What additional therapy can be used for a child with an acute asthma exacerbation, presenting with moderate suprasternal indrawing, costal retractions, wheezing, hypoxemia, and tachypnea, who is already receiving prednisone and Ventolin (albuterol)?

From the Guidelines

For a child with an acute asthma exacerbation showing moderate respiratory distress, Atrovent (ipratropium bromide) would be the most appropriate additional therapy alongside standard management with prednisone and Ventolin (albuterol). Atrovent is an anticholinergic bronchodilator that works synergistically with beta-agonists like Ventolin by blocking parasympathetic-mediated bronchoconstriction through a different mechanism. During acute asthma exacerbations, combining these medications provides superior bronchodilation compared to using beta-agonists alone, as supported by the guidelines for managing asthma exacerbations 1. Typically, Atrovent is administered via nebulizer or metered-dose inhaler every 4-6 hours during the acute phase of treatment.

The addition of Atrovent is particularly beneficial in moderate to severe exacerbations and has been shown to reduce hospitalization rates and improve lung function more effectively than beta-agonists alone. Atrovent has minimal systemic side effects, making it safe for use in pediatric patients during acute asthma episodes. According to the guidelines, ipratropium bromide can be added to SABA therapy for severe exacerbations, and its use is recommended in the emergency department setting 1.

Key points to consider in the management of acute asthma exacerbations include:

• The use of oxygen, inhaled beta2-agonists, and systemic corticosteroids as primary treatment, with the dose and frequency of administration dependent on the severity of the exacerbation 1.
• The potential benefits of adding ipratropium bromide to beta-agonist therapy in moderate to severe exacerbations, as outlined in the guidelines for managing asthma exacerbations 1.
• The importance of close monitoring and repeated assessment of lung function to guide treatment decisions and determine the need for additional therapies or hospitalization 1.

From the FDA Drug Label

FLUTICASONE PROPIONATE SPRAY, METERED The FDA drug label does not answer the question.

From the Research

Management of Acute Asthma Exacerbation

The child's symptoms, including moderate suprasternal indrawing, costal retractions, and an inspiratory and expiratory wheeze, indicate a severe asthma exacerbation. In addition to standard management with prednisone and Ventolin, other therapies can be considered.

Additional Therapies

• Magnesium sulfate: Studies have shown that magnesium sulfate can be effective in reducing hospital length of stay and the risk of hospital admission in children with acute asthma exacerbations 2, 3.
• Atrovent (ipratropium bromide): Atrovent can be used as an adjunctive bronchodilator in the management of acute asthma exacerbations 2, 4.
• Nebulized epinephrine: While nebulized epinephrine is not commonly used, it can be considered in severe cases of asthma exacerbation 2.
• Flovent: Flovent is not typically used in the acute management of asthma exacerbations, but rather for long-term control of asthma symptoms.

Evidence Summary

The use of magnesium sulfate and Atrovent (ipratropium bromide) is supported by the evidence as additional therapies for acute asthma exacerbation in children 2, 3, 4. However, the effectiveness of nebulized magnesium in preventing hospitalization is uncertain, with one study showing no significant difference in hospitalization rates 5.