What is the appropriate management for a 13-year-old male with uncontrolled asthma, weighing 68 pounds, considering a 7-day oral course of Prednisone and powdered albuterol (Salbutamol) aerosol?

Management of Uncontrolled Asthma in a 13-Year-Old Male (68 lbs)

For this 13-year-old with uncontrolled asthma, initiate oral prednisolone 1-2 mg/kg daily (maximum 40 mg) for up to 5 days along with nebulized albuterol (salbutamol) 2.5-5 mg every 4-6 hours, delivered via nebulizer or metered-dose inhaler with spacer. 1

Prednisolone Dosing

Weight-based calculation for this patient:

• 68 lbs = 31 kg
• Dose: 1-2 mg/kg = 31-62 mg daily
• Maximum pediatric dose: 40 mg daily 1

Duration and tapering:

• Continue for up to 5 days if treating at home 1
• No taper needed for courses ≤2 weeks - can stop abruptly from full dose 1
• If no improvement after 5 days, immediate hospital referral is required 1

The British Thoracic Society guidelines specifically state that children requiring high-dose inhaled bronchodilators should receive prednisolone 1-2 mg/kg as a single daily dose (maximum 40 mg) repeated for up to 5 days 1. Research supports that even single-dose oral steroids significantly improve outcomes in acute pediatric asthma, preventing deterioration and reducing hospitalization 2.

Albuterol (Salbutamol) Administration

Dosing options:

• Nebulized: 2.5-5 mg every 4-6 hours for maintenance; can increase to every 15-30 minutes if not improving 1
• Alternative delivery: MDI with large-volume spacer (1 puff every few seconds, maximum 20 puffs) may be equally effective 1

Important caveat: Research demonstrates that 2.5 mg albuterol every 20 minutes is as effective as 7.5 mg for most patients with acute asthma 3. Higher doses offer no routine advantage unless the patient has very severe obstruction 3.

Critical Assessment Points

Before initiating treatment, assess severity:

• Respiratory rate >50 breaths/min indicates severe asthma 1
• Pulse >140 beats/min indicates severe asthma 1
• Peak expiratory flow <50% predicted indicates severe asthma 1
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, exhaustion, altered consciousness 1

Immediate hospital referral criteria:

• Failure to respond to initial bronchodilator treatment 1
• Severe breathlessness and increasing tiredness 1
• PEF <50% predicted 10 minutes after treatment 1
• Any life-threatening features present 1

Monitoring and Follow-Up

If treating at home:

• Objective confirmation of improvement required before leaving the patient 1
• Peak flow monitoring on a chart 1
• Surgery review within 48 hours 1
• Self-management plan provided 1

Lower threshold for admission if:

• Attack occurs in afternoon/evening 1
• Recent nocturnal symptoms or worsening 1
• Previous severe attacks or hospital admissions 1

Safety Considerations

Prednisolone precautions:

• Short courses (≤2 weeks) produce very low rates of gastrointestinal bleeding 1
• Children receiving ≥4 "bursts" per year may develop hypothalamic-pituitary-adrenal axis suppression 4
• For this single 5-7 day course, HPA axis concerns are minimal 4

Albuterol precautions:

• May cause transient hypokalemia (20-25% decline in serum potassium with repeated dosing) 5
• Use with caution if patient has cardiovascular disorders, though this is rarely relevant in pediatrics 5
• Should not be used more frequently than recommended without medical consultation 5

Critical pitfall: Many asthma deaths result from underestimating severity and underusing corticosteroids 1. Objective measurement (peak flow) is essential - do not rely solely on clinical impression 1.