From the Guidelines
The most appropriate management for this 8-year-old girl with acute asthma exacerbation involves immediate escalation of therapy, including three back-to-back treatments of albuterol nebulizer (2.5mg) combined with ipratropium bromide (0.5mg), along with oral prednisolone (1-2mg/kg, typically 30-40mg) or equivalent systemic corticosteroid, as recommended by the British Thoracic Society guidelines 1. The patient's symptoms, including a rattling cough, wheeze, low-grade fever, and sore throat, despite recent albuterol treatment via nebulizer, indicate a moderate-to-severe exacerbation requiring more aggressive bronchodilation and anti-inflammatory therapy. The presence of fever and sore throat suggests a possible viral trigger for her exacerbation, which is common in pediatric asthma. Supplemental oxygen should be provided to maintain oxygen saturation above 92%, as suggested by the guidelines for the management of asthma 1. After these initial treatments, reassessment is crucial to determine if hospitalization is needed. If improvement occurs, continue albuterol every 4-6 hours and complete a 3-5 day course of oral steroids. Close follow-up with her primary care provider within 24-48 hours is essential to adjust her maintenance asthma therapy and develop an action plan to prevent future exacerbations, as emphasized in the guidelines for self-management of asthma 1. Key aspects of her management include:
- Aggressive bronchodilation with beta-agonists and anticholinergics
- Reduction of airway inflammation with systemic corticosteroids
- Supplemental oxygen to maintain adequate oxygen saturation
- Close monitoring and follow-up to adjust treatment as needed
- Development of a self-management plan to prevent future exacerbations, including education on the proper use of inhaled drugs, recognition of worsening symptoms, and the importance of nocturnal symptoms.
From the FDA Drug Label
Patient Package Insert PATIENT’S INSTRUCTIONS FOR USE Read complete instructions carefully before using. Remove vial from the foil pouch, twist open the top of one unit-dose vial and squeeze the contents into the nebulizer reservoir (Figure 1). Connect the nebulizer reservoir to the mouthpiece or face mask (Figure 2). Connect the nebulizer to the compressor Sit in a comfortable, upright position; place the mouthpiece in your mouth (Figure 3) or put on the face mask and turn on the compressor. If a face mask is used, care should be taken to avoid leakage around the mask as temporary blurring of vision, pupil enlargement, precipitation or worsening of narrow angle glaucoma, or eye pain may occur if the solution comes into direct contact with the eyes Breathe as calmly, deeply and evenly as possible until no more mist is formed in the nebulizer chamber (about 5 to 15 minutes). At this point, the treatment is finished. Clean the nebulizer (see manufacturer’s instructions). Note: Use only as directed by your physician. More frequent administration or higher doses are not recommended Ipratropium bromide inhalation solution can be mixed in the nebulizer with albuterol or metaproterenol if used within one hour but not with other drugs. Drug stability and safety of ipratropium bromide inhalation solution when mixed with other drugs in a nebulizer have not been established.
The most appropriate management for this patient would be to add ipratropium bromide to her current treatment, as it can be mixed with albuterol in the nebulizer. Key points to consider:
- The patient has already received albuterol via nebulizer with no change in symptoms.
- Ipratropium bromide can be used in conjunction with albuterol.
- The patient's symptoms, such as wheezing and cough, may be alleviated with the addition of ipratropium bromide to her treatment regimen 2. Main considerations for this patient's management include:
- Monitoring her oxygen saturation and respiratory status.
- Ensuring proper use of the nebulizer and administration of the medication.
- Considering the potential for side effects, such as eye pain or blurred vision, if the solution comes into contact with the eyes.
From the Research
Assessment of the Patient's Condition
The patient is an 8-year-old girl with asthma, presenting with a rattling cough, wheeze, low-grade fever, and sore throat. She has been experiencing these symptoms for the past 24 hours, with no improvement after two doses of albuterol via nebulizer. Her current medications include loratadine and albuterol via dose inhaler and nebulizer.
Appropriate Management
Given the patient's symptoms and history, the most appropriate management would include:
- Continued use of short-acting beta agonist therapy (albuterol) as needed 3
- Administration of systemic corticosteroids, such as prednisone or dexamethasone, to reduce airway inflammation and prevent future relapses 4
- Consideration of adding ipratropium bromide to the treatment regimen, although its benefit in pediatric patients is still debated 5
- Maintenance of adequate arterial oxygen saturation with supplemental oxygen as needed
- Monitoring of the patient's condition and adjustment of the treatment plan accordingly
Treatment Options
The following treatment options may be considered:
- Inhaled ipratropium bromide in combination with beta(2)-agonists for severe acute asthma 6
- Systemic corticosteroids, such as prednisone or dexamethasone, for reduction of airway inflammation and prevention of future relapses 4
- Leukotriene receptor antagonists, such as montelukast, as an alternative to inhaled corticosteroids for mild persistent asthma 7