What should I consider for an asthma exacerbation in a 6-year-old despite using two inhalers, a reliever (e.g., albuterol) and a controller (e.g., fluticasone)?

Management of Asthma Exacerbation in a 6-Year-Old Despite Two Inhalers

For a 6-year-old child experiencing an asthma exacerbation despite using both a reliever (albuterol) and controller (fluticasone) inhaler, add ipratropium bromide to albuterol for immediate relief, initiate a short course of oral corticosteroids (1-2 mg/kg/day of prednisone for 3-10 days), and assess for potential triggers and adherence issues. 1

Immediate Management of the Exacerbation

Step 1: Assess Severity

• Evaluate ability to speak in complete sentences
• Check respiratory rate (mild exacerbation: <25 breaths/min)
• Monitor heart rate (mild exacerbation: <110 beats/min)
• Assess work of breathing and oxygen saturation 2

Step 2: Intensify Rescue Medication

• Administer albuterol via MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 1, 2
• For nebulizer treatment: 0.075 mg/kg (minimum dose 1.25 mg) every 20 minutes for 3 doses 1
• Add ipratropium bromide:
  • Via nebulizer: 0.25-0.5 mg every 20 minutes for 3 doses 1
  • Via MDI: 4-8 puffs every 20 minutes for up to 3 hours 1

Step 3: Add Systemic Corticosteroids

• Initiate oral prednisone/prednisolone: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1
• No need to taper for courses less than 1 week 1

Post-Exacerbation Assessment

Evaluate Medication Adherence

• Check inhaler technique with both devices
• Verify dosing frequency and timing
• Assess understanding of maintenance vs. rescue medication use 1, 3

Identify Potential Triggers

• Environmental allergens (dust mites, pet dander)
• Recent respiratory infections
• Exercise-induced symptoms
• Weather changes
• Indoor air quality issues 1

Review Current Controller Therapy

• Assess if current controller dose is adequate
• For mild persistent asthma: low-dose inhaled corticosteroid (ICS) is the preferred controller 1, 2
• For moderate persistent asthma: consider step-up options 1

Step-Up Options for Inadequately Controlled Asthma

Option 1: Increase ICS Dose

• If currently on low-dose fluticasone, consider increasing to medium-dose range 1
• Note: Evidence shows that increasing ICS dose alone may not be sufficient for exacerbation prevention 4

Option 2: Add Second Controller Medication

• For children ≥4 years: Consider adding long-acting beta-agonist (LABA) to ICS 1, 5
• For children <4 years: Consider adding leukotriene receptor antagonist (LTRA) like montelukast 1
• Note: Combination ICS-LABA therapy provides better control than increasing ICS dose alone in children ≥4 years 1, 5

Important Considerations and Pitfalls

Common Pitfalls to Avoid

• Failing to assess inhaler technique - proper spacer use is critical for effective medication delivery in children 2
• Not addressing adherence issues before stepping up therapy 3
• Overlooking alternative diagnoses or comorbidities that may mimic or worsen asthma 3, 6
• Neglecting to provide a written asthma action plan for future exacerbations 1

Monitoring for Side Effects

• Monitor for tachycardia and tremors with increased albuterol use 2, 7
• Be aware of potential hypokalemia with repeated beta-agonist dosing 7
• For systemic corticosteroids: monitor for short-term effects like increased appetite, mood changes, and sleep disturbances 1
• For long-term ICS: monitor growth velocity 1, 2

When to Refer to a Specialist

• If symptoms persist despite adherence to step 3 or 4 therapy
• If the child has had life-threatening asthma exacerbations
• If there are significant comorbidities complicating management
• If the diagnosis is uncertain 3, 6

Remember that proper technique with spacer devices is essential for effective medication delivery in children. Always ensure the child is using age-appropriate devices and that both the child and caregivers understand proper administration techniques.