What is the immediate management for a 10-year-old male patient presenting with Shortness Of Breath (SOB), gasping, and bilateral (B/L) wheeze?

Immediate Management of Acute Severe Asthma in a 10-Year-Old

This child requires immediate aggressive treatment with high-flow oxygen, nebulized salbutamol, and systemic corticosteroids without delay—this is acute severe asthma until proven otherwise. 1, 2

Initial Assessment and Recognition

This 10-year-old presents with features of acute severe asthma based on:

• Gasping and inability to complete sentences (too breathless to talk) 2, 3
• Bilateral wheeze indicating widespread bronchospasm 1
• Shortness of breath requiring immediate intervention 2

Critical point: Regard each emergency presentation as potentially severe until proven otherwise—doctors and families failing to appreciate severity is a major factor in preventable asthma deaths. 2

Immediate Treatment Protocol (First 5 Minutes)

1. High-Flow Oxygen

• Administer 40-60% oxygen via face mask immediately to maintain oxygen saturation >92% 1, 4, 2
• Do not use inadequate oxygen delivery (nasal cannula is insufficient in acute severe asthma) 2

2. Nebulized Bronchodilator

• Give salbutamol 5 mg via oxygen-driven nebulizer (half dose if very young, but at age 10 use full 5 mg dose) 1, 4, 2
• Alternative: terbutaline 10 mg via oxygen-driven nebulizer 1, 4
• If no nebulizer available: give 1 puff of β-agonist via large volume spacer every few seconds until improvement (maximum 20 puffs) 1

3. Systemic Corticosteroids

• Give prednisolone 1-2 mg/kg orally immediately (maximum 40 mg) 1, 2
• Alternative if unable to take oral: intravenous hydrocortisone 200 mg 1, 2
• Do not delay steroids—underuse of corticosteroids is a major factor in preventable asthma deaths 2

4. Add Ipratropium Bromide

• Give ipratropium 100 mcg nebulized (can be mixed with salbutamol in same nebulizer) 2, 3
• Repeat every 6 hours 2
• This is specifically indicated when initial β-agonist treatment requires augmentation 3

Monitoring at 15-30 Minutes Post-Treatment

Reassess the child systematically: 2, 3

• Measure peak expiratory flow (PEF) if child can cooperate 1, 2
• Continuous pulse oximetry maintaining SaO₂ >92% 4, 2
• Respiratory rate (severe if >50 breaths/min) 2, 3
• Heart rate (severe if >140 beats/min) 2, 3
• Ability to speak in sentences 2, 3

If Improving:

• Continue high-flow oxygen 4, 2
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) for up to 5 days 1, 2
• Nebulized β-agonist every 4-6 hours 4, 2

If NOT Improving or Deteriorating:

• Increase nebulized β-agonist frequency to every 30 minutes 2, 3
• Continue oxygen and steroids 2
• Prepare for hospital admission 1, 2

Life-Threatening Features Requiring Escalation

If any of these develop, prepare for ICU transfer: 2

• Silent chest, cyanosis, or feeble respiratory effort 1, 2
• Exhaustion, confusion, drowsiness, or reduced consciousness 2, 3
• PEF <33% predicted 2
• Persistent hypoxia despite high-flow oxygen 4, 2

For life-threatening features, add: 2

• Intravenous aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour maintenance infusion 2
• Caution: Omit loading dose if already on oral theophyllines 1, 2

Hospital Admission Criteria

Admit if any of the following: 1, 2

• Failure to respond to initial treatment 1
• Any life-threatening features present 1
• PEF <50% predicted 15-30 minutes after treatment 1, 2
• Persistent features of acute severe asthma after initial treatment 3
• Afternoon or evening presentation (lower threshold for admission) 1, 3

Critical Pitfalls to Avoid

• Do not delay treatment for investigations—no other tests are needed for immediate management 2
• Do not give repeated albuterol alone without systemic corticosteroids—this represents treatment failure requiring escalation 3
• Do not use aminophylline at home—this is hospital-only treatment 1
• Do not underestimate severity—patients may not have all abnormalities but presence of any should alert you 1