What is the best course of action for an 8-year-old patient with asthma (Flixotide (fluticasone) and Ventolin (salbutamol)) and a recent lower respiratory tract infection, who continues to experience a persistent cough and shortness of breath (SOB) after completing a 5-day course of amoxicillin?

Management of Post-Infectious Asthma Exacerbation with Persistent Symptoms

This child requires immediate intensification of asthma therapy with a short course of oral prednisolone (1-2 mg/kg daily for 3-5 days, maximum 40 mg) combined with increased frequency of bronchodilator therapy, given the worsening shortness of breath and presence of inspiratory wheeze indicating ongoing airway inflammation despite completing antibiotics. 1

Immediate Assessment and Treatment Plan

Current Clinical Status

• The child demonstrates ongoing asthma exacerbation evidenced by:

  • Inspiratory wheeze on examination 1
  • Worsening dyspnea with minimal activity (running around house) 1
  • Persistent cough despite completing antibiotics 1
  • History of asymmetric air entry during hospitalization 1

• Reassuring features include:

  • Normal vital signs (pulse 84, respiratory rate not elevated at rest, SpO2 99%) 2
  • No increased work of breathing at rest 1
  • Able to speak normally and remain playful 2

Primary Treatment Approach

Initiate oral corticosteroids immediately - this is the critical intervention that addresses the underlying airway inflammation driving persistent symptoms. 1, 3

• Prednisolone 1-2 mg/kg once daily (maximum 40 mg) for 3-5 days 2, 1
• Early corticosteroid administration speeds resolution of airflow obstruction and reduces relapse rates 3
• The presence of wheeze and worsening dyspnea post-infection indicates ongoing inflammation requiring systemic steroids, not just bronchodilator therapy 1, 3

Optimize bronchodilator therapy:

• Increase Ventolin (salbutamol) frequency to 4-8 puffs via MDI with spacer every 4-6 hours while symptomatic 1, 3
• Continue Flixotide (fluticasone) at current dose - do not discontinue inhaled corticosteroids 2
• Consider temporarily increasing inhaled corticosteroid dose during recovery period 2

Role of Antibiotics

Do not prescribe additional antibiotics - the completed 5-day amoxicillin course was appropriate for the initial lower respiratory tract infection, but persistent symptoms now represent post-infectious bronchial hyperreactivity and asthma exacerbation, not ongoing bacterial infection. 2, 4

• Antibiotics should only be given if bacterial infection is confirmed with clear signs/symptoms 2, 1
• Current presentation (resolved sore throat, no fever, good air entry bilaterally, normal vital signs) does not suggest bacterial pneumonia 2, 4
• Cochrane review evidence shows antibiotics provide no benefit for asthma exacerbations without confirmed bacterial infection 4, 5

Monitoring and Follow-Up Protocol

Structured reassessment is mandatory:

• Review within 48 hours to assess response to oral steroids 2
• Monitor for improvement in dyspnea with activity and reduction in cough 1, 3
• Check inhaler technique for both Flixotide and Ventolin 2
• Provide written asthma action plan if not already in place 2, 1

Criteria requiring urgent reassessment or hospital admission:

• Worsening dyspnea at rest 1, 3
• Inability to complete sentences 2
• Pulse >110 bpm or respiratory rate >25/min 2
• SpO2 <92% 1, 3
• Exhaustion, drowsiness, or confusion 1

Common Pitfalls to Avoid

Do not delay systemic corticosteroids - the most critical error in asthma management is underuse of corticosteroids in exacerbations. 2 This child has clear evidence of ongoing airway inflammation (wheeze, worsening dyspnea) that will not resolve with bronchodilators alone.

Do not prescribe antibiotics for post-viral bronchial hyperreactivity - viral respiratory infections commonly trigger asthma exacerbations, and symptoms can persist for weeks after the infection resolves. 1, 4 Additional antibiotics will not help and may cause unnecessary side effects.

Do not assume current controller therapy is adequate - after this exacerbation resolves, reassess whether the child needs step-up in maintenance therapy (e.g., higher dose inhaled corticosteroid or addition of leukotriene receptor antagonist). 2, 1

Long-Term Management Considerations

Post-exacerbation follow-up within 1-4 weeks to review:

• Asthma control and need for maintenance therapy adjustment 2
• Inhaler technique verification 2
• Written asthma action plan education 2, 1
• Peak flow meter provision if age-appropriate 2

Consider stepping up maintenance therapy if this represents frequent exacerbations or poor baseline control - options include increasing Flixotide dose or adding leukotriene receptor antagonist (montelukast). 2