What is the treatment for a 9-year-old male with severe asthma exacerbation, presenting with hypoxemia and severe retractions, unresponsive to Albuterol (salbutamol)?

From the Guidelines

The treatment for a 9-year-old male with severe asthma exacerbation, presenting with hypoxemia and severe retractions, unresponsive to Albuterol (salbutamol), should include oxygen therapy, systemic corticosteroids, and ipratropium bromide in addition to continued inhaled beta2-agonists.

Treatment Approach

• Oxygen therapy: should be administered to maintain SaO2 > 92% 1
• Systemic corticosteroids: such as prednisolone 1-2 mg/kg body weight orally (maximum 40 mg) should be given to reduce airway inflammation 1
• Inhaled beta2-agonists: such as albuterol 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 should be continued 1
• Ipratropium bromide: should be added to the treatment regimen, with a dose of 0.25–0.5 mg every 20 minutes for 3 doses, then as needed 1

Monitoring and Adjunctive Therapy

• The patient's response to treatment should be closely monitored, with repeat PEF measurement 15-30 minutes after starting treatment and oximetry to maintain SaO2 > 92% 1
• If the patient is not improving after 15-30 minutes, nebulised agonist may be given more frequently, up to every 30 minutes, and magnesium sulfate or heliox may be considered as adjunctive treatments 1

From the Research

Treatment for Severe Asthma Exacerbation

The treatment for a 9-year-old male with severe asthma exacerbation, presenting with hypoxemia and severe retractions, unresponsive to Albuterol (salbutamol) includes:

• Oxygen therapy to control hypoxemia 2
• Administration of beta(2)-adrenoceptor agonists, such as salbutamol (albuterol), followed by corticosteroids 2, 3, 4
• Consideration of ipratropium bromide in addition to beta(2)-adrenoceptor agonists 2, 3, 4
• Use of intravenous magnesium sulfate for severe asthma exacerbations not responsive to conventional therapy 3, 5, 4
• Subcutaneous and intramuscular β2 agonists, such as terbutaline and epinephrine, for children with severe asthma exacerbation who have poor air entry or are uncooperative with nebulized therapy 4

Escalating Therapy

For patients with worsening clinical status, therapy can be escalated to include:

• Continuous β-agonists 5
• Helium-oxygen mixtures 5
• Intravenous terbutaline and/or aminophylline 5
• High-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia 5
• Sedation with low-dose ketamine (with or without benzodiazepines) infusions to allow better toleration of non-invasive ventilation and prepare the patient for tracheal intubation and mechanical ventilation, if indicated 5

Alternative Therapies

Alternative therapies, such as monoclonal anti-IgE antibody (omalizumab) and humanized monoclonal antibodies targeting interleukin pathway, have shown promise in severe refractory eosinophilic asthma 6, 4 Mepolizumab, an antagonist of interleukin-5, has been shown to improve lung function, reduce bronchial inflammation, and improve quality of life in a 9-year-old boy with severe asthma 6