TEXAS CHILDREN'S HOSPITAL DATE 7/2008 EVIDENCE-BASED CLINICAL OUTCOMES DECISION SUPPORT ASTHMA/RECURRENT WHEEZING MANAGEMENT CLINICAL GUIDELINE Guideline Eligibility Criteria: Patients ≥ 1 year with a diagnosis of asthma/recurrent wheezing in whom foreign body or vocal cord dysfunction have been ruled out. Guideline Exclusion Criteria: Bronchiolitis, cystic fibrosis, bronchopulmonary dysplasia, bacterial pneumonia, neurological disorders, immuno-deficiency diseases, trach patients, and cardiac patients (unless ordered). (1-3)

Definition: Asthma is the most common chronic disorder in childhood (10-12%). It is an inflammatory disorder of the airways in which cells and cellular elements play a role. In susceptible individuals, inflammation causes recurrent episodes of coughing (particularly at night or early morning), wheezing, breathlessness, and chest tightness. Asthma breathing problems or exacerbations are “episodic”, however, the underlying inflammation is continuous. Environmental factors play a critical role in asthma recognition and management. Asthma exacerbations are associated with widespread but variable airflow obstruction and are often reversible with or without treatment. (1, 3-5)

Pathophysiology: Asthma is a complex, interactive process that depends on the interaction of:  Bronchoconstriction  Airway hyper responsiveness  Airway edema (1, 9-12)

Asthma Predictors:  Family history of asthma, eczema, and/or smoking  Patient history of allergic rhinitis, sinusitis, nasal polyps, eczema, or BPD  Recurrent cough, bronchitis, and bronchiolitis (1-5)

Diagnosis: The initial diagnosis of asthma in children is often difficult and requires that other diagnoses be excluded. An in depth clinical history combined with a thorough physical examination are necessary to make this determination. (1, 3-5)

History: Assessment of  Cough, wheeze, shortness of breath, and/or chest tightening that occurs in an “episodic” fashion. These symptoms may occur or worsen with: - Exercise - Changes in the weather - Night hours - Viral infection(s) - Inhalant trigger exposure (smoke, fur, dust mites, mold, pollen, etc.) - Irritant trigger exposure (airborne chemicals (aerosols), smoke, etc.) - Strong emotional expressions (laughing, crying) - Menstrual cycles Tests to exclude other diagnoses when H&P is equivocal:  Chest x-ray  Bronchoprovocation test  Allergen testing (eosinophilia, total IgE, rarely aspergillosis)

(1, 3-5)

Physical Examination: Assess for  Severity of respiratory symptoms using the Clinical Respiratory Score (CRS, p.2)  Rhinitis, increased nasal secretions, mucosal swelling, or nasal polyps  Airflow obstruction or airway hyper responsiveness are present and are at least partially reversible e.g. spirometry shows  Forced Expiratory Volume in 1 second of  12% from baseline or  10% of predicted after the patient inhales a short-acting bronchodilator. Note: Office based physicians who manage asthma patients should have access to spirometry that meets (1,6) ATS standard (1,6)

Diagnostic Tools to Assess Severity (Tables 1 & 3) 1. Spirometry - FEV1 in children ≥ 5 years Airway hyper responsiveness test using Methacholine

Patients at risk of asthma-related death should be advised to seek medical care early during an exacerbation (Table 3, p 4). Factors that place patients at risk for asthma-related (1, 4) death include:  Co-morbid conditions such as heart or lung disease  Previous severe exacerbation (e.g. intubation or ICU admission)  ≥ 2 hospitalizations or > 3 EC visits in the past year  Use of > 1 canister of Short Acting Beta Agonist (SABA) per month  Difficulty perceiving airway obstruction or the severity of worsening asthma (parent &/or child)  Low socioeconomic status or inner-city residence  Illicit drug use  Major psychosocial problems or psychiatric disease Life-threatening asthma is a constellation of symptoms that can occur in any patient with asthma and includes:  Marked chest tightness  Wheezing, severe shortness of breath  Retractions  Cyanosis  Inability to speak or speak in sentences due to dyspnea  Hunched posture  Altered mental status (agitation, anxiety, lethargy) (1, 7-8)

Co-morbid Conditions: Gastroesophogeal reflux disease (GERD), obstructive sleep apnea (OSA), obesity, rhinitis, and sinusitis Goals of Therapy: To reduce the frequency and severity of asthma exacerbations and reduce long term sequelae by maintaining asthma control with the least amount of therapeutic interventions/medications possible. Intensive education and monitoring are required in caring for all (1, 15-17) children with asthma.

1

Clinical Respiratory Score (CRS) Assess Score 0 Score 1 Respiratory Rate

Auscultation

Use of Accessory Muscles

< 2 mos < 50 2-12 mos < 40 1-5 yrs < 30 > 5 yrs < 20 Good air movement, scattered expiratory wheezing, loose rales/crackles.

< 2 mos 50-60 2-12 mos 40-50 > 1- 5 yrs 30-40 > 5 yrs 20-30 Depressed air movement, inspiratory and expiratory wheezes or rales/crackles.

