1

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 adiagnosis of asthma/recurrent wheezing in whom foreignbody or vocal cord dysfunction have been ruled out.

Guideline Exclusion Criteria: Bronchiolitis, cystic fibrosis,bronchopulmonary dysplasia, bacterial pneumonia,neurological disorders, immuno-deficiency diseases, trachpatients, and cardiac patients (unless ordered).

Definition:(1-3)

Asthma is the most common chronicdisorder in childhood (10-12%). It is an inflammatorydisorder of the airways in which cells and cellular elementsplay a role. In susceptible individuals, inflammation causesrecurrent episodes of coughing (particularly at night or earlymorning), 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 asthmarecognition and management. Asthma exacerbations areassociated with widespread but variable airflow obstructionand are often reversible with or without treatment.

Pathophysiology:(1, 3-5)

Asthma is a complex, interactiveprocess that depends on the interaction of: Bronchoconstriction Airway hyper responsiveness Airway edema

Asthma Predictors:(1, 9-12)

Family history of asthma, eczema, and/or smoking Patient history of allergic rhinitis, sinusitis, nasal polyps,

eczema, or BPD Recurrent cough, bronchitis, and bronchiolitis

Diagnosis:(1-5)

The initial diagnosis of asthma in childrenis often difficult and requires that other diagnoses beexcluded. An in depth clinical history combined with athorough physical examination are necessary to make thisdetermination.

History: Assessment of(1, 3-5)

Cough, wheeze, shortness of breath, and/or chesttightening that occurs in an “episodic” fashion. Thesesymptoms 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)

Physical Examination: Assess for(1, 3-5)

Severity of respiratory symptoms using the ClinicalRespiratory Score (CRS, p.2)

Rhinitis, increased nasal secretions, mucosalswelling, or nasal polyps

Airflow obstruction or airway hyper responsiveness arepresent and are at least partially reversible

e.g. spirometry shows Forced Expiratory Volumein 1 second of 12% from baseline or 10% ofpredicted after the patient inhales a short-actingbronchodilator.

Note: Office based physicians who manage asthmapatients should have access to spirometry that meetsATS standard

(1,6)

Diagnostic Tools to Assess Severity (Tables 1 & 3)(1,6)

1. Spirometry - FEV1 in children ≥ 5 yearsAirway hyper responsiveness test using Methacholine

Patients at risk of asthma-related death should beadvised to seek medical care early during anexacerbation (Table 3, p 4).

Factors that place patients at risk for asthma-relateddeath include:

(1, 4)

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 thatcan 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)

Co-morbid Conditions:(1, 7-8)

Gastroesophogeal refluxdisease (GERD), obstructive sleep apnea (OSA), obesity,rhinitis, and sinusitis

Goals of Therapy: To reduce the frequency and severityof asthma exacerbations and reduce long term sequelae bymaintaining asthma control with the least amount oftherapeutic interventions/medications possible. Intensiveeducation and monitoring are required in caring for allchildren with asthma.

(1, 15-17)

2

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

Exacerbation Management (see RespiratoryAssessment and Management Protocol (RAMP, p 6):In-Home and/or Office1. 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 measures4. Initiate use of inhaled short acting beta agonist

(SABA)5. Begin oral systemic corticosteroid6. Offer supplemental oxygen if necessary and available7. Identify and manage aggravating co-morbid conditions8. Provide ongoing education (Table 4, p 4)9. Consider EC admission if symptoms persist, are of

sufficient severity, or patient has risk factors forasthma related death (see sections below)

Emergency Center1. Follow above steps, and if severity warrants2. Place on continuous SABA3. Double up dose of inhaled corticosteroids4. Initiate ipratropium bromide5. Change systemic corticosteroids to IV6. If condition unchanged or worsening consider initiation

of adjunctive therapies including: IV magnesiumsulfate (evidence supports), IV terbutaline (evidenceinconclusive), heliox (evidence inconclusive), andnon-invasive positive pressure ventilation (NPPV -evidence inconclusive). If symptoms do not improveconsider PICU admission

7. If symptoms are unchanged or improving slightly butcontinued close monitoring is still required considerinpatient admission

