Place patient on the monitor, recording HR, RR, BP and oxygen saturation.
Apply oxygen to keep oxygen saturation >90%
Administer 3 nebulized albuterol (Ventolin)/ipratropium bromide (Atrovent) treatments every 10-20 minutes
Albuterol 5 mg /ipratropium bromide 0.5mg (2.5 mL unit dose vial)
Start continuous albuterol if severe asthma
Max 15 mg/hr Albuterol
Start IV steroids; Methylprednisolone (Solu-Medrol)
2 mg/kg/dose (max of 60mg/dose)
Ipratropium bromide (Atrovent) nebulized every 6 hr as needed.
< 1 year 0.25 mg (1.25 ml or one-half of vial)
> 1year 0.5 mg (one unit dose).
NPO and IV hydration at maintenance (with K added) if requiring more than every 2 hr nebs.
Magnesium sulfate: 25-50 mg/kg (Max 2000 mg) over 20-60 minutes.
Fluid bolus 20 ml/kg (NS) if decreased capillary refill time. Reassess and repeat if needed. (see Vascular Access/Fluid Management)
Intubation for impending respiratory failure. Placement of cuffed ETT is preferred. (see Intubation/RSI protocol)
Mechanical ventilation with 100% FIO2, low rate, short I-time. Titrate O2 for a SpO2 in the low 90’s and permissive hypercapnia. Tolerate high pCO2 as long as pH ≥ 7.2.
Continue with sedation drips and neuromuscular paralysis (if needed) (see Intubation/RSI)
NIH. National Asthma Education and Prevention Program. Expert Panel Report III: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; National Heart, Lung, and Blood Institute; 2007. NIH Publication No. 07-4051.
Bacharier LB, Boner A, Carlsen KH, Eigenmann PA, Frischer T, Gotz M, Helms PJ, Hunt J, Liu A, Papadopoulos N, Platts-Mills T, Pohunek P, Simons FE, Valovirta E, Wahn U, Wildhaber J. European Pediatric Asthma Group. Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy. 2008;63:5–34