What is the management for an 11-year-old with uncontrolled asthma?

Management of Uncontrolled Asthma in an 11-Year-Old Child

For an 11-year-old with uncontrolled asthma, the management should include stepping up therapy with daily long-term controller medications, particularly inhaled corticosteroids, and adding additional agents as needed based on asthma control assessment. 1

Assessment of Asthma Control

• Determine the level of control by evaluating:
  • Symptom frequency (>2 days/week indicates not well-controlled) 1
  • Nighttime awakenings (≥2 times/month indicates not well-controlled) 1
  • Interference with normal activity 1
  • Short-acting β2-agonist use for symptom control (>2 days/week indicates not well-controlled) 1
  • Lung function (FEV1 or peak flow 60%-80% of predicted indicates not well-controlled) 1
  • Exacerbations requiring oral systemic corticosteroids (≥2/year indicates very poorly controlled) 1

Stepwise Approach to Treatment

Step 1: Optimize Current Therapy

• Verify proper inhaler technique and medication adherence 1
• Address the child's concerns, preferences, and school schedule in selecting treatments 1
• Ensure daily long-term control therapy is being used as prescribed 1

Step 2: Step Up Therapy Based on Current Control

• For not well-controlled asthma:

  • Increase inhaled corticosteroid (ICS) dose to medium level 1, 2
  • Consider adding a long-acting beta2-agonist (LABA) in combination with ICS for children aged 5-11 years 2
  • Fluticasone propionate/salmeterol combination (Wixela Inhub 100/50) is indicated for twice-daily treatment in children aged 4-11 years 2

• For very poorly controlled asthma:

  • Increase to high-dose ICS plus LABA 1
  • Consider adding ipratropium for acute exacerbations 3
  • Consider oral systemic corticosteroids for short-term use 1

Step 3: Consider Additional Controllers

• Add-on options include:
  • Leukotriene receptor antagonists (LTRAs) 4
  • Cromolyn sodium or nedocromil 4
  • Theophylline (less commonly used due to side effect profile) 4

Step 4: Referral to Asthma Specialist

• Refer to specialist if:
  • Difficulties achieving or maintaining control 1
  • Consideration of biologic therapy for severe, therapy-resistant asthma 5
  • Need for additional testing 1

Management of Acute Exacerbations

• For acute severe asthma symptoms:
  • High-flow oxygen via face mask to maintain SaO₂ >92% 3
  • Nebulized salbutamol 5 mg (or half dose for younger children) 3
  • Intravenous hydrocortisone followed by oral prednisolone 1-2 mg/kg daily (maximum 40 mg) 1, 3
  • Add ipratropium 100 mg nebulized every 6 hours 1, 3
  • Monitor peak expiratory flow (PEF) before and after treatment 1

Follow-up and Monitoring

• Monitor response to therapy closely 1
• Adjust treatment if no clear positive response within 4-6 weeks 1
• Schedule follow-up within 1-4 weeks after changing therapy 1
• Provide the child with a peak flow meter and written asthma action plan 1
• Assess for factors contributing to poor control:
  • Environmental triggers 6
  • Comorbidities 7
  • Medication adherence issues 8

Common Pitfalls to Avoid

• Overreliance on short-acting beta-agonists without adequate controller medications 8
• Failure to step up therapy when asthma is not well-controlled 1
• Inadequate assessment of inhaler technique 1
• Not addressing environmental triggers and comorbidities 6
• Insufficient follow-up after medication changes 1

Remember that uncontrolled asthma in children can compromise lung function development and overall well-being, making aggressive management essential 6.