From the Guidelines
For an eight-year-old girl with asthma experiencing worsening symptoms over the past 24 hours but with good oxygenation and fever who is currently on albuterol, the recommended treatment is to continue the albuterol treatments at an increased frequency (every 20 minutes for 3 doses, then every 1-4 hours as needed) and add an oral corticosteroid such as prednisolone at 1-2 mg/kg/day (typically 20-30 mg for an average eight-year-old) for a 3-5 day course, as suggested by 1.
Rationale for Treatment Approach
The rationale for this approach is based on the combination of a bronchodilator (albuterol) to address the acute bronchoconstriction and corticosteroids to reduce the underlying airway inflammation. Short-term oral steroids help quickly control the exacerbation, while daily inhaled steroids provide longer-term control to prevent future episodes. This dual approach targets both the immediate symptoms and the underlying inflammatory process causing the asthma exacerbation.
Key Components of Treatment
- Continue albuterol treatments at an increased frequency as needed, following the dosages outlined in 1 and 1.
- Add an oral corticosteroid like prednisolone for a short course, as recommended by 1 and 1.
- Consider starting or continuing a daily inhaled corticosteroid for long-term control, although the provided evidence does not directly address this for the acute management scenario.
- Monitor for signs of worsening symptoms or inadequate response to treatment, which would necessitate immediate medical reevaluation.
Monitoring and Follow-Up
Parents should monitor for increased work of breathing, decreased ability to speak in full sentences, or persistent symptoms despite treatment, which would warrant immediate medical attention. Regular follow-up with a healthcare provider is essential to adjust the treatment plan as needed and to ensure the child's asthma is well-controlled over time.
From the FDA Drug Label
In controlled clinical trials, most patients exhibited an onset of improvement in pulmonary function within 5 minutes as determined by FEV1. Published reports of trials in asthmatic children aged 3 years or older have demonstrated significant improvement in either FEV1 or PEFR within 2 to 20 minutes following a single dose of albuterol inhalation solution An increase of 15% or more in baseline FEV1 has been observed in children aged 5 to 11 years up to 6 hours after treatment with doses of 0. 10 mg/kg or higher of albuterol inhalation solution.
The patient is already on albuterol, which is the recommended treatment for asthma exacerbations.
- The patient's oxygenation is good, and she is febrile, which suggests that her asthma symptoms are worsening.
- Since the patient is already on albuterol, the best course of action would be to continue the current treatment and monitor her symptoms closely.
- If her symptoms worsen or do not improve, medical consultation should be sought promptly 2, 2.
From the Research
Treatment Options for Asthma Exacerbation
- The patient is currently on albuterol, but the worsening of symptoms over the past 24 hours suggests the need for additional treatment options.
- Studies have shown that the addition of ipratropium bromide to albuterol can provide more effective acute relief of bronchospasm in moderate-to-severe asthma 3, 4, 5.
- A meta-analysis of pediatric asthma patients found that ipratropium added to beta2-agonists improves lung function and decreases hospitalization rates, especially among children with severe exacerbations of asthma 5, 6.
Efficacy of Ipratropium Bromide and Albuterol Combination
- The combination of ipratropium bromide and albuterol has been shown to reduce the risk of hospital admission compared to albuterol alone in children and adolescents with asthma 6.
- Subgroup analysis found that the combination was most effective in participants with severe asthma exacerbation and moderate-to-severe exacerbation 6.
- The use of ipratropium bromide in conjunction with beta2-agonists has been found to improve airflow obstruction and decrease hospitalization rates without severe adverse effects 4, 5.
Management of Respiratory Failure in Asthma
- The goal of management is to restore patients to a state of quiet breathing without complication, often achieved by pharmacotherapy alone 7.
- Inhaled albuterol sulfate, oxygen, and systemic corticosteroids are mainstays of acute care drug management, while other data support the use of inhaled steroids, ipratropium bromide, and other treatments 7.