What is the optimal management plan for a 10-year-old male patient with uncontrolled asthma, exercise-induced bronchospasm, and allergic rhinitis?

Complete Asthma Action Plan for 10-Year-Old Male with Uncontrolled Asthma

This patient requires immediate step-up to combination inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) therapy, specifically fluticasone-salmeterol 100/50 mcg twice daily, as his current symptoms of nighttime coughing, exercise-induced bronchospasm, and frequent rescue inhaler use clearly indicate uncontrolled asthma requiring Step 3 controller therapy. 1

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Daily Controller Medications (MUST TAKE EVERY DAY)

Primary Controller: Fluticasone-Salmeterol (Advair Diskus or equivalent)

Prescription:

• Fluticasone-Salmeterol 100/50 mcg inhaler
• Sig: Inhale 1 puff twice daily (morning and evening, approximately 12 hours apart)
• Dispense: 1 inhaler (60 doses)
• Refills: 5

Parent Instructions:

• Give this medication EVERY DAY at the same times (e.g., 8 AM and 8 PM), even when your child feels well 1
• This is the maintenance medication that prevents asthma attacks—it does NOT work for sudden symptoms 2
• Have your child rinse mouth with water and spit after each dose to prevent thrush 3
• Do NOT stop this medication without consulting the doctor, even if symptoms improve 1
• This replaces the orange fluticasone-only inhaler from Canada 1

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Rescue Medication (USE AS NEEDED)

Albuterol HFA Inhaler

Prescription:

• Albuterol HFA 90 mcg/actuation inhaler
• Sig: Inhale 2 puffs every 4 hours as needed for wheezing, cough, chest tightness, or shortness of breath
• Dispense: 1 inhaler (200 doses)
• Refills: 3

Parent Instructions for Rescue Use:

• Use 2 puffs when your child has sudden breathing problems, coughing, wheezing, or chest tightness 1
• Wait 1 minute between puffs 4
• Can repeat every 4 hours if needed 1

Pre-Exercise Prevention (CRITICAL)

Parent Instructions:

• Give 2 puffs of albuterol 15-20 minutes BEFORE any vigorous exercise (wrestling, running, PE class, recess) 4, 5
• This pre-exercise use does NOT count as poor asthma control 2
• Your child should be able to participate fully in all sports and activities with proper pre-treatment 4
• If symptoms occur despite pre-treatment, asthma control needs reassessment 4

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Peak Flow Monitoring at Home

Personal Best: 195 L/min (established at today's visit) 1

Peak Flow Zones

GREEN ZONE (Safe Zone): 156-195 L/min (80-100% of personal best)

What it means: Asthma is under good control 1

What to do:

• Continue daily fluticasone-salmeterol twice daily 1
• Use albuterol before exercise as directed 4
• No additional treatment needed

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YELLOW ZONE (Caution Zone): 98-155 L/min (50-79% of personal best)

What it means: Asthma is getting worse 1

What to do:

1. Give albuterol 2 puffs immediately 1
2. Continue regular fluticasone-salmeterol doses 1
3. Can repeat albuterol every 4 hours as needed 1
4. Call the doctor within 24 hours if not improving or if staying in yellow zone for more than 24 hours 1
5. Monitor peak flow every 4 hours while in yellow zone

Warning signs to watch for:

• Increased coughing, especially at night
• Waking up at night with breathing problems
• Needing albuterol more than every 4 hours
• Difficulty keeping up with normal activities

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RED ZONE (Danger Zone): Below 98 L/min (Less than 50% of personal best)

What it means: MEDICAL EMERGENCY 1

What to do IMMEDIATELY:

1. Give albuterol 2 puffs right away 1
2. Give prednisolone 30 mg by mouth (see emergency prescription below) 1
3. Can repeat albuterol every 20 minutes up to 3 times (total 6 puffs over 1 hour) 1
4. Call 911 or go to emergency room immediately if:
   • Peak flow does not return to yellow zone after treatment 1
   • Your child has severe difficulty breathing, talking, or walking 1
   • Lips or fingernails turn blue 1
   • Your child is struggling to breathe (chest pulling in, flaring nostrils) 1

DO NOT WAIT—seek emergency care immediately if in red zone 1

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Emergency Oral Steroid (Keep at Home)

Prescription:

