What are the next steps for a 14-year-old with severe shortness of breath and a history of asthma, after administering albuterol (Ventolin) and ipratropium (Atrovent) twice?

Management of Severe Asthma in a 14-Year-Old After Initial Bronchodilator Treatment

For a 14-year-old with severe shortness of breath and history of asthma who has already received albuterol and ipratropium twice, the next steps should include administering systemic corticosteroids, continuing oxygen therapy, and increasing the frequency of bronchodilator treatments while closely monitoring for signs of respiratory failure that would necessitate ICU transfer. 1

Assessment of Severity

First, quickly assess the severity of the asthma exacerbation:

• Check for life-threatening features: PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue/exhaustion, agitation, or reduced level of consciousness 1
• Monitor vital signs: respiratory rate >50/min and pulse >140/min indicate severe asthma in children 1
• Evaluate ability to speak or feed - inability indicates severe exacerbation 1
• Measure oxygen saturation - maintain SaO2 >92% 1

Immediate Next Steps

1. Continue Respiratory Support

• Administer high-flow oxygen via face mask to maintain SaO2 >92% 1
• Monitor oxygen saturation continuously 1

2. Add Systemic Corticosteroids

• Give oral prednisolone 1-2 mg/kg body weight (maximum 40 mg) 1
• If unable to take oral medication, administer intravenous hydrocortisone 1
• Corticosteroids speed resolution of airflow obstruction and reduce relapse rates 1

3. Intensify Bronchodilator Therapy

• If not improving after the two treatments already given:
  • Increase frequency of nebulized albuterol (salbutamol) up to every 15-30 minutes 1
  • Continue ipratropium bromide (100 μg for children) and repeat every 6 hours until improvement begins 1
  • The combination of albuterol and ipratropium has been shown to reduce hospitalization rates in severe asthma exacerbations 2

4. Consider Delivery Method

• MDI with valved holding chamber may be more effective than nebulizer for delivering bronchodilators, even in severe exacerbations 3
• A randomized clinical trial showed lower hospitalization rates (5.8% vs 27.5%) when using MDI with valved holding chamber versus nebulizer for severe exacerbations 3

Monitoring Response

• Repeat peak flow measurement 15-30 minutes after each treatment 1
• Chart PEF before and after bronchodilator administration 1
• Monitor for clinical improvement: decreased work of breathing, improved air entry, decreased wheezing 1
• If using a clinical asthma score, reassess regularly 2

Escalation of Care

Transfer to ICU if:

• Deteriorating PEF despite treatment 1
• Worsening exhaustion, feeble respirations 1
• Persistent hypoxia despite oxygen therapy 1
• Development of confusion or drowsiness 1
• Respiratory arrest or coma 1

Consider IV Aminophylline if Life-Threatening Features Present:

• Administer 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h 1
• Omit loading dose if child is already receiving oral theophyllines 1, 4
• Note that aminophylline requires careful monitoring due to its narrow therapeutic window 4

Important Considerations

• Avoid sedatives as they may worsen respiratory depression 1
• Consider chest radiograph to exclude pneumothorax if patient is very ill 1
• Blood gas measurements are rarely helpful in initial management of children but may be considered if the patient is not improving 1
• Warmed humidified oxygen with nebulized medications may provide additional benefit in winter months 5

Disposition Planning

If the patient improves with the above interventions:

• Continue treatment with high-flow oxygen, corticosteroids, and scheduled bronchodilators 1
• Plan for at least 24 hours of observation before considering discharge 1

If the patient requires hospitalization, ensure they meet discharge criteria before sending home:

• On discharge medications for 24 hours with proper inhaler technique 1
• PEF >75% of predicted with diurnal variability <25% 1
• Treatment plan including oral steroids, inhaled steroids, and bronchodilators 1
• Follow-up with primary care within 1 week 1

The combination approach of intensifying bronchodilator therapy while adding systemic corticosteroids has been shown to be the most effective strategy for managing severe asthma exacerbations in children 1, 2.