What is the treatment for an acute asthma exacerbation in a 7-year-old male?

From the Guidelines

For a 7-year-old male experiencing an asthma exacerbation, immediate treatment should begin with a short-acting beta-agonist (SABA) such as albuterol via metered-dose inhaler with spacer (4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed) or nebulizer (0.15 mg/kg, minimum dose 2.5 mg, every 20 minutes for 3 doses, then 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed) 1.

Key Treatment Components

• Oral corticosteroids should be started promptly - prednisolone or prednisone at 1-2 mg/kg/day (maximum 60 mg) for 3-5 days without tapering.
• Oxygen should be administered if oxygen saturation is below 92%.
• If the child shows severe distress or poor response to initial treatment, add ipratropium bromide (0.25-0.5 mg every 20 minutes for 3 doses, then as needed) to the albuterol treatments.

Monitoring and Hospitalization

• Continuous monitoring of respiratory rate, heart rate, oxygen saturation, and work of breathing is essential.
• The child should be hospitalized if there's inadequate response to treatment, persistent oxygen requirement, or signs of respiratory fatigue.

Post-Acute Episode Management

• After the acute episode resolves, review the child's maintenance therapy, ensure proper inhaler technique, and develop a written asthma action plan to prevent future exacerbations, as recommended by guidelines for managing asthma exacerbations 1.

Rationale

These medications work by quickly relaxing airway smooth muscles (albuterol), reducing inflammation (corticosteroids), and providing additional bronchodilation (ipratropium) 1. The treatment approach is guided by the principles of managing asthma exacerbations, which emphasize prompt recognition, treatment, and monitoring to prevent severe outcomes 1.

From the FDA Drug Label

Acute Exacerbations or Deteriorations Formoterol Fumarate Inhalation Solution is not indicated for relief of acute symptoms, and extra doses should not be used for that purpose Acute symptoms should be treated with an inhaled, short-acting beta2-agonist (the healthcare provider should provide the patient with such medication and instruct the patient in how it should be used) The treatment for an acute asthma exacerbation in a 7-year-old male is to use an inhaled, short-acting beta2-agonist as directed by a healthcare provider.

• The patient should be instructed on how to use this medication.
• Formoterol Fumarate Inhalation Solution is not indicated for relief of acute symptoms. 2

From the Research

Treatment for Acute Asthma Exacerbation

• The treatment for an acute asthma exacerbation in a 7-year-old male involves the administration of oxygen to keep the oxygen saturation above 92% 3
• Short-acting, selective beta-2 agonists should be administered, which can be delivered by intermittent nebulization, continuous nebulization, or by metered dose inhaler (MDI) with a spacer 3
• The early administration of systemic corticosteroids is essential for the management of acute asthma in children, and when tolerated, can be given orally 3
• Administration of multiple doses of ipratropium bromide has been shown to decrease the hospitalization rate in children and adolescents with severe asthma 3

Combination Therapy

• The combination of inhaled anticholinergics and short-acting beta2-agonists (SABAs) has been shown to reduce the risk of hospital admission in children with acute asthma exacerbations 4
• The addition of an anticholinergic to a SABA significantly reduced the risk of hospital admission, with a number needed to treat for an additional beneficial outcome (NNTB) of 16 4
• However, in children hospitalized for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulized anticholinergics were added to short-acting β2-agonists 5

Status Asthmaticus

• Status asthmaticus is an acute exacerbation of asthma that is persistent and intractable and remains unresponsive to initial treatment with bronchodilators and systemic corticosteroids 6
• Supplemental oxygen should be given to maintain an oxygen saturation of ≥ 92% in room air, and short-acting, β2 agonists such as salbutamol (albuterol) should be administered by metered-dose inhaler with spacer or by nebulizer 6
• Inhaled ipratropium bromide and intravenous magnesium sulfate should be considered in children with severe asthma exacerbations not responsive to conventional therapy 6

Factors Associated with Treatment Failure

• Factors associated with a poor response to intermittent nebulized SABA in children with severe asthma exacerbation include a previous history of intubation, receiving <3 doses of nebulized salbutamol in the emergency room, ER measured oxygen saturation (SpO2) <92%, and exacerbation triggered by pneumonia 7