8. If symptoms have improved or ceased initiateASTHMA ACTION PLAN and discharge home to f/uwith PCP.

PICU1. Continue above and consider adjunctive therapies yet

to be initiated (see RAMP p 6)2. Consider intubation for mechanical ventilation

Inpatient Care1. 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 (Table4, p 4)

3. Initiate Asthma Action Plan to prevent chronic anddisabling symptoms

Office Follow-up and Long-term Management1. 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 andassess reversibility in patients ≥ 5 years

2. Consider daily peak-flow monitoring in patients withmoderate or severe persistent asthma; a history ofsevere exacerbations; or who are unable to perceiveairway 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 yearsQuick Relief or Exacerbation Medications: Short acting ß agonists (SABA) Oral systemic corticosteroids (OCS)

(Refer to TCH Formulary for prescribing info)(22)

Outcome Measures:(23-25)

1. Increased use of asthma order sets2. All pts have Action Plans with copy on chart3. Appropriate treatment with anti-inflammatory medication4. Reduction in Average Length of Stay (LOS)5. Arrival to delivery timing of steroid administration6. Number of IDS pts with an Action Plan at admission7. Increased % of pts receiving influenza immunization8. Neb Mask vs MDI exclusions appropriately applied

Critical Points of Evidence

Evidence Supports(1, 15-17)

Subcutaneous immunotherapy for pts who have aclearly documented allergen relationship with their mild-moderate persistent asthma symptoms

(26)

Immediate use of steroids during an exacerbation(27-29)

Magnesium sulfate in acute severe exacerbation(30-34)

Ipratropium bromide in an acute exacerbation in theemergency department setting

(35, 36)

Educational interventions to improve outcomes(19-21)

Clinical Respiratory Score (CRS)Assess Score 0 Score 1 Score 2

RespiratoryRate

< 2 mos < 502-12 mos < 401-5 yrs < 30> 5 yrs < 20

< 2 mos 50-602-12 mos 40-50> 1- 5 yrs 30-40> 5 yrs 20-30

< 2 mos > 602-12 mos > 50> 1-5 yrs > 40> 5 yrs > 30

AuscultationGood airmovement,scatteredexpiratorywheezing, looserales/crackles.

Depressed airmovement,inspiratory andexpiratorywheezes orrales/crackles.

Diminished orabsent breathsounds, severewheezing, orrales/crackles,or markedprolongedexpiration.

Use ofAccessoryMuscles

Mild to no useof accessorymuscles. Mild tono retractions,nasal flaring oninspiration.

Moderateintercostalretractions, mildto moderate useof accessorymuscles, nasalflaring.

Severeintercostal andsubsternalretractions,nasal flaring.

Mental Status Normal to mildlyirritable

Irritable,agitated,restless.

Lethargic

Room Air Sp02 > 95% 90-95% < 90%Color Normal Pale to normal Cyanotic, dusky

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Evidence Supports (continued)(1, 15-17)

Viral respiratory infection as a developmental factor forasthma and asthma symptom exacerbation

(33-39)

Spirometry in children ≥ 5 years as a diagnostic aid, toclassify severity, and for periodic monitoring by officebased physicians who care for asthma patients

(1,6, 40-41)

Spirometry in children ≥ 5 years as a diagnostic aid, toclassify severity, and for periodic monitoring by officebased physicians who care for asthma patients

(1,6, 40-41)

Evidence Against(1, 15-17)

Inhaled Corticosteroids (ICSs) for the purpose ofaltering the underlying severity or progression of thedisease

(1, 42)

Use of IV magnesium sulfate in patients with mild tomoderate acute asthma in the EC

(30-34)

Anticholinergic use for in-hospital care(35,36)

Utility of CXR for improved diagnosis of asthma in firsttime wheezing patients

(1)

Ketamine for acute rescue therapy(43)

Evidence Lacking/Inconclusive Doubling the dose of ICSs for an established asthma

exacerbation(44-46)

Heliox as an added benefit to SABA and corticosteroidsfor treatment of acute exacerbations

(47-49)

Non Invasive Positive Pressure Ventilation (NPPV) asan added benefit for acute exacerbations

(50-56)

Terbutaline as an added benefit for acute exacerbationscompared to SABA, corticosteroids and Ipratropium

(57)

