From the Guidelines
To treat an adolescent with asthma or shortness of breath (SOB) in an outpatient clinic, start with a thorough assessment including history, physical examination, and lung function testing, and prescribe an inhaled corticosteroid (ICS) such as fluticasone as first-line controller therapy, as recommended by the most recent guidelines 1. For acute symptoms, administer a short-acting beta-agonist like albuterol (2-4 puffs via MDI with spacer or 2.5 mg via nebulizer) and assess response. The treatment approach should be based on a stepwise approach for managing asthma, with the goal of achieving and maintaining control of persistent asthma, as outlined in the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1. Key considerations in the management of asthma include:
- Identifying and controlling environmental triggers
- Patient education and involvement in their care plan
- Monitoring of pulmonary function
- Pharmacological treatment, including the use of ICS, LABAs, and leukotriene modifiers, as needed
- Regular follow-ups to assess control and adjust treatment as necessary The most effective long-term control medications are those that attenuate the underlying inflammation characteristic of asthma, such as ICS, which reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, and block late-phase reaction to allergen 1. For severe cases, consider adding a leukotriene modifier (montelukast 10 mg daily) or referring to a specialist, and ensure proper inhaler technique, develop a written asthma action plan, and schedule regular follow-ups every 3-6 months 1. Patient education is crucial for successful management, as asthma involves chronic airway inflammation that requires consistent treatment to prevent exacerbations and maintain normal lung function, and adolescents should be directly involved in their care plan to improve adherence and outcomes.
From the FDA Drug Label
In a 12-week trial in adult and adolescent subjects with asthma, fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg twice daily was compared with fluticasone propionate inhalation powder 250 mcg alone, salmeterol inhalation powder 50 mcg alone, and placebo The systemic pharmacodynamic effects of salmeterol were not altered by the presence of fluticasone propionate in fluticasone propionate and salmeterol inhalation powder. In 72 adult and adolescent subjects with asthma given either fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg or fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg, continuous 24-hour electrocardiographic monitoring was performed after the first dose and after 12 weeks of therapy, and no clinically significant dysrhythmias were noted
The treatment approach for an adolescent presenting with asthma or shortness of breath (SOB) in an outpatient clinic may involve the use of fluticasone propionate and salmeterol inhalation powder.
- The dosage may be 100 mcg/50 mcg or 250 mcg/50 mcg twice daily.
- Monitoring for cardiovascular effects, such as pulse rate, blood pressure, and QTc interval, is recommended.
- The treatment should be individualized and based on the severity of the asthma and the patient's response to therapy 2
From the Research
Treatment Approach for Adolescent Asthma or Shortness of Breath
The treatment approach for an adolescent presenting with asthma or shortness of breath (SOB) in an outpatient clinic involves several key considerations, including:
- Diagnosis and assessment of asthma severity 3, 4
- Management of asthma using a supportive approach, involving the young person in management decisions about their asthma 3
- Use of inhaled corticosteroid (ICS)/long-acting beta(2)-agonist (LABA) combinations as preferred maintenance therapy for asthma patients uncontrolled by ICS alone 5
- Consideration of alternative diagnoses, such as vocal cord dysfunction, and the importance of an appropriate transition process to prepare the young person for transfer from child-centred care to adult-centred care 3, 6
Key Management Strategies
Some key management strategies for adolescent asthma or SOB include:
- Avoiding SABA-only treatment in the long-term management of asthma 4
- Using budesonide/formoterol reliever, with or without maintenance budesonide/formoterol, as preferred to SABA reliever, with or without maintenance ICS or ICS/LABA, across the spectrum of asthma severity 4
- Introduction of the terminology 'anti-inflammatory reliever (AIR)' therapy to describe the use of budesonide/formoterol as a reliever medication, with or without maintenance budesonide/formoterol therapy 4
- Consideration of biologic therapies for severe asthma, such as omalizumab and mepolizumab 4, 6
Difficult-to-Treat Asthma
For adolescents with difficult-to-treat asthma, a multidisciplinary team approach and systematic assessment are required to address key questions, including: