What is the immediate treatment for a 13-year-old with moderate persistent asthma presenting with severe symptoms, including tachypnea (respiratory rate of 35), substernal retractions, loud inspiration and expiratory wheezing, and hypoxemia (o2 saturation of 89%)?

From the Guidelines

The immediate treatment for a 13-year-old with moderate persistent asthma presenting with severe symptoms, including tachypnea, substernal retractions, loud inspiration and expiratory wheezing, and hypoxemia, should focus on rapid bronchodilation, oxygenation, and reducing airway inflammation, with administration of high-flow oxygen, albuterol, and systemic corticosteroids as the cornerstone of treatment. The treatment approach should prioritize the patient's respiratory status, with the goal of maintaining oxygen saturation above 92% and alleviating bronchospasm. Key interventions include:

• Administering high-flow oxygen via face mask to maintain oxygen saturation above 92% 1
• Giving 4-6 puffs of albuterol (salbutamol) via metered-dose inhaler with spacer or 2.5-5 mg via nebulizer immediately, repeating every 20 minutes for the first hour 1
• Simultaneously administering oral prednisolone at 1-2 mg/kg (maximum 60 mg) or equivalent intravenous methylprednisolone if the patient cannot take oral medications 1
• Considering adding ipratropium bromide 0.5 mg via nebulizer or 4-8 puffs via MDI with spacer to enhance bronchodilation 1
• Continuous cardiac and oxygen saturation monitoring is essential to quickly identify any deterioration in the patient's condition 1 If the patient shows minimal improvement after initial treatments, intravenous magnesium sulfate (25-75 mg/kg, maximum 2 grams) should be considered 1. These interventions work by relaxing bronchial smooth muscle, reducing inflammation, and improving oxygenation, with the beta-agonist providing immediate bronchodilation and corticosteroids addressing the underlying inflammatory process, though their effect takes several hours 1. Reassess the patient frequently, as some may require escalation to intensive care if they fail to respond to these measures 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The immediate treatment for a 13-year-old with moderate persistent asthma presenting with severe symptoms is albuterol inhalation solution.

• The patient's weight is not provided, but assuming they weigh at least 15 kg, the recommended dosage is 2.5 mg of albuterol administered by nebulization.
• The treatment should be administered as soon as possible to help alleviate the severe symptoms, including tachypnea, substernal retractions, loud inspiration and expiratory wheezing, and hypoxemia.
• It is essential to monitor the patient's response to the treatment and seek medical advice immediately if the symptoms do not improve or worsen, as this may indicate a sign of seriously worsening asthma that requires reassessment of therapy 2.

From the Research

Immediate Treatment for Severe Asthma Symptoms

The immediate treatment for a 13-year-old with moderate persistent asthma presenting with severe symptoms, including tachypnea, substernal retractions, loud inspiration and expiratory wheezing, and hypoxemia, involves several key steps:

• Administering a short-acting beta2-agonist (SABA) such as albuterol via a metered-dose inhaler (MDI) with a spacer or nebulization to help relieve bronchospasm and improve lung function 3.
• Considering the addition of ipratropium bromide to the treatment regimen, as it has been shown to provide additive bronchodilator effects when used in conjunction with a beta2-agonist in patients with moderate-to-severe asthma 4, 5.
• Ensuring adequate oxygenation, as the patient's oxygen saturation is 89%, which is below the normal range 6.
• Monitoring the patient's response to treatment and adjusting the therapy as needed to achieve optimal control of symptoms.

Medication Options

The following medications may be considered for the treatment of severe asthma symptoms:

• Short-acting beta2-agonists (SABAs) such as albuterol for quick relief of bronchospasm 3.
• Ipratropium bromide as an add-on therapy to SABAs for patients with moderate-to-severe asthma 4, 5.
• Inhaled corticosteroids (ICS) as a long-term control medication to reduce airway inflammation and prevent exacerbations 7, 6.

Delivery Methods

The choice of delivery method for albuterol, such as MDI with a spacer or nebulization, may depend on the patient's age, severity of symptoms, and personal preference:

• MDI with a spacer is a convenient and effective method for delivering albuterol, especially in pediatric patients 3.
• Nebulization may be preferred in severe cases or when the patient is unable to use an MDI with a spacer effectively 3.