Asthma – Peds  


Asthma Protocol 

If patient has symptoms that match an asthma attack (frequent cough, wheezing, or shortness of breath) AND has a diagnosis of asthma, have been prescribed asthma medications, OR has used albuterol inhaler in the past more than once use this protocol, unless patient has been diagnosed with RSV/Bronchiolitis/Pneumonia which all have follow-up protocols. 

Quick Relief Treatment with Urgent follow up call by nurse in 1 hour: 

  • Purpose of back to back rescue treatments is to move patient from the asthma Yellow zone to the Green zone. 


  • Instruct patient to use Albuterol (or Xopenex)  neb treatments with a mask (given over 10 minutes) OR an inhaler treatment with a spacer (4 puffs). If the caller only has duoneb, recommend giving one dose (not BTB) and calling back. 


  • Wait 1 minute between each puff. Repeat with an additional 4 puffs in 20 minutes (unless the patient has improved and moved into the GREEN Zone). For the inhaler, that's a total of 8 puffs. For the neb treatment, that's a total of two 10 minute treatments 20 minutes apart.  


  • Home Treatment Failure: Difficulty breathing or tight wheezing that doesn't improve after 2 Rescue Treatments separated by 20 minutes (NAEPP 2007 guidelines) in which you must send patient to ER/UCC for evaluation.  

  • Children with an asthma attack who have an incomplete response (remains in the YELLOW Zone with PEFR 50-80%) to the 2 back-to-back albuterol rescue treatments need to be started on a steroid burst. If they do not have access to prednisone through their PCP, they need to be seen. 


  • For children who have been receiving albuterol inhaler or neb treatments every 4 hours for OVER 24 hours AND meet the criteria for being seen: 

  • A back-to-back treatment is optional. These children do not need to receive a back-to-back albuterol treatment before sending them in. Reason: After 24 hours, the child's symptoms will be caused more by inflammation. Inflammation is unresponsive to a bronchodilator and needs a steroid burst. 

  • If it has been over 1 hour since the last treatment, have the family give one treatment before going in.  

  • If it has been less than 1 hour since the last treatment, just send the child in. 

  • For children who haven’t been receiving albuterol treatments every 4 hours for the past 24 hours: 

  • If it has been 1 hour or more since the last treatment, give a back-to-back treatment (2 treatments 20 minutes apart). Then, call the family back and re-triage. 

  • If it has been less than 1 hour, give only one additional treatment.  Then, call the family back and re-triage. 


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