Mild to no use of accessory muscles. Mild to no retractions, nasal flaring on inspiration.

Moderate intercostal retractions, mild to moderate use of accessory muscles, nasal flaring. Irritable, agitated, restless. 90-95% Pale to normal

Mental Status

Normal to mildly irritable

Room Air Sp02 Color

> 95% Normal

Score 2 < 2 mos > 60 2-12 mos > 50 > 1-5 yrs > 40 > 5 yrs > 30 Diminished or absent breath sounds, severe wheezing, or rales/crackles, or marked prolonged expiration. Severe intercostal and substernal retractions, nasal flaring.

Lethargic

< 90% Cyanotic, dusky

(Add score from all rows to calculate total CRS score)

Exacerbation Management (see Respiratory Assessment and Management Protocol (RAMP, p 6): In-Home and/or Office 1. Assess severity to initiate therapy (1st time episode (CRS Score above & Table 1, p 3) 2. Classify severity of exacerbations (Table 3, p 4) 3. Identify triggers and manage control measures 4. Initiate use of inhaled short acting beta agonist (SABA) 5. Begin oral systemic corticosteroid 6. Offer supplemental oxygen if necessary and available 7. Identify and manage aggravating co-morbid conditions 8. Provide ongoing education (Table 4, p 4) 9. Consider EC admission if symptoms persist, are of sufficient severity, or patient has risk factors for asthma related death (see sections below) Emergency Center 1. Follow above steps, and if severity warrants 2. Place on continuous SABA 3. Double up dose of inhaled corticosteroids 4. Initiate ipratropium bromide 5. Change systemic corticosteroids to IV 6. If condition unchanged or worsening consider initiation of adjunctive therapies including: IV magnesium sulfate (evidence supports), IV terbutaline (evidence inconclusive), heliox (evidence inconclusive), and non-invasive positive pressure ventilation (NPPV evidence inconclusive). If symptoms do not improve consider PICU admission 7. If symptoms are unchanged or improving slightly but continued close monitoring is still required consider inpatient admission 8. If symptoms have improved or ceased initiate ASTHMA ACTION PLAN and discharge home to f/u with PCP.

PICU 1. Continue above and consider adjunctive therapies yet to be initiated (see RAMP p 6) 2. Consider intubation for mechanical ventilation Inpatient Care 1. Continue therapies initiated and wean as appropriate according to RAMP (p 6) 2. Evaluate patient/caregiver knowledge and skills and provide re-enforcement or required education (Table 4, p 4) 3. Initiate Asthma Action Plan to prevent chronic and disabling symptoms Office Follow-up and Long-term Management 1. Assess control (frequency of SABA use for symptom management and PEF) to monitor and adjust therapy (Table 2, p 3) Note: Spirometry can demonstrate obstruction and assess reversibility in patients ≥ 5 years 2. Consider daily peak-flow monitoring in patients with moderate or severe persistent asthma; a history of severe exacerbations; or who are unable to perceive airway obstruction or worsening asthma. 3. Classify severity of exacerbations (Table 3, p 4) 4. Initiate Asthma Action Plan (see p 7 & 8) Pharmacotherapies that should be included are: Long Term Control Medications:  Inhaled corticosteroids (ICS)  Long acting ß agonists for mod persistent asthma (LABA)  Leukotriene receptor agonists  Anti-immunoglobulin E for severe persistent allergic asthma in children ≥ 12 years Quick Relief or Exacerbation Medications:  Short acting ß agonists (SABA)  Oral systemic corticosteroids (OCS) (22) (Refer to TCH Formulary for prescribing info) (23-25)

Outcome Measures: 1. Increased use of asthma order sets 2. All pts have Action Plans with copy on chart 3. Appropriate treatment with anti-inflammatory medication 4. Reduction in Average Length of Stay (LOS) 5. Arrival to delivery timing of steroid administration 6. Number of IDS pts with an Action Plan at admission 7. Increased % of pts receiving influenza immunization 8. Neb Mask vs MDI exclusions appropriately applied Critical Points of Evidence (1, 15-17)

Evidence Supports  Subcutaneous immunotherapy for pts who have a clearly documented allergen relationship with their mild(26) moderate persistent asthma symptoms (27-29)  Immediate use of steroids during an exacerbation (30-34)  Magnesium sulfate in acute severe exacerbation  Ipratropium bromide in an acute exacerbation in the (35, 36) emergency department setting (19-21)  Educational interventions to improve outcomes 2

(1, 15-17)

 

Evidence Supports (continued)  Viral respiratory infection as a developmental factor for (33-39) asthma and asthma symptom exacerbation  Spirometry in children ≥ 5 years as a diagnostic aid, to classify severity, and for periodic monitoring by office (1,6, 40-41) based physicians who care for asthma patients  Spirometry in children ≥ 5 years as a diagnostic aid, to classify severity, and for periodic monitoring by office (1,6, 40-41) based physicians who care for asthma patients (1, 15-17) Evidence Against  Inhaled Corticosteroids (ICSs) for the purpose of altering the underlying severity or progression of the (1, 42) disease  Use of IV magnesium sulfate in patients with mild to (30-34) moderate acute asthma in the EC