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

Table 2: ASSESSING CONTROL and ADJUSTING THERAPYComponents of Control Well Controlled Not Well Controlled Very Poorly Controlled

Symptoms ≤ 2 days/wk > 2 days/week or if ≤ 12yrsmultiple times on ≤ 2days/wk

Throughout the day

Nighttimeawakenings

≤ 1x/mos if ≤ 12 yrs,≤ 2x/mos if >12 yrs

≥ 2x/mos if ≤ 12 yrs,1-3x/wk if > 12 yrs

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

Interference withnormal activity

None Some limitation Extremely limited

SABA use forsymptoms

≤ 2 days/wk > 2 days/wk Several times per day

Impairment

Lung function* FEV1 > 80%FEV1/FVC > 80%

FEV1 60- 80%FEV1/FVC 75-80%

< 60%< 75%

Exacerbationsrequiring OCS†

0-1x/yr 2-3x/yr if < 5 yrs≥ 2x/yr if ≥ 5 years

> 3x/yr if < 5 yrs≥ 2x/yr if ≥ 5 yrs

Reduction in lunggrowth

Requires long term follow-up

Risk

Treatment relatedadverse effects

Medication side effects do not correlate with specific levels of control, but should be considered inoverall assessment of risk.

Recommended Action forTreatment (see Table 5, p 7)

Consider step down if wellcontrolled for 3 mos.

Step up 1 step. Re-evaluatein 2-6 wks.

Consider short course oral cortico-steroid. Step up 1-2 steps. Re-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 NORMALLYhave FEV1 <80% and/or FEV1/FVC < 85%. Lung function measures should be correlated with clinical assessment of asthma severity.† For initial therapy of moderate or severe persistent asthma consider short course of oral corticosteroids.Adapted from: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for theDiagnosis and Management of Asthma, Full Report, U.S. Department of Health and Human Services, National Institutes of Health, 2007: 72.

PersistentComponents of Severity Intermittent

Mild Moderate Severe

Symptoms ≤ 2 days/wk > 2 days/ wk Daily Throughout the dayNighttimeawakenings

0 if < 5 yrs≤ 2/mos if 5-12yrs

1-2/mos if < 5 yrs3-4x/mos if 5-12 yrs

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

> 1x/week if < 5 yrsOften 7x/wk if 5-12 yrs

SABA use forsymptoms

≤ 2 days/wk > 2 days/wk Daily Several times per day

Limitation ofnormal activity

None Minor Some Extreme

Impairment

Lung function* FEV1> 80%FEV1/FVC > 85% if5-12 yrsFEV1/FVC normal if≥ 12 yrs

FEV1> 80%FEV1/FVC > 80% if5-12 yrsFEV1/FVC normal if≥ 12 yrs

FEV1 > 60%FEV1/FVC > 75%(5-12 yrs)FEV1/FVC reduced by5% if ≥ 12 yrs)

FEV1< 60%FEV1/FVC< 75% if 5-12yrsFEV1/FVC reduced > 5%if ≥ 12 yrs

Risk Exacerbationsrequiring oralcorticosteroids†

0-1/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

Recommended Step forInitiating Therapy(see Table 5, p 5)

Step 1 Step 2 Step 3 Step 3 if < 5 yrsStep 3 or 4 if 5-12 yrsStep 4 or 5 if ≥ 12 yrs

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Table 3: CLASSIFYING SEVERITY of EXACERBATIONS

Symptoms and signs Initial PEF (or FEV1)* Clinical CourseMild Dyspnea only with

activity(assess tachypnea inyoung children)

PEF 70 percentpredicted or personalbest

Usually cared for at home Prompt relief with inhaled SABA Possible short course of oral systemic corticosteroids May consider early escalation to high dose inhaled

corticosteroid

Moderate Dyspnea interferes withor limits usual activity

PEF 40–69 percentPredicted or personalbest

Usually requires office or EC visit Relief from frequent inhaled SABA Oral systemic corticosteroids; Some symptoms last for 1–2 days after treatment is begun

Severe Dyspnea at rest;interferes withconversation

PEF < 40 percentpredicted or personalbest

Usually requires EC visit and likely hospitalization Partial relief from frequent inhaled SABA Oral systemic corticosteroids; some symptoms last for >3

days after treatment is begun Adjunctive therapies are helpful

LifeThreatening

Too dyspneic to speak;perspiring

PEF < 25 percentpredicted or personalbest

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

* 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 clinicalassessment 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, NationalInstitutes 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 whohas and a person whodoes not have asthma

The role of inflammation.

