincial working group. Recommendations requiring provincial adaptation (e.g. medication calculations for pharmacy) were adapted by seeking advice and consensus from clinical experts across the Health Authorities. A series of provincial meetings were held to review the guideline (Part B) and care algorithm, line by line and seek consensus. Draft documents were distributed to the working group members following each set of revisions and feedback was reviewed at the next meeting. Once a final draft was agreed upon the provincial working group members and the CHBC Regional Coordinators were asked to circulate for wider feedback within the Provincial Health Authorities. Feedback was collected and final revisions were circulated to the group for consensus. Acceptance of the guideline was sought from the CHBC steering committee and the Provincial Emergency Services Advisory Council.

# Procedure for Updating the Guideline
This guideline will be reviewed every three years (or earlier if new evidence is published) by a multidisciplinary provincial advisory group consisting of clinical experts in emergency and respiratory care. This guideline will be reviewed again in 2021. 

# Summary of Recommendations with Levels of Evidence
The following section will outline the key recommendations and assign a level of evidence based on the 

# Appendix A: Methods

# Appendix A: Acknowledgments
This group would like to acknowledge the many health care professionals who contributed to the development of this guideline by sharing their expert opinion and by acting as reviewers. In addition to the working group members, Connie Yang, MD, FRCP(C), MSc (Clinical Assistant Professor, Division of Respiratory Medicine British Columbia Children's Hospital) and Simi Khangura MD, FRCPC (Clinical Associate Professor Division of Emergency Medicine, Department of Pediatrics, UBC, BC's Children's Hospital) provided significant input into the development of the guideline and accompanying algorithm. Appendix C: Editorial Independence

# Working Group Members
BC

# Appendix C: Editorial Independence
There are no conflicts of interest to report.

# i. Disclaimer
Child Health BC develops evidence-based clinical support documents that include recommendations for the care of children and youth across British Columbia. These documents are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. These documents are for guidance only and not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of a clinical problem. Healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Neither Provincial Health Services Authority nor Child Health BC assume any responsibility or liability from reliance on or use of the documents.