How to manage a 1.5-year-old child with a second episode of wheezing who responded well to nebulised (nebulized) salbutamol (albuterol)?

Management of Second Wheezing Episode in a 1.5-Year-Old Child

For a 1.5-year-old child experiencing a second wheezing episode with good response to nebulised salbutamol, continue acute treatment with nebulised salbutamol 2.5 mg (0.15 mg/kg) as needed, and strongly consider initiating regular inhaled corticosteroids given the recurrent nature of symptoms. 1, 2

Acute Episode Management

Immediate Treatment

• Administer nebulised salbutamol 2.5 mg (appropriate dose for children <20 kg) via nebulizer 1
• Monitor response 15-30 minutes after nebulisation 3
• If available, use oxygen-driven nebulizer to maintain oxygen saturation >92% 4
• Alternatively, if no nebulizer is available, deliver salbutamol via metered-dose inhaler with spacer and face mask (2 puffs every 10 minutes for 5 doses in the first hour) 5

Important caveat: MDI with spacer may actually provide faster response than nebulizer in children under 2 years with moderate-severe wheezing, with 90% success rate versus 71% with nebulizer after one hour 5

Assessment of Severity

Evaluate for features requiring escalation 3:

• Too breathless to feed
• Respiratory rate >50/min
• Pulse >140/min
• Use of accessory muscles
• Poor respiratory effort, cyanosis, or exhaustion

Consider Oral Corticosteroids

• Add prednisolone 2 mg/kg/day (maximum 40 mg) for 3 days if the child has moderate symptoms or incomplete response to initial salbutamol 3, 6
• Evidence shows prednisolone combined with high-dose salbutamol reduces relapse rates within 2 months 6

Ongoing Management After Acute Episode

Step-Up to Controller Therapy

Given this is the second wheezing episode, initiate regular inhaled corticosteroids 2:

• Nebulised beclomethasone 400 mcg twice daily is effective in reducing symptom-free days by 35% compared to prn salbutamol alone 2
• Regular inhaled glucocorticoid is the most effective treatment for frequent wheezing in preschool children 2
• Continue prn salbutamol 2.5 mg for breakthrough symptoms 2

Alternative approach: Some evidence supports prn combination therapy (beclomethasone 800 mcg + salbutamol 1600 mcg as needed), though this is less effective than regular inhaled corticosteroids 2

Short-Term Corticosteroid Option

If regular controller therapy is not feasible, consider one-week treatment with nebulised beclomethasone 400 mcg twice daily plus prn salbutamol during acute exacerbations 7:

• Increases symptom-free days by day 6 of treatment 7
• Reduces cough scores significantly by day 5 7
• Provides clinical rationale for episodic use in wheezing exacerbations 7

Follow-Up Requirements

Immediate Follow-Up

• Review within 48 hours to assess response and adjust treatment 3
• Monitor symptoms and document response to treatment 3
• Ensure proper inhaler/nebulizer technique is demonstrated and checked 3

Ongoing Monitoring

• Arrange follow-up within 4 weeks if hospitalization was required 3
• Provide written instructions for parents on when to seek emergency care 3
• Consider referral to pediatric respiratory specialist given recurrent episodes 3

Critical Pitfalls to Avoid

Oxygen Administration

Caution: Nebulised salbutamol can cause transient hypoxemia, particularly with acidic formulations 8:

• Transcutaneous oxygen pressure drops significantly in the first 5 minutes and worsens at 15-20 minutes 8
• May not return to baseline for 2 hours 8
• Always monitor oxygen saturation during and after nebulization 8

Undertreatment Risk

• Do not rely solely on prn bronchodilators for a child with two wheezing episodes—this represents frequent wheezing requiring controller therapy 2
• Failure to initiate inhaled corticosteroids increases risk of future exacerbations 2
• Delay in recognizing severity can be fatal; assess objectively rather than relying on parental or clinical impression alone 3

Delivery System Selection

• Metered-dose inhaler with spacer is cheaper, more convenient, and may be more effective than nebulizer in this age group 3, 5
• However, some infants cannot tolerate face masks, necessitating nebulizer use 3
• Ensure parents are taught proper technique with whichever device is chosen 3

Admission Criteria

Lower threshold for hospital admission if: 3

• Attack occurs in afternoon or evening
• Recent hospital admission or previous severe attacks
• Incomplete response to initial treatment
• Any life-threatening features present
• Social circumstances preclude adequate home monitoring