(35,36)

Anticholinergic use for in-hospital care Utility of CXR for improved diagnosis of asthma in first (1) time wheezing patients (43)  Ketamine for acute rescue therapy Evidence Lacking/Inconclusive  Doubling the dose of ICSs for an established asthma (44-46) exacerbation  Heliox as an added benefit to SABA and corticosteroids (47-49) for treatment of acute exacerbations  Non Invasive Positive Pressure Ventilation (NPPV) as (50-56) an added benefit for acute exacerbations  Terbutaline as an added benefit for acute exacerbations (57) compared to SABA, corticosteroids and Ipratropium

Table 1: CLASSIFYING ASTHMA SEVERITY and INITIATING THERAPY (note that some criteria vary by age) Components of Severity

Intermittent

Persistent Moderate

Mild Impairment

Symptoms Nighttime awakenings SABA use for symptoms Limitation of normal activity Lung function*

Risk

Exacerbations requiring oral corticosteroids† Recommended Step for Initiating Therapy (see Table 5, p 5)

≤ 2 days/wk 0 if < 5 yrs ≤ 2/mos if 5-12yrs ≤ 2 days/wk

> 2 days/ wk 1-2/mos if < 5 yrs 3-4x/mos if 5-12 yrs > 2 days/wk

Daily 3-4x/mos if < 5 yrs >1x/wk if 5-12yrs Daily

Throughout the day > 1x/week if < 5 yrs Often 7x/wk if 5-12 yrs Several times per day

None

Minor

Some

Extreme

FEV1> 80% FEV1/FVC > 85% if 5-12 yrs FEV1/FVC normal if ≥ 12 yrs 0-1/yrs

FEV1> 80% FEV1 > 60% FEV1< 60% FEV1/FVC > 80% if FEV1/FVC > 75% FEV1/FVC< 75% if 5-12 5-12 yrs (5-12 yrs) yrs FEV1/FVC normal if FEV1/FVC reduced by FEV1/FVC reduced > 5% ≥ 12 yrs 5% if ≥ 12 yrs) if ≥ 12 yrs ≥ 2 in 6 mos if < 5 yrs OR ≥ 4 wheezing episodes per 1 year and lasting > 1 day if < 5 yrs ≥ 2/yrs if 5 -12 yrs Step 2 Step 3 Step 3 if < 5 yrs Step 3 or 4 if 5-12 yrs Step 4 or 5 if ≥ 12 yrs

Step 1

Table 2: ASSESSING CONTROL and ADJUSTING THERAPY Components of Control Well Controlled Impairment

Risk

Symptoms

≤ 2 days/wk

Nighttime awakenings Interference with normal activity SABA use for symptoms Lung function* Exacerbations requiring OCS† Reduction in lung growth Treatment related adverse effects Recommended Action for Treatment (see Table 5, p 7)

Severe

Not Well Controlled

Very Poorly Controlled Throughout the day

≤ 1x/mos if ≤ 12 yrs, ≤ 2x/mos if >12 yrs None

> 2 days/week or if ≤ 12yrs multiple times on ≤ 2 days/wk ≥ 2x/mos if ≤ 12 yrs, 1-3x/wk if > 12 yrs Some limitation

≤ 2 days/wk

> 2 days/wk

Several times per day

FEV1 > 80% FEV1/FVC > 80% 0-1x/yr

FEV1 60- 80% FEV1/FVC 75-80% 2-3x/yr if < 5 yrs ≥ 2x/yr if ≥ 5 years

< 60% < 75% > 3x/yr if < 5 yrs ≥ 2x/yr if ≥ 5 yrs

≥ 2x/week if ≤ 12 yrs, ≥ 4x/wk if >12 yrs Extremely limited

Requires long term follow-up Medication side effects do not correlate with specific levels of control, but should be considered in overall assessment of risk. Consider step down if well Step up 1 step. Re-evaluate Consider short course oral corticoin 2-6 wks. steroid. Step up 1-2 steps. Recontrolled for  3 mos. evaluate in 2 wks

* Note that some individuals with smaller lungs in relation to their height (such as a thin individual with narrow A-P diameter to their chest) may NORMALLY have FEV1 3 days after treatment is begun Adjunctive therapies are helpful

   

Requires EC/hospitalization; possible ICU Minimal or no relief from frequent inhaled SABA Intravenous corticosteroids Adjunctive therapies are helpful

PEF < 25 percent predicted or personal best

* Note that some individuals with smaller lungs in relation to their height (such as a thin individual with narrow A-P diameter to their chest) may NORMALLY have FEV1 < 80% and/or FEV1/FVC < 85%. Lung function measures should be correlated with clinical assessment of asthma severity. Adapted from: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report, U.S. Department of Health and Human Services, National Institutes of Health, 2007: 72.

Table 4: ON-GOING PATIENT and FAMILY EDUCATION

Keys Components of Patient and Family Asthma Education

Basic Facts:  The contrast between airways of a person who has and a person who does not have asthma

Role of Medications:  Long-term control medications: o Prevent symptoms, often by reducing inflammation. Must be taken daily.



