We encourage you to share these guidelines with others and we welcome their use as a reference. Please cite each document (part 1 and part 2) in the guideline in keeping with the citation on the table of contents of each of the two documents. If referencing the full guideline, please cite as:# Initial Management of Pediatric Asthma
In Emergent/Urgent Care Settings

# Purpose
This document outlines recommendations for the initial management of pediatric patients presenting to emergent/urgent care settings across British Columbia (BC) with acute asthma exacerbations. This guideline provides recommended actions based on the use of the Pediatric Respiratory Assessment Measure (PRAM) 1,2 .

# Background
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 . The Translating Emergency Knowledge for Kids (TREKK) Bottom Line Recommendations: Asthma (2017) were used as the foundation for building this guideline 3 .

# 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.
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.  

# Equipment

# Treatment
Initiate treatment based on severity as determined by PRAM score (mild and moderate pathways may be nurse initiated in known asthmatics only as specifically outlined in the BCCNP limits and conditions) 4 .
- Communicate findings to MRP for treatment orders and ongoing care direction.  Older children may present with a lower PRAM score despite having a low FEV1 (Forced expiratory volume measured during the first second of the forced breath) 5 . Consider supplementing the PRAM score with objective markers of airway obstruction such as peak-flow or spirometry. Particularly in patients with a history of severe exacerbations.
*It is important to note that a substantial proportion of patients are not able to perform spirometry during exacerbations and spirometry is not available at all sites 1 .

# Key Points for MILD Category 1
- It is recommended that salbutamol be delivered with metered dose inhalers (MDIs) and spacers rather than nebulization.  For children experiencing MILD respiratory distress, there is no clear evidence supporting the administration of oral corticosteroids.

# Key Points for MODERATE Category 1
- It is recommended that salbutamol be delivered with metered dose inhalers (MDIs) and spacers rather than nebulization.  Administration of oral corticosteroids just before or immediately after initiating bronchodilator therapy substantially decreases respiratory distress within 2-6 hours of treatment and substantially decreases hospitalization rates.  Oral dexamethasone or prednisone/prednisolone are likely to be comparably effective.
Some studies have reported substantially lower rates of vomiting with dexamethasone.  The intravenous form of dexamethasone may be given orally in order to minimize the volume of steroid needed to be taken by pediatric patients.  Multiple doses of ipratropium (two to three) added to salbutamol aerosols and oral corticosteroids in the first 60 minutes of treatment yield greater improvement and lower hospital rates.  There is no role for ipratropium in ongoing asthma management after the initial 2-3 doses.

# Child Health BC Provincial Asthma Guideline
Initial Management of Pediatric Asthma In Emergent/Urgent Care Settings

# Key Points for SEVERE Category 1
- Patients with severe respiratory distress improve more rapidly when bronchodilators are delivered continuously via aerosol over 60 to 180 minutes as compared to intermittently.  Although delivery via MDI/spacers is more efficient than nebulization, it is much more convenient to deliver aerosols continuously via nebulization than via MDI/spacers.  Large volume nebulizers allow administration of bronchodilators continuously over 60 minutes or more, and should be used in preference to standard-sized nebulizers.  Children with severe respiratory distress who do not respond to repeated or continuous bronchodilators and oral corticosteroids have been shown to have greater subsequent improvement if treated with intravenous magnesium sulfate (in addition to repeated or continuous bronchodilator therapy).

# Discharge

# Patient and Caregiver Teaching
Consider using a Patient Education Checklist to guide discharge teaching.
- Patient Education Checklist (Appendix B)

# Key Points
Ensure patients and their caregivers understand:  How to take their medication properly (have patient demonstrate this, not just describe it). Are Prescriptions up to date? Are they using an appropriately sized spacer?  The difference between a reliever and controller medication.  How to use their written action plan (including when to seek help).  How to monitor for symptom control.  What triggers their asthma and how to avoid their triggers (if possible).

# Action Plans
Asthma fillable action plans for ages 1-5 and 6-18 are available and can be filled out and provided to families on discharge 6 .  See www.bcguidelines.ca for more information, including the full guideline "Asthma in Children -Diagnosis and Management (2015), translated action plans (available in Chinese and Punjabi), and fillable PDF versions of the action plans with drop-down medication menus.

# Medications 6
- It is recommended that metered dose inhaler (MDI) always be used with a spacer device in children and are as effective as nebulizers. Spacers increase the amount of medication delivered to the lungs and decrease side effects from medication.  In selecting a medication delivery device it is important to ensure that the patient can demonstrate how to use it properly.  Controller medication does not need to be increased with an acute loss of asthma control in children.

# Child Health BC Provincial Asthma Guideline
Initial Management of Pediatric Asthma In Emergent/Urgent Care Settings
Inhaled Corticosteroids (ICS) 6  There is insufficient evidence to recommend one ICS molecule over another with respect to efficacy or safety.  Children who present with moderate to severe exacerbation should be started on a moderate dose of ICS.  Consider starting a trial of ICS in children who present with a mild exacerbation if they have had recurrent exacerbations.

# Follow Up
- All children presenting to the ED with an acute asthma exacerbation should be followed up by their community physician/health care provider within two weeks to ensure resolution of their exacerbation and discuss how to prevent future exacerbations.  For patients with good inhaler technique and adherence to daily controller medication, their baseline therapy should be escalated given the high risk of exacerbation in the year following an Emergency Room visit. Please refer to the CHBC/GPAC Guidelines for further details on the management of chronic asthma:  

# Documentation
Document the full assessment, medications given, steps taken to escalate care (if applicable), patient and family teaching and discharge instructions in the patient's chart as per your agency's documentation guidelines.

# Definitions
Asthma: Is a chronic inflammatory disease of the airways that is characterized by bronchial hyper reactivity and variable airway obstruction which results in recurrent episodes of wheezing, breathlessness, chest tightness and/or coughing that can vary over time and in intensity.

# College of Registered Nurses of British Columbia (BCCNP):
Under provincial legislation (Health Professions Act), it is the duty of BCCNP to protect the public through regulation of registered nurses, nurse practitioners, and licensed graduate nurses.
Pediatric Respiratory Assessment Measure (PRAM): Is a 12 point clinical scoring rubric that captures a patient's asthma severity using a combination of scalene muscle contraction, suprasternal retractions, wheezing, and air entry and oxygen saturation.

# Child Health BC Provincial Asthma Guideline