1. Admit to:
2. Diagnosis: Exacerbation of asthma
3. Condition:
4. Vital Signs: q6h. Call physician if P >140; R >30, <10;
T >38.5°C; pulse oximeter <90%
5. Activity: Up as tolerated.
6. Nursing: Pulse oximeter, bedside peak flow rate before and
after bronchodilator treatments.
7. Diet: Regular, no caffeine.
8. IV Fluids: D5 ½ NS at 125 cc/h.
9. Special Medications:
-Oxygen 2 L/min by NC. Keep O2 sat >90%.
Beta Agonists, Acute Treatment:
-Albuterol (Ventolin) 0.5 mg and ipratropium (Atrovent)
0.5 mg in 2.5 mL NS q1-2h until peak flow meter
$200-250 L/min and sat $90%, then q4h OR
-Albuterol (Ventolin) MDI 3-8 puffs, then 2 puffs q3-6h prn,
or powder 200 mcg/capsule inhaled qid.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Systemic Corticosteroids:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h;then 30-60 mg PO qd. OR
-Prednisone 20-60 mg PO qAM.
Aminophylline and Theophylline (second-line therapy):
-Aminophylline load dose: 5.6 mg/kg total body weight in 100 mL D5W IV
over 20min. Maintenance of 0.5-0.6 mg/kg ideal body weight/h (500 mg in 250 mLD5W);
reduce if elderly, heart/liver failure (0.2-0.4mg/kg/hr).
Reduce load 50-75% if taking theophylline (1 mg/kg of aminophylline will raise levels 2mcg/mL) OR
-Theophylline IV solution loading dose 4.5 mg/kg total
body weight, then 0.4-0.5 mg/kg ideal body weight/hr.
-Theophylline (Theo-Dur) 100-400 mg PO bid (3 mg/kg q8h); 80% of total
daily IV aminophylline in 2-3doses.
Inhaled Corticosteroids (adjunct therapy):
-Beclomethasone (Beclovent) MDI 4-8 puffs bid, with spacer 5 min after bronchodilator,
followed by gargling with water
-Triamcinolone (Azmacort) MDI 2 puffs tid-qid or 4 puffs bid.
-Flunisolide (AeroBid) MDI 2-4 puffs bid.
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110mcg/puff); requires 1-2 weeks for full effect.
Maintenance Treatment:
-Salmeterol (Serevent) 2 puffs bid; not effective for acute asthma because
of delayed onset of action.
-Pirbuterol (Maxair) MDI 2 puffs q4-6h prn.
-Bitolterol (Tornalate) MDI 2-3 puffs q1-3min, then 2-3 puffs q4-8h prn.
-Fenoterol (Berotec) MDI 3 puffs, then 2 bid-qid.
-Ipratropium (Atrovent) MDI 2-3 puffs tid-qid.
Prevention and Prophylaxis:
-Cromolyn (Intal) 2-4 puffs tid-qid.
-Nedocromil (Tilade) 2-4 puffs bid-qid.
-Montelukast (Singulair) 10 mg PO qd.
-Zafirlukast (Accolate) 20 mg PO bid.
-Zileuton (Zyflo) 600 mg PO qid.
Acute Bronchitis
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Cefuroxime axetil (Ceftin) 250-500 mg PO bid OR
-Trimethoprim/sulfamethoxazole (Bactrim DS), 1 tab PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV PO qd [250,500 mg].
-Amoxicillin 875 mg/clavulanate 125 mg (Augmentin 875) 1 tab PO bid.
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, ECG, pulmonary function tests
before and after bronchodilators; pulmonary rehabilitation;
impedance cardiography, echocardiogram.
12. Labs: ABG, CBC with eosinophil count, SMA7, B-type
natriuretic peptide (BNP). Theophylline levell stat and after
24h of infusion. Sputum Gram stain, C&S.