The role of inflammation.





What happens to the airways during an asthma attack.

Quick-relief medications: o Short acting beta agonists relax airway muscles to provide prompt relief of symptoms.

Note: Use of short acting ß agonist quick relief medications >2 days a week to relieve asthma symptoms suggests the need to re-assess asthma control and consider escalation of therapy.

Patient Skill Set:  Self-monitoring: o Self-assessment of level of asthma control. o Monitoring symptoms and, if prescribed, Peak Expiratory Flow Measures. o Recognizing symptom patterns & early signs and symptoms of worsening asthma. o Use of a written asthma action plan to know when and how to: - Take daily actions to control asthma. - Adjust medication(s) early in response to signs of worsening asthma - Seek medical care as directed - Value of compliance and periodic monitoring to adjust therapy  Taking medications correctly  Inhaler technique (demonstration/return demonstration)  Use of devices as prescribed (valved holding chamber or spacer, nebulizer).  Identifying and avoiding triggers that worsen the patient’s asthma (allergens, irritants, tobacco smoke)

Adapted from: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report, U.S. Department of Health and Human Services, National Institutes of Health, 2007: 72

4

Table 5: STEPWISE APPROACH to MANAGEMENT Before stepping up: review adherence, inhaler technique, environmental control, and co morbid conditions

Preferred treatment Step 1 Step 2

SABA prn Low dose ICS

Step 3

< 5 yrs: Medium dose ICS  5 yrs: Low dose ICS + LABA or medium dose ICS Medium dose ICS + LABA or Montelukast < 5 yrs: High dose ICS + LABA or montelukast  5 yrs: High dose ICS + LABA 0-4 yrs: High does ICS + oral corticosteroids + LABA or Montelukast  5 yrs: High dose ICS + LABA + oral corticosteroids  12 yrs: Consider Omalizumab for patients who have allergies.

Step 4 Step 5 Step 6

Alternative treatments < 5 yrs: Cromolyn, montelukast  5 yrs: Cromolyn, nedocromil, LRTA, or theophylline Low dose ICS + either LRTA or theophylline Medium dose ICS + theophylline  5 yrs: High dose ICS + LRTA or theophylline.  12 yrs: Consider Omalizumab for patients who have allergies. High dose ICS + LABA+LRTA or theophylline 5-12 yrs: High dose ICS + LRTA or theophylline + oral corticosteroids

Note: The stepwise approach is meant to assist, not replace clinical decision making. If clear benefit is not observed within 4-6 weeks when patient technique and adherence is satisfactory, consider adjusting therapy and/or consider alternative diagnoses. Adapted from: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report, U.S. Department of Health and Human Services, National Institutes of Health, 2007: 72

5

RESPIRATORY ASSESSMENT AND MANAGEMENT PROTOCOL (RAMP) Patients ≥ 1 year of age with asthma/wheezing excluding bronchiolitis, cystic fibrosis, trach pts, neuromuscular diseases & cardiac pts (unless ordered)

Alert: Consider Fast Tracking Life Threatening Asthma Clinic Patients Brief history & physical exam w/ CRS Monitor oxygen saturation and administer oxygen to maintain SpO2 ≥ 90% Consider PEF if Personal Best Known or use Predicted Table; FEV1 may be used in children > 6 yrs and available Consider Child Life consult for coping techniques, procedural teaching and psychological support

Mild = CRS ≤ 3; FEV1 or PEF ≥ 60% ■ Suppl Oxygen to achieve SpO2 ≥ 90% ■ SABA neb or MDI w/valved holding chamber < 2 yrs: 4 puffs; ≥ 2 yrs: 6 puffs X 1 dose Reassess for D/C or further tx ■ Begin corticosteroid

■ ■ ■ ■

Moderate = CRS 4-6; FEV1 or PEF ≥ 40% Suppl Oxygen to achieve SpO2 ≥ 90% SABA neb or MDI w/valved holding chamber < 2 yrs: 6 puffs; ≥ 2 yrs: 6-8 puffs Q 20 min PRN up to 3 doses; then Q 1-3 h Begin corticosteroid Consider Ipratropium

Severe = CRS 6-8; FEV1 or PEF < 40% ■ Suppl Oxygen to achieve SpO2 ≥ 90% ■ SABA neb or MDI w/valved holding chamber 8 puffs Q 20 min X 3 doses; if no response after 1st tx ADD Ipratropium ■ Begin corticosteroid ■ Assess patient after 3srd treatment; if no improvement notify MD immediately and place on continuous SABA and give 3rd dose of Ipratropium

Impending or Actual Respiratory Arrest = CRS 8-12; FEV1 or PEF < 25% Unable to Talk, Severe Distress ■ Suppl Oxygen to achieve SpO2 ≥ 90% ■ Continuous SABA ■ Consider IV magnesium sulfate in cases of severe acute exacerbation only ■ Intravenous corticosteroid ■ Add Ipratropium ■ ABG, VBG, or CBG ■ May consider adjunctive therapies where evidence is inconclusive (e.g. IV terbutaline, NPPV, heliox) ■ Mechanical ventilation as needed ■ Admit to PICU

