What treatment should be given to a 9-year-old with an asthma flare illness already using Albuterol (salbutamol) 4 times a day?

Management of Asthma Flare in a 9-Year-Old Already Using Albuterol 4 Times Daily

A 9-year-old child with an asthma flare who is already using albuterol 4 times daily should receive oral corticosteroids (prednisone/prednisolone 1-2 mg/kg/day, maximum 60 mg) in addition to their albuterol therapy, and should have ipratropium bromide added to their nebulizer treatments if symptoms are severe. 1

Assessment of Severity

• Determine if the child has features of acute severe asthma: too breathless to talk or feed, respiratory rate >50 breaths/min, pulse >140 beats/min, or peak expiratory flow (PEF) <50% predicted 1
• Life-threatening features include: PEF <33% predicted, poor respiratory effort, cyanosis, silent chest, fatigue, or reduced level of consciousness 1
• The need for albuterol 4 times daily indicates poor asthma control and potential for deterioration 1

Immediate Treatment

For Moderate Exacerbation:

• Continue albuterol via nebulizer at 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses, then every 1-4 hours as needed 1
• Add oral prednisolone/prednisone 1-2 mg/kg/day (maximum 60 mg) for 3-10 days 1
• Consider adding ipratropium bromide (0.25-0.5 mg nebulized every 20 minutes for 3 doses, then as needed) 1

For Severe Exacerbation:

• Provide high-flow oxygen via face mask to maintain SaO₂ >92% 2
• Administer salbutamol (albuterol) 5 mg (or 2.5 mg if child weighs <20 kg) via oxygen-driven nebulizer 3, 2
• Add ipratropium bromide 100 mg nebulized every 6 hours 2
• Give oral prednisolone 1-2 mg/kg daily (maximum 40 mg) 2
• Consider hospitalization if no improvement after treatment 1

Evidence for Adding Ipratropium Bromide

• In children with severe asthma exacerbations (PEF <50% predicted), adding ipratropium bromide to albuterol and corticosteroid therapy significantly reduces hospitalization rates (37.5% vs 52.6%, P=0.02) 4
• Ipratropium should be added to nebulizer treatment and repeated 6 hourly until improvement starts 1
• The combination may be used for up to 3 hours in the initial management of severe exacerbations 1

Monitoring Response

• Measure PEF 15-30 minutes after starting treatment if age-appropriate 2
• Chart PEF before and after β-agonist administration 2
• Monitor oxygen saturation continuously to maintain SaO₂ >92% 2
• Assess for improvement in respiratory rate, work of breathing, and ability to speak or feed 1

When to Seek Emergency Care

• Failure to respond to or early deterioration after inhaled bronchodilators 1
• Severe breathlessness and increasing tiredness 1
• PEF <50% of expected value 10 minutes after treatment 1
• Presence of any life-threatening features 1

Common Pitfalls to Avoid

• Avoid overreliance on short-acting beta-agonists without adequate controller medications 3
• Do not delay administration of corticosteroids in acute exacerbations 3
• Avoid inadequate assessment of inhaler technique, which can lead to suboptimal medication delivery 3
• Do not use theophylline in addition to nebulized albuterol and corticosteroids, as it provides no additional benefit and may increase side effects 5

Follow-up Plan

• Ensure proper inhaler technique and medication adherence 3
• Schedule follow-up with primary care provider within 1 week 1
• Consider referral to asthma specialist within 4 weeks 1
• Evaluate need for daily controller medication (inhaled corticosteroid) to prevent future exacerbations 6