What happens to theairways during an asthmaattack.

Role of Medications: Long-term control medications:

o Prevent symptoms, often byreducing inflammation. Mustbe taken daily.

Quick-relief medications:o Short acting beta agonists

relax airway muscles toprovide prompt relief ofsymptoms.

Note: Use of short acting ß agonistquick relief medications >2 days aweek to relieve asthma symptomssuggests the need to re-assessasthma control and considerescalation 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, NationalInstitutes of Health, 2007: 72

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

Preferred treatment Alternative treatmentsStep 1 SABA prnStep 2 Low dose ICS < 5 yrs: Cromolyn, montelukast

5 yrs: Cromolyn, nedocromil, LRTA, or theophyllineStep 3 < 5 yrs: Medium dose ICS

5 yrs: Low dose ICS + LABA or medium dose ICSLow dose ICS + either LRTA or theophylline

Step 4 Medium dose ICS + LABA or Montelukast Medium dose ICS + theophyllineStep 5 < 5 yrs: High dose ICS + LABA or montelukast

5 yrs: High dose ICS + LABA 5 yrs: High dose ICS + LRTA or theophylline. 12 yrs: Consider Omalizumab for patients who have allergies.

Step 6 0-4 yrs: High does ICS + oral corticosteroids + LABA orMontelukast 5 yrs: High dose ICS + LABA + oral corticosteroids 12 yrs: Consider Omalizumab for patients who haveallergies.

High dose ICS + LABA+LRTA or theophylline5-12 yrs: High dose ICS + LRTA or theophylline + oralcorticosteroids

Note: The stepwise approach is meant to assist, not replace clinical decision making. If clear benefit is not observed within 4-6 weekswhen 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, NationalInstitutes of Health, 2007: 72

6

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 PatientsBrief 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

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 ADDIpratropium■ Begin corticosteroid■ Assess patient after 3srd treatment; if no improvement notifyMD immediately and place on continuous SABA and give 3rd

dose of Ipratropium

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 puffsQ 20 min PRN up to 3 doses; then Q 1-3 h

■ Begin corticosteroid■ Consider Ipratropium

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 doseReassess for D/C or further tx

■ Begin corticosteroid

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. IVterbutaline, 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 airStep Down to Discharge

CRS ≥ 6 with no improvementFEV1 or PEF < 40 %

■ Admit to Special Care Unit based onpatient 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

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 includingdrug delivery technique

- Review Written Action Plan- Recommend close medical

follow-up including discharge visitrecommendations with appropriatephone numbers

- Perform Med Reconcilliation

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 ifon 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 hadmit to Special Care & re-evaluate dx. )

Continuing ImprovementCRS 3 - 6; FEV1 or PEF 40%- 60 %

■ If in Special Care transfer to Acute Care Status■ Continue Weaning until Discharge Criteria met

Continuing ImprovementCRS < 3; FEV1 or PEF > 60%■ Continue Weaning until

Discharge criteria met

Repeat Assessment

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

SABA Weaning Criteria & RegimenCRS 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 taperContinuous SABA → Q 2 hQ 1 h → Q 2 hQ 2 h → Q 3 hComplete Asthma Action Plan & Prepare for DischargeQ 3 h → Q 4 h for cough or wheezeDischarge Criteria: Room air, SABA Q4 h X 2 & CRS < 3

7

8

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

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

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 whatneeds to be done until I resume following my Every Day Action Plan.