• Prednisolone 15 mg/5 mL oral solution
• Sig: Give 10 mL (30 mg) by mouth once for severe asthma symptoms (red zone) or as directed by physician
• Dispense: 120 mL bottle
• Refills: 0 (must call doctor for refills)

Parent Instructions:

• Keep this medication at home for emergencies 1
• Give 10 mL (30 mg) by mouth if peak flow drops to red zone or if your child has severe breathing difficulty 1
• Always seek emergency medical care after giving this medication 1
• This is a 5-day supply (1-2 mg/kg/day, maximum 40 mg) 6
• Side effects may include increased appetite, hyperactivity, or mood changes—these are temporary 6

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Additional Medications for Allergic Rhinitis

Fluticasone Propionate Nasal Spray

Prescription:

• Fluticasone propionate nasal spray 50 mcg/spray
• Sig: Spray 1 spray in each nostril once daily
• Dispense: 1 bottle (120 sprays)
• Refills: 5

Parent Instructions:

• Use daily to control nasal allergies that can worsen asthma 3
• Shake bottle before use 3
• Have child blow nose gently before using 3
• Point spray away from the center of the nose (toward the outer wall) 3
• May take several days to see full benefit 3

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When to Call the Doctor

Call within 24 hours if:

• Peak flow stays in yellow zone for more than 24 hours 1
• Needing albuterol more than 2 days per week (not counting pre-exercise use) 2
• Waking up at night with asthma symptoms more than once per month 2
• Missing school or activities due to asthma 2
• Any concerns about medication side effects

Call immediately or go to emergency room if:

• Peak flow in red zone that doesn't improve with treatment 1
• Severe difficulty breathing 1
• Lips or fingernails turning blue 1
• Difficulty walking or talking due to breathing problems 1
• No improvement after 3 albuterol treatments (6 puffs over 1 hour) 1

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Follow-Up Appointments

• 2-week follow-up visit: To check medication adherence, inhaler technique, and early treatment response 1
• 4-6 week comprehensive reassessment: To evaluate asthma control and adjust medications if needed 1
• Every 3 months once controlled: For ongoing monitoring 1

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Important Reminders for Parents

Medication Adherence

• The fluticasone-salmeterol MUST be taken twice daily every day, even when your child feels completely well 1
• Missing doses will result in loss of asthma control within days 1
• Set phone alarms or link to daily routines (breakfast and bedtime) to remember doses

Inhaler Technique

• Proper technique is critical—we will review this at every visit 1
• Shake inhaler before each use
• Breathe out fully, then inhale slowly and deeply while pressing inhaler
• Hold breath for 10 seconds after inhaling
• Wait 1 minute between puffs if taking multiple puffs

Exercise and Activities

• Your child should participate fully in all physical activities and sports 4
• Always give albuterol 15-20 minutes before vigorous exercise 4, 5
• If symptoms occur despite pre-treatment, contact the doctor 4

Avoiding Triggers

• Minimize exposure to pets (known trigger for this patient) 2
• Avoid shellfish (known allergy) 2
• Monitor for environmental allergens that worsen symptoms 2

Peak Flow Monitoring

• Check peak flow every morning before medications 1
• Check peak flow whenever symptoms worsen 1
• Record values in a diary or phone app 1
• Bring peak flow diary to all appointments 1

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Pre-Anesthesia Information for Dental Procedure

ASA Classification: ASA 3 (patient with severe systemic disease due to uncontrolled asthma)

Critical information for anesthesiologist:

• Patient has uncontrolled asthma with nighttime symptoms and exercise-induced bronchospasm
• Currently being stepped up to fluticasone-salmeterol 100/50 mcg twice daily
• Requires optimization of asthma control before elective procedures
• Albuterol must be immediately available during procedure
• Consider pre-procedure bronchodilator administration
• Increased risk of perioperative bronchospasm

Recommendation: Delay elective dental procedure until asthma control improves to "well-controlled" status (reassess at 4-6 week follow-up) 1

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Common Pitfalls to Avoid

• Do NOT use albuterol as the only treatment—this patient needs daily controller medication 1
• Do NOT stop fluticasone-salmeterol when symptoms improve—this leads to loss of control 1
• Do NOT wait until symptoms are severe to use albuterol—treat early 1
• Do NOT forget pre-exercise albuterol—this prevents exercise-induced symptoms 4
• Do NOT confuse the orange fluticasone-only inhaler with the new fluticasone-salmeterol combination—the combination is now the primary controller 1