Repeat Assessment after Each Treatment and Determine if Inpatient Admission is Required

CRS ≤ 3; FEV1 or PEF ≥ 60% V/S stable & on room air Step Down to Discharge

Discharge Home ■ Continue SABA treatment as per Asthma Action Plan ■ Complete course of oral systemic corticosteroid ■ Initiation or continue Long Term Control Meds (escalate if necessary) ■ Patient Education - Review medications including drug delivery technique - Review Written Action Plan - Recommend close medical follow-up including discharge visit recommendations with appropriate phone numbers - Perform Med Reconcilliation

SABA Weaning Criteria & Regimen CRS 3 - 6 and improving V/S stable and weaning from O2 Previous Treatment Level: Wean To: SABA or MDI 8 puffs → 6 puffs & continue to taper Continuous SABA → Q2h Q1h→ Q2h Q2h→ Q3h Complete Asthma Action Plan & Prepare for Discharge Q3h→ Q 4 h for cough or wheeze Discharge Criteria: Room air, SABA Q4 h X 2 & CRS < 3

CRS > 3 and < 6; FEV1 or PEF ≥ 40% and Not Improving - Admit to Hospital ■ Suppl oxygen to achieve SpO2 ≥ 90% ■ SABA or MDI w/valved holding chamber Obtain order to increase strength if on Levalbuterol (if applicable) < 2 yrs: 4 puffs; ≥ 2 yrs: 6-8 puffs Q 1- 3 h (if requiring more than Q 2 h X 12 h admit to Special Care & re-evaluate dx. )

CRS ≥ 6 with no improvement FEV1 or PEF < 40 % ■ Admit to Special Care Unit based on patient care requirements and policy ■ Suppl oxygen to achieve SpO2 ≥ 90% ■ Place on continuous SABA ■ Add Ipratropium if not already given ■ IV route for corticosteroid ■ Consider adjunct therapies as above ■ Mechanical ventilation as needed

Repeat Assessment

Continuing Improvement CRS < 3; FEV1 or PEF > 60% ■ Continue Weaning until Discharge criteria met

Continuing Improvement CRS 3 - 6; FEV1 or PEF 40%- 60 % ■ If in Special Care transfer to Acute Care Status ■ Continue Weaning until Discharge Criteria met

No Improvement or Worsening Condition ■ Treat as Impending or Actual Resp. Arrest ■ Consider Pulmonary Consult and Referal to Life Threatening Asthma (LTA) Clinic ■ Consider Referral to Allergy & Immunology ■ Off Algorithm

6

7

MY TEMPORARY ASTHMA ACTION PLAN DATE: ___ - ___ - ___

Patient name: _____________________ (Optional Patient I.D. Label)

After being seen by a doctor for RED ZONE asthma symptoms I need to: Call Dr. ____________________ at ____ - _____ - ______ for an appointment within ____ days Remember to always WASH MY HANDS and AVOID ASTHMA TRIGGERS including: _________________________________________________________________________________________ _________________________________________________________________________________________ ADD Prednisone ______tabs OR Prednisolone _______mL’s _____ times a day for _________days while following my YELLOW ZONE PLAN Then: I should stop the extra medicine and follow my EVERY DAY ASTHMA ACTION PLAN

I need to follow my EVERY DAY ASTHMA ACTION PLAN all the time to get better control of my asthma

Temporary Action Plan Developed by: Dr. _____________________ on ___/ ___/ ___; Signature: ___________________________________ Asthma Teaching Completed by: ____________________________ on ___/ ___/ ___; Signature: ____________________________________ Patient/Parent: My signature here means that this Temporary Asthma Action Plan has been discussed with me and that I understand what needs to be done until I resume following my Every Day Action Plan. Signature: _______________________________________________________________