Signature: _______________________________________________________________

MY TEMPORARY ASTHMA ACTION PLAN

DATE: ___ - ___ - ___

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Guideline Preparation

This guideline was prepared by the Evidence-Based (EB)Clinical Decision Support Team in collaboration with contentexperts at Texas Children’s Hospital and the Texas Children’sPediatric Associates. Development of this guideline supports theTCH Quality and Patient Safety Program initiative to promoteclinical guidelines and outcomes that build a culture of qualityand safety

EB Clinical Decision Support TeamCo-Chair: Marilyn Hockenberry, PhD, RN-CS, PNP, FAANCo-Chair: Charles Macias, MD, MPHResearch Specialist: Bonnie L. Magliaro, MS, RN

Content Expert Team Members

Team Chairperson:Stuart L. Abramson, MD - Allergy/ImmunologyBloom, Joey, RN – IRIS/EPICAlva Cambric-Hargrove – TCPA AdministrationTiffany Clarke, RN - IRIS/EPIC LiaisonEkiria Collins, MA - Asthma EducatorAnne Dykes, MS, RN - Emergency Center CNSHarold Farber, MD – Pulmonary MedicineQuinn Franklin, MS – Child LifeYong S. Han, MD - FISSuzanne Iniguez – Respiratory TherapyJulie P. Katkin, MD – Pulmonary MedicineMona L. McPherson, MD – Critical Care MedicineBinita Patel, MD – Nephrology & Parent RepresentativeDiana L. Schaumburg, RN – Quality & Outcomes ManagementArchana Shah. MD - TCPAMarianna M. Sockrider, MD – Pulmonary MedicineWayne P. Toote, RN – Emergency CenterJeffrey L. Wagner – Clinical Pharmacist

Development Process

This guideline was developed using the process outlined in theEB Clinical Decision Support Manual (2007). The reviewsummary 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 Care-

Dr. 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. Critically Analyze the Evidence5. 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 meetingminutes are maintained in a bronchiolitis EB reviewmanual within the Center for Quality.

Evaluating the Quality of the Evidence

The Critical Appraisal Skills Program (CASP) criteria wereused to evaluate the quality of articles reviewed. Application ofthe CASP criteria are completed by rating each reviewed studyor review as:

Strong study/systematic review - well designed, wellconducted, adequate sample size, reliable measures, validresults, appropriate analysis, and clinically applicable/relevant.

Study/systematic review with minor limitations - specificallylacking in one of the above criteriaStudy/systematic review with major limitations - specificallylacking in several of the above criteria.

Published clinical guidelines evaluated for this review using theAGREE criteria. The summary of these guidelines are found atthe end of this document. AGREE criteria uses a 1-4 point likertscale to evaluate 23 questions evaluating: Guideline Scope andPurpose, Stakeholder Involvement, Rigor of Development,Clarity and Presentation, Applicability, and EditorialIndependence. The higher the score the more comprehensivethe guideline.

This guideline specifically summarizes the evidence in supportof or against specific interventions and identifies whereevidence is lacking. The following categories describe howresearch findings provide support for treatment interventions.

“Evidence that supports” the guideline (p.2 & 3) providesevidence from more than one well-done randomized controlledtrial (RCT) (based on CASP criteria) that the benefits of theintervention exceed harm.“Evidence against” (p.2 & 3) provides clear evidence from

more than one well-done RCT (based on CASP criteria) that theintervention is likely to be ineffective or that it is harmful.“Evidence lacking” (p.2 & 3) indicates there is currentlyinsufficient data or inadequate data to recommend for or againstspecific intervention.

RecommendationsRecommendations for the guidelines were developed by aconsensus process directed by the existing evidence, contentexperts and patient and family preference when possible. TheContent Expert Team and EB Clinical Decision Support Teamremain aware of the controversies in the management ofbronchiolitis in young patients. When evidence is lacking, optionsin care are provided in the guideline and the order sets thataccompany the guideline.

Approval ProcessGuidelines are reviewed and approved by the Content ExpertTeam, EB Clinical Decision Support Team, EB ExecutiveSteering Team, Pharmacy and Therapeutics Committee andother appropriate hospital committees as deemed appropriate forthe guideline’s intended use. Guidelines are reviewed andupdated as necessary every 2 years within the EB ClinicalDecision Support Team at Texas Children’s Hospital. ContentExpert Teams will be involved with every review and update.

DisclaimerGuideline recommendations are made from the best evidence,expert opinions and consideration for the patients and familiescared for within TCH/TCPA. The guideline is NOT intended toimpose standards of care preventing selective variation inpractice that are necessary to meet the unique needs ofindividual patients. The physician must consider each patient’scircumstance to make the ultimate judgment regarding best care.

© Evidence-Based Outcomes Center, 2008Quality and Outcomes Center, Texas Children’s Hospital