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    Pediatric Asthma Score (PAS)

    Stratifies asthma severity in children.
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    INSTRUCTIONS

    Do not use in patients under 2 years of age, in severe distress, or with clear alternative diagnosis.

    When to Use
    Pearls/Pitfalls
    Why Use
    • Use in children aged 2-18 years with asthma exacerbation to guide inpatient medical management.  
    • Can also be applied in the emergency department.
    • Should not be used to evaluate patients with significant comorbidities (e.g. sickle cell disease, cystic fibrosis).
    • The PAS was evaluated based on patients that had already received oral or IV steroids within 30 minutes of treatment initiation.
    • Helpful in patients unwilling or unable to comply with peak expiratory flow measurement.
    • May quantify severity of asthma, but cannot predict response to treatment prior to intervention.
    • Good inter-observer agreement among physicians, nurses, and respiratory therapists in an ED setting.
    • Developed based on published guidelines of the National Asthma Education and Prevention Program in an effort to improve outcomes.

    Asthma is the most common reason for hospital admission from the emergency department in children. When combined with a treatment protocol based on severity, the PAS has been shown to decrease length of stay, reduce costs, and improve quality of care.

    breaths/min
    years
    >95% on room air
    +1
    90-95% on room air
    +2
    <90% on room air or any supplemental oxygen
    +3
    Normal breath sounds to end-expiratory wheeze only
    +1
    Expiratory wheezing
    +2
    Inspiratory and expiratory wheezing to diminished breath sounds
    +3
    None or intercostal
    +1
    Intercostal and substernal
    +2
    Intercostal, substernal, and supraclavicular
    +3
    Speaks in sentences (or coos and babbles)
    +1
    Speaks partial sentences (or short cry)
    +2
    Speaks in single words or short phrases (or grunts)
    +3

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Mild (PAS 5-7)

    • Consider de-escalation of current therapy. Consider spacing of albuterol and interval assessments, or preparation for discharge if tolerating home controller regimen.

    Moderate (PAS 8-11)

    • Continue current treatment and interval assessment.

    Severe (PAS 12-15)

    • Consider escalation of treatment, including increasing frequency of nebulizer treatments, adding another controller medication (e.g. ipratropium bromide, terbutaline), and transfer to monitored unit.

    Management

    • The authors used a therapy-driven protocol derived from review of asthma practice patterns in the hospital, NHLBI guidelines, and a review of literature regarding inpatient management of status asthmaticus. The protocol was designed to use either the PAS or PEFR to measure response.
    • Another example of a pathway for management of asthma in the inpatient setting: Children's Hospital of Philadelphia Inpatient Asthma Pathway

    Critical Actions

    • Always assess airway, breathing, and circulation prior to assessing PAS.  The PAS was not developed for use on unstable patients and emergent intervention must not be withheld to determine the score.
    • Any patient being treated for asthma exacerbation should receive steroids in addition to nebulized albuterol unless there is a contraindication.
    • Prior to discharge, every patient and their family should receive education on use of home inhalers and/or nebulizers, an asthma action plan, and scheduled follow-up with their primary care physician.  Ensure the patient has adequate supply of home controller medications, peak flow meter, and spacer if applicable.

    Formula

    Addition of the selected points:

     

    1 point

    2 points

    3 points

    Respiratory Rate by Age

         

    2-3 years

    ≤34

    35-39

    ≥40

    4-5 years

    ≤30

    31-35

    ≥36

    6-12 years

    ≤26

    27-30

    ≥31

    >12 years

    ≤23

    24-27

    ≥28

    Oxygen Requirements

    >95% on room air

    90-95% on room air

    <90% on room air or any supplemental oxygen

    Auscultation

    Normal breath sounds to end-expiratory wheeze only

    Expiratory wheezing

    Inspiratory and expiratory wheezing to diminished breath sounds

    Retractions

    None or intercostal

    Intercostal and substernal

    Intercostal, substernal, and supraclavicular

    Dyspnea

    Speaks in sentences (or coos and babbles)

    Speaks partial sentences (or short cry)

    Speaks in single words or short phrases (or grunts)



    Facts & Figures

    Interpretation:

    Pediatric Asthma Score (PAS)

    Severity of Exacerbation

    Percent of Peak Flow (Personal Best or Predicted)

    5-7

    Mild

    >70%

    8-11

    Moderate

    50-70%

    12-15

    Severe

    <50%

    Evidence Appraisal

    The goal of the primary study was to develop and “evaluate the effect of an inpatient asthma clinical pathway on cost and quality of care for children with asthma.”  The study was performed by physicians in the department of pediatrics at the Western Virginia Medical School.  The study site was Children’s Hospital of The King’s Daughters in Norfolk, Virginia.

    The PAS was based on previous practice methods at the institution, NHLBI guidelines, and a search of the literature at the time. Outcomes and costs of treatment of asthmatic children before and after implementation of the PAS and associated treatment guidelines were examined in a retrospective cohort.  

    149 children were treated according to the clinical pathway from Sept to Dec 1997.  Thirty-four were randomly selected and matched based on demographics (age, race, gender, admission, time of year, and comorbidities) to a cohort control group of asthmatic children treated prior to the implementation of the PAS and treatment protocol.  

    When comparing the two groups, they found:

    • Length of stay was approximately 50% lower in the group that used the PAS and treatment pathway.
    • Cost was on average $1,200 lower in the group that used the PAS and pathway.
    • Children in the PAS and pathway group were more likely to receive asthma education, prescriptions for controller medications, and equipment (spacers and peak flow meters) prior to discharge
    • PAS patients were more likely to receive oral corticosteroids over IV corticosteroids.
    • PAS patients were more likely to have close follow-up arranged at discharge than control patients.

    While the results were profound and statistically significant, it is important to note that the sample size in this study was small.  Additionally, although the control and cohort groups had similar demographics, they may not reflect the general population of pediatric asthmatics. For example, the two groups compared in the study were both 76% male, 97% African-American, and mostly between the ages of 2 and 15.

    In a review article on severe acute asthma exacerbations, Neivas and Anand cite the PAS as a reliable means of assessing asthma severity in the ICU setting.

    Dr. Cynthia Kelly

    About the Creator

    Cynthia Kelly, MD, is a professor of pediatrics at Eastern Virginia Medical School. She has been the primary investigator for research funded by the Robert Wood Johnson Foundation, U.S. Departments of Health and Human Services, and Housing and Urban Development. Dr. Kelly’s clinical practice and research focuses on pediatric patients with allergic and immunologic disorders, including asthma, allergic rhinitis and others.

    To view Dr. Cynthia Kelly's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. Cynthia Kelly
    Content Contributors