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References 1. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report, U.S. Department of Health and Human Services, National Institutes of Health, 2007. 2. Kelly KJ, Walsh-Kelly CM, Christenson P, Rogalinski S, Gorelick H, Barthell EN, Grabowski L. Emergency department allies: a web-based multi-hospital pediatric asthma tracking system. J Pediatr 2006; 117(4):S63-S70. 3. Letz KL, Jain N. Pediatric asthma bridging the gap between knowledge and practice. Clinical Advisor 2007; Suppl. August: 2-14. 4. Murphy KR, Hopp RJ, Kittelson EB, Hansen G, Windle ML, Walburn JN. Life-threatening asthma and anaphylaxis in schools: a treatment model for school-based programs. Ann Allergy, Asthma & Immunol, 2006; 96(3):398-405. 5. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not enough. J Pediatr 2007; 120(4):855-864. 6. Yawn BP, Enright PL, Lemanske RF Jr, Pace W, Wollan P, Boushey H. Spirometry can be done in family physicians’ offices and alters clinical decisions in management of asthma and COPD. Chest 2007; 132(4):1162-1168. 7. Gibson PG, Henry RL, Coughlan JL, Gastroesophogeal reflux treatment for asthma in adults and children. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. NO.: CD001496.DOI: 10.1002/14651858.CD0011496. 8. Lafond C, Series F, Lemiere C. Impact of CPAP on asthmatic patients with obstructive sleep apnoea. Eur Respir J 2007; 29(2):307-311. 9. Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Care Med. 2000; 162(4 Pt 1):1403-1406. 10. van der Hulst AE, Klip H, Brand LP. Risk of developing asthma in young children with atopic eczema: a systematic review. J Allergy Clin Immunol 2007; 120(3):565-569. 11. Al Sayyad JJ, Fedorowicz Z, Alshimi D, Jamal A. Topical steroids for intermittent persistent allergic rhinitis in children. Cochrane Database of Systematic Reviews 2007, Issue 1. Art.No.: CD003163.DOI: 10.1002/14651858.CD003163.pub4. 12. Bailey EJ, Morris PS, Kruske SG, Chang AB. Clinical pathways for chronic cough in children. Cochrane Database of Systematic Reviews 2008, Issue 2. Art.No.: CD006595.DOI: 10.1002/14651858.CD006595.pub2. 13. Bayley DL, Abusriwill H, Ahmad A, Stockley RA. Validation of assay for inflammatory mediators in exhaled breath condensate. Eur Respir J 2008 May; 31(5):943-948 14. Stockley RA, Bayley DL. Validation of assay for inflammatory mediators in sputum. Eur Respir J 2000; 15(4):778-781 15. Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI). Global strategy for asthma management and prevention. Bethesda (MD): Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI); 2007. 92 p. [372 references] www.ginasthma.com 16. CDC Guide for State Health Agencies In the Development of Asthma Programs http://www.cdc.gov/asthma/interventions/children.htm

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References (continued) 17. Scottish Intercollegiate Guidelines Network (SIGN), British Thoracic Society. British guideline on the management of asthma. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2007 Jul. 94 p. [680 references] 18. Teach SJ, Crain EF, Quint DM, Hylan ML, Joseph JG. Indoor environmental exposures among children with asthma seen in an urban emergency department. J Pediatr 2006 Apr; 117(4 Pt 2):S152-158. 19. Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children's use of acute care services: a meta-analysis. J Pediatr 2008 Mar; 121(3):575-586 20. Kwok MY, Walsh-Kelly CM, Gorelick MH, Grabowski L, Kelly KJ. National Asthma Education and Prevention Program severity classification as a measure of disease burden in children with acute asthma. J Pediatr 2006 Apr; 117(4 Pt 2):S71-7. 21. Sockrider MM, Abramson S, Brooks E, Caviness AC, Pilney S, Koerner C, Macias CG. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. J Pediatr 2006 Apr; 117(4 Pt 2):S135-44. 22. Texas Children's Hospital Drug Information and Formulary. 9th ed. Hudson (OH): Lexi-Comp; 2007. 23. Reeves MJ, Lyon-Callo S, Brown MD, Rosenman K, Wasilevich E, Williams SG. Using billing data to describe patterns in asthma-related emergency department visits in children. J Pediatr 2006 Apr;117(4 Pt 2):S106-17 24. National Initiative for Children’s Healthcare Quality. Measures for Practice. 2006 http://www.nichq.org/nichq 25. JCAHO Children's Asthma Care (CAC) Performance Measure Set. Specifications Manual for National Hospital Quality Measures’, version 2.4bb’. Last Updated June 2008 26. Jacobsen L, Valovirta E. How strong is the evidence that immunotherapy in children prevents the progression of allergy and asthma? Curr Opin Allergy Clin Immunol 2007; 7(6):556-560. 27. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000195. DOI: 10.1002/14651858.CD000195.pub2. 28. Manning P, Gibson PG, Lasserson TJ. Ciclesonide versus placebo for chronic asthma in adults and children. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006217. DOI: 10.1002/14651858.CD006217.pub2. 29. Manning P, Gibson PG, Lasserson TJ. Ciclesonide versus other inhaled steroids for chronic asthma in children and adults. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007031. DOI: 10.1002/14651858.CD007031. 30. Aggarwal P, Sharad S, Handa R, Dwiwedi SN, Irshad M. Comparison of nebulised magnesium sulphate and salbutamol combined with salbutamol alone in the treatment of acute bronchial asthma: a randomised study. Emerg Med J. 2006 May; 23(5):358-362. 31. Blitz M, Blitz S, Beasely R, Diner BM, Hughes R, Knopp JA, Rowe BH. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003898. DOI: 10.1002/14651858.CD003898.pub4. 32. Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium sulfate for treating acute asthma. Arch Dis Child. 2005 Jan; 90(1):74-77

