What is the treatment for a 15-year-old patient with shortness of breath due to an upper respiratory infection?

Treatment of Upper Respiratory Infection with Shortness of Breath in a 15-Year-Old

For a 15-year-old with shortness of breath from an upper respiratory infection, you must first determine if this represents asthma exacerbation or bronchospasm triggered by the viral infection, which requires immediate bronchodilator therapy, or if this is simple viral URI with mild dyspnea that will resolve with supportive care alone.

Initial Assessment and Risk Stratification

The critical first step is distinguishing between different causes of respiratory distress in this age group:

• Assess severity immediately: Check if the patient can complete sentences, respiratory rate (>25/min is concerning), heart rate (>110/min is concerning), and oxygen saturation 1
• Most URIs in adolescents are viral and self-limited, resolving in 7-10 days without specific treatment 2, 3
• However, viral respiratory infections are the predominant trigger for asthma exacerbations in children and adolescents, making this the most important differential 4

When Shortness of Breath Indicates Asthma/Bronchospasm

If the patient shows signs of bronchospasm or has a history of asthma:

Immediate Treatment for Acute Bronchospasm

• Administer nebulized beta-agonist immediately: Salbutamol 5 mg or terbutaline 10 mg via nebulizer, repeated every 1-4 hours if improving 1
• Add oxygen if oxygen saturation <92% to maintain saturation above 92% 1
• Consider oral corticosteroids: Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) for moderate to severe exacerbations 1, 4

Escalation Criteria

• If not improving after 15-30 minutes: Add ipratropium bromide 250 µg to the nebulizer and repeat every 6 hours 1
• Consider hospital admission if: respiratory rate >50/min, heart rate >140/min, cannot talk or feed, oxygen saturation remains <92% despite treatment 1

When It's Simple Viral URI Without Bronchospasm

If examination reveals normal lung sounds, no wheezing, and the patient can speak in full sentences:

Symptomatic Treatment Only

• Acetaminophen or ibuprofen for fever and discomfort (acetaminophen preferred based on COVID-era guidance, though this applies broadly) 1, 2
• Antihistamines and/or decongestants for congestion and rhinorrhea 2
• No antibiotics indicated for uncomplicated viral URI 1, 4, 2
• Reassurance that symptoms typically resolve in 7-10 days 1, 2, 3

Antibiotic Considerations

Antibiotics are NOT indicated for simple viral URI, but consider them in specific circumstances:

• In children over 3 years with pneumonia: Amoxicillin 80-100 mg/kg/day is first-line if pneumococcal pneumonia is suspected 1
• Macrolides may be considered in adolescents if atypical bacteria (Mycoplasma pneumoniae, Chlamydia pneumoniae) are suspected based on clinical presentation 1, 4
• Amoxicillin-clavulanate for bacterial sinusitis or if fever >38.5°C persists beyond 3 days with purulent symptoms 1

Critical Red Flags Requiring Immediate Escalation

Watch for these concerning features that warrant urgent evaluation:

• Respiratory distress: Cannot complete sentences, respiratory rate >50/min, using accessory muscles 1
• Hypoxia: Oxygen saturation <92% on room air 1
• Severe symptoms: Cyanosis, confusion, exhaustion, or altered consciousness 1
• Stridor or upper airway obstruction: Requires immediate airway assessment 5

Follow-Up and Monitoring

• Re-evaluate if not improving within 48 hours of symptom onset 1
• Return immediately if worsening: Increased work of breathing, inability to maintain hydration, or development of high fever 1
• For diagnosed asthma exacerbation: Follow up within 1 week with primary care and consider respiratory specialist within 4 weeks 1

Common Pitfalls to Avoid

• Don't assume all wheezing is asthma: Consider foreign body aspiration, cardiac disease, or other structural abnormalities in new-onset wheezing 4
• Don't prescribe antibiotics for viral URI: This contributes to resistance without benefit 1, 4, 2
• Don't underestimate viral-triggered bronchospasm: Even without prior asthma diagnosis, viral infections can cause significant bronchospasm requiring bronchodilator therapy 4
• Don't delay bronchodilator therapy while waiting for diagnostic workup if clinical signs of bronchospasm are present 1