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

Management of Asthma in an 11-Year-Old Child

The management of asthma in an 11-year-old should follow a stepwise approach, with inhaled corticosteroids (ICS) as the preferred long-term control therapy, supplemented by short-acting beta-agonists (SABA) for quick relief. 1

Assessment and Diagnosis

• Confirm asthma diagnosis through history of recurrent wheeze, cough (especially at night), activity limitation, and symptoms triggered by viral infections, exercise, allergens, or environmental irritants 1, 2
• Assess severity using objective measures when possible, including peak expiratory flow (PEF) measurements for children aged 5 years and over 1
• Evaluate for comorbidities that may worsen asthma control, such as allergic rhinitis, sinusitis, or gastroesophageal reflux 3

Stepwise Management Approach

Step 1: Mild Intermittent Asthma

• Short-acting beta-agonists (SABA) like albuterol as needed for symptom relief 1, 4
• No daily controller medication needed 1

Step 2: Mild Persistent Asthma

• Low-dose inhaled corticosteroids (ICS) as daily controller medication 1, 5
• SABA as needed for symptom relief 1, 4

Step 3: Moderate Persistent Asthma

• Medium-dose ICS 1
• OR low-dose ICS plus a long-acting beta-agonist (LABA) 1
• SABA as needed for symptom relief 1, 4

Step 4: Severe Persistent Asthma

• Medium to high-dose ICS plus LABA 1
• Consider adding tiotropium, montelukast, or theophylline as additional controller options 6
• SABA as needed for symptom relief 1, 4

Step 5: Very Severe Persistent Asthma

• High-dose ICS plus LABA 1
• Consider referral to asthma specialist 1
• Consider omalizumab for allergic asthma 6
• Consider oral corticosteroids for short periods 2

Medication Considerations for 11-Year-Olds

• Inhaled corticosteroids are the preferred long-term control therapy, with benefits outweighing potential risks of small growth reduction 1, 5
• Ensure appropriate inhaler device selection based on the child's ability to use it correctly 1
• For children who cannot coordinate breathing with metered-dose inhalers (MDIs), use a spacer device 1
• Titrate ICS to the lowest effective dose to maintain control while minimizing potential side effects 1, 5
• Monitor height regularly in children using ICS 1, 5

Management of Acute Exacerbations

• Administer SABA via spacer device or nebulizer every 20-30 minutes for the first hour 1, 2
• Add oral corticosteroids (prednisolone 1-2 mg/kg, maximum 40 mg) for moderate to severe exacerbations 1, 2
• Consider adding nebulized ipratropium bromide for severe exacerbations 1, 7
• Maintain oxygen saturation above 92% using supplemental oxygen if needed 1, 2
• If life-threatening features present (silent chest, cyanosis, poor respiratory effort, altered consciousness), consider IV aminophylline and immediate hospital transfer 1
• Reserve epinephrine for catastrophic asthma when other treatments have failed 7

Self-Management Education

• Provide a written asthma action plan that includes when to increase medications and when to seek medical help 1, 2
• Teach proper inhaler technique and check regularly 1
• Educate about the difference between "reliever" and "preventer" medications 1
• Ensure the child and family can recognize signs of worsening asthma 1, 2
• Encourage peak flow monitoring for children aged 5 and older 1, 2

Follow-up and Monitoring

• Schedule follow-up within 1 week after an exacerbation 1
• Regular follow-up every 1-3 months until control is achieved, then every 3-6 months 2
• Monitor response to therapy; if no clear benefit within 4-6 weeks, reevaluate diagnosis or adjust treatment 1, 2
• Document height and weight regularly to monitor growth velocity 1, 5
• Consider stepping down therapy after 3 months of good control 1

Environmental Control Measures

• Identify and reduce exposure to triggers such as allergens and irritants 1
• Address maternal/parental smoking as a priority 1
• Consider allergen testing if symptoms suggest allergic triggers 1

Common Pitfalls to Avoid

• Overreliance on SABA without adequate controller medication 2
• Failure to step up therapy when asthma is not well-controlled 2
• Inadequate assessment of inhaler technique 2
• Insufficient follow-up after medication changes 2
• Underuse of written asthma action plans 1
• Overlooking growth monitoring in children on ICS 1, 5