Helping Kids "Breathe Easy"

CCH's approach to asthma care emphasizes clear communication


By Kristen Hughes, MD


Asthma remains the most common chronic disease in childhood, affecting over 6 million children in the United States and resulting in over 200,000 annual hospitalizations.  At Cottage Children's Hospital, acute asthma exacerbations contribute to a large portion of admissions.  Our dedicated staff have teamed together to create a multidisciplinary approach in which physicians, nurses, and respiratory therapists clearly communicate respiratory scores, phases of treatment and discharge instructions.


Patients admitted with asthma exacerbations are placed on an asthma pathway.  This pathway includes four phases.  Phase one consists of continuous administration of high-dose, short-acting beta agonist (SABA) and takes place in the intensive care unit. 


Kristen Hughes, MD


Phase two offers high-frequency (every two hours), high-dose SABA typically dispensed through nebulization; however, this can also be offered through an HFA (hydrofluoroalkane) inhaler.


Phase three uses low-frequency (every four hours), high-dose SABA. 


And finally, during phase four, low-frequency, low-dose SABA is given.  In addition, patients in phases one through three are started on IV steroids, usually at a dose of 1mg/kg/dose every six hours. 

During phase four, an inhaled corticosteroid is substituted.  Other adjuncts to therapy, especially when the patient has an allergic trigger, include montelukast, antihistamines and intranasal steroids.  Evolution through phases is physician-driven, using asthma scoring by pediatric respiratory therapists.


Since 2007, when the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program (Expert Panel Report 3) produced new guidelines on the diagnosis and management of asthma, there has been a strong move by providers toward classifying patients' severity based on impairment and risk assessment.  Impairment is determined by number of nighttime awakenings, frequency of SABA use for symptom control, and degree of interference with normal activity.  Risk is assigned by number of exacerbations requiring oral steroids, number of wheezing episodes/year lasting >1 day, and risk factors for persistent asthma (defined as parental history of asthma, personal history of atopy, and sensitization to aeroallergens or food).  Once classification of asthma severity has been assigned, a step-up/step-down approach to management has been outlined.


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