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References (continued) 33. Mohammed S, Goodacre S. Intravenous and nebulised magnesium sulfate for acute asthma: systematic review and meta-analysis. Emerg Med J. 2007 Dec;24(12):823-830 34. Rowe BH, Bretzlaff JA, BourdonC, Bota GW, Camargo Jr CA. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database of Systematic Reviews 2000, Issue 1. Art.No.: CD001490. DOI: 10.1002/14651858.CD001490. 35. Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med. 1998 Oct 8; 339(15):1030-1035. 36. Zorc JJ, Pusic MV, Ogborn CJ, Lebet R, Duggan AK. Ipratropium bromide added to asthma treatment in the pediatric emergency department. J Pediatr 1999 Apr; 103(4 Pt 1):748-52 37. Mohapatra SS, Boyapalle S. Epidemiologic, Experimental, and Clinical Links between Respiratory Syncytial Virus Infection and Asthma. Clin Microbiol Rev 2008 Jul; 21(3):495-504. 38. Santiago J, Hernandez-Cruz JL, Manjarrez-Zaval ME, Montes-Vizuet R, Rosete-Olevera DP, Tapia-Diaz AM, Zepeda-Peney H, Teran LM. Role of MCP-3 and -4 in children with virus exacerbation of asthma. Eur Respir J. 2008 Jun 25. [Epub ahead of print] 39. Jackson DJ, Gangnon RE, Evans MD, Roberg KA, Anderson EL, Pappas TE, Printz MC, Lee WM, Shult PA, Reisdorf E, Carlson-Dakes KT, Salazar LP, Dasilva DF, Tisler CJ, Gern JE, Lemanske Jr RF. Wheezing Rhinovirus Illnesses in Early Life Predict Asthma Development in High Risk Children. Am J Respir Crit Care Med. 2008 Jun 19 [Epub ahead of print]. 40. Nair SJ, Daigle KL, Decoir P, Lapin CD, Schramm CM. The influence of pulmonary function testing on the management of asthma in children. J Pediatr 2005 Dec; 147(6):797-801. 41. Stout JW, Visness CM , Enright P, Lamm C, Shapiro G, Gan VN, Adams III GK, Mitchell HE. Classification of asthma severity in children: the contribution of pulmonary function testing. Arch Pediatr Adolesc Med 2006 Aug; 160(8):844-50. 42. Murray CS. Can inhaled corticosteroids influence the natural history of asthma? Curr Opin Allergy Immunol 2008; 21(1):877-881. 43. Denmark TK, Crane HA, MD, Brown L. Ketamine to avoid mechanical ventilation in severe pediatric asthma. J Emerg Med 2006; 30(2):163-166. 44. Farber HJ. What color is your yellow zone? Is there a role for escalation of anti-inflammatory therapy short of an oral corticosteroid burst? Pediatr Asthma Allergy Immunol. 2008 21(1): 1-7 45. Kelly, HW. Rationale for the major changes in the pharmacotherapy section of the National Asthma Education and Prevention Program guidelines. J Allergy Clin Immunol. 2007 Nov; 120(5):989-94; quiz 995-6. Review. 46. Randhawa I, Klaustermeyer WB. Oral corticosteroid-dependent asthma: a 30-year review. Ann Allergy Asthma Immunol. 2007 Oct;99(4):291-302 47. Colebourn CL, Barber V, Young JD. Use of helium-oxygen mixture in adult patients presenting with exacerbations of asthma and chronic obstructive pulmonary disease: a systematic review. Anesthes 2007; 62(1):34042. 48. Ho AM, Lee A, Karmakar MK, Dion PW, Chung DC, Contardi LH. Heliox vs air-oxygen mixtures for the treatment of patients with acute asthma: a systematic overview. Chest. 2003 Mar; 123(3):882-90

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References (continued) 49. Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for non-intubated acute asthma patients. Cochrane Database of Systematic Reviews 2006, Issues 4. Art. No.: CD002884. DOI: 10.1002/14651858.CD002884.pub2. 50. Ambrosino N, Vagheggini G. Noninvasive positive pressure ventilation in the acute care setting: where are we? Eur Respir J 2008; 31(4):874-886. 51. Beers SL, Abramo TJ, Bracken A, Wiebe RA. Bi-level positive airway pressure in the treatment of status asthmaticus in pediatrics. Am J Emerg Med 2007; 25(1):6-9. 52. Lafond C. Series F, Lemiere C. Impact of CPAP on asthmatic patients with obstructive sleep apnea. Eur Respir J 2007; 29(2):307-311. 53. Loh LE, Chan YH, Chan I. Noninvasive ventilation in children: a review. J Pediatr 2007; 83(2 Suppl): S91-S99. 54. Ram FSF, Wellington SR, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database of Systematic Reviews 2005, Issues 3. Art. No.: CD004360. DOI: 10.1002/14651858.CD004360.pub3. 55. Soma T, Hino M, Kida K, Kudoh S. A prospective and randomized study for improvement of acute asthma by non-invasive positive pressure ventilation (NPPV). Int Med 2008; 47( ):493-501. 56. Yim S, Fredberg JJ, Malhotra A. Continuous positive airway pressure for asthma: not a big stretch? Eur Respir J 2007; 29(2):226-228 57. Bogie AL, Towne D. Luckett PM, Abramo TJ, Wiebe RA. Comparison of intravenous terbutaline versus normal saline in pediatric patients on continuous high-dose nebulized albuterol for status asthmaticus. Pediatr Emerg Care 2007; 23(6):355-361.

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Guideline Preparation This guideline was prepared by the Evidence-Based (EB) Clinical Decision Support Team in collaboration with content experts at Texas Children’s Hospital and the Texas Children’s Pediatric Associates. Development of this guideline supports the TCH Quality and Patient Safety Program initiative to promote clinical guidelines and outcomes that build a culture of quality and safety EB Clinical Decision Support Team Co-Chair: Marilyn Hockenberry, PhD, RN-CS, PNP, FAAN Co-Chair: Charles Macias, MD, MPH Research Specialist: Bonnie L. Magliaro, MS, RN Content Expert Team Members Team Chairperson: Stuart L. Abramson, MD - Allergy/Immunology Bloom, Joey, RN – IRIS/EPIC Alva Cambric-Hargrove – TCPA Administration Tiffany Clarke, RN - IRIS/EPIC Liaison Ekiria Collins, MA - Asthma Educator Anne Dykes, MS, RN - Emergency Center CNS Harold Farber, MD – Pulmonary Medicine Quinn Franklin, MS – Child Life Yong S. Han, MD - FIS Suzanne Iniguez – Respiratory Therapy Julie P. Katkin, MD – Pulmonary Medicine Mona L. McPherson, MD – Critical Care Medicine Binita Patel, MD – Nephrology & Parent Representative Diana L. Schaumburg, RN – Quality & Outcomes Management Archana Shah. MD - TCPA Marianna M. Sockrider, MD – Pulmonary Medicine Wayne P. Toote, RN – Emergency Center Jeffrey L. Wagner – Clinical Pharmacist Development Process This guideline was developed using the process outlined in the EB Clinical Decision Support Manual (2007). The review summary documents the following steps: 1. Review Preparation -PICO questions established -Evidence search terms confirmed with content experts 2.

Review of Existing Internal and External Guidelines - One internal bronchiolitis guideline found (Critical CareDr. McPherson) - One published guideline from the AAP/AHRQ and two from children’s hospitals were used

3.

Search for Relevant Evidence -Searched: Medline, EmBase, Cochrane, AHRQ, CINAHL, Trip, Best BETS, AAP, PedsCCM, U of Mich, Google Scholar

4. 5.

Critically Analyze the Evidence Summarize the Evidence by preparing the guideline, order sets and interdisciplinary plan of care - Materials used in the development of the guidelines, review summaries and content expert team meeting minutes are maintained in a bronchiolitis EB review manual within the Center for Quality.

Study/systematic review with minor limitations - specifically lacking in one of the above criteria Study/systematic review with major limitations - specifically lacking in several of the above criteria. Published clinical guidelines evaluated for this review using the AGREE criteria. The summary of these guidelines are found at the end of this document. AGREE criteria uses a 1-4 point likert scale to evaluate 23 questions evaluating: Guideline Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity and Presentation, Applicability, and Editorial Independence. The higher the score the more comprehensive the guideline. This guideline specifically summarizes the evidence in support of or against specific interventions and identifies where evidence is lacking. The following categories describe how research findings provide support for treatment interventions. “Evidence that supports” the guideline (p.2 & 3) provides evidence from more than one well-done randomized controlled trial (RCT) (based on CASP criteria) that the benefits of the intervention exceed harm. “Evidence against” (p.2 & 3) provides clear evidence from more than one well-done RCT (based on CASP criteria) that the intervention is likely to be ineffective or that it is harmful. “Evidence lacking” (p.2 & 3) indicates there is currently insufficient data or inadequate data to recommend for or against specific intervention. Recommendations Recommendations for the guidelines were developed by a consensus process directed by the existing evidence, content experts and patient and family preference when possible. The Content Expert Team and EB Clinical Decision Support Team remain aware of the controversies in the management of bronchiolitis in young patients. When evidence is lacking, options in care are provided in the guideline and the order sets that accompany the guideline. Approval Process Guidelines are reviewed and approved by the Content Expert Team, EB Clinical Decision Support Team, EB Executive Steering Team, Pharmacy and Therapeutics Committee and other appropriate hospital committees as deemed appropriate for the guideline’s intended use. Guidelines are reviewed and updated as necessary every 2 years within the EB Clinical Decision Support Team at Texas Children’s Hospital. Content Expert Teams will be involved with every review and update. Disclaimer Guideline recommendations are made from the best evidence, expert opinions and consideration for the patients and families cared for within TCH/TCPA. The guideline is NOT intended to impose standards of care preventing selective variation in practice that are necessary to meet the unique needs of individual patients. The physician must consider each patient’s circumstance to make the ultimate judgment regarding best care. © Evidence-Based Outcomes Center, 2008 Quality and Outcomes Center, Texas Children’s Hospital

Evaluating the Quality of the Evidence The Critical Appraisal Skills Program (CASP) criteria were used to evaluate the quality of articles reviewed. Application of the CASP criteria are completed by rating each reviewed study or review as: Strong study/systematic review - well designed, well conducted, adequate sample size, reliable measures, valid results, appropriate analysis, and clinically applicable/relevant.

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