What is the recommended treatment for a child with severe asthma and new onset nasal congestion, specifically regarding the use of steroids?

Management of Severe Asthma with New Onset Nasal Congestion in Children

For a child with severe asthma and new onset nasal congestion, systemic corticosteroids (oral prednisolone 1-2 mg/kg daily, maximum 40 mg) should be initiated immediately alongside aggressive bronchodilator therapy, as the nasal congestion may signal a viral upper respiratory infection triggering an asthma exacerbation. 1

Immediate Assessment of Asthma Severity

First, determine if this represents an acute severe or life-threatening exacerbation by assessing specific clinical parameters:

Features of Acute Severe Asthma in Children:

• Too breathless to talk or feed 1
• Respiratory rate >50 breaths/min 1
• Heart rate >140 beats/min 1
• Peak expiratory flow (PEF) <50% predicted or personal best 1

Life-Threatening Features Requiring Immediate Escalation:

• PEF <33% predicted or best 1
• Silent chest, cyanosis, or poor respiratory effort 1
• Fatigue, exhaustion, or altered level of consciousness 1

The presence of systemic symptoms like nasal congestion alongside respiratory symptoms warrants aggressive management, as viral upper respiratory infections commonly trigger severe asthma exacerbations. 2

Immediate Treatment Protocol

Systemic Corticosteroids (Essential First-Line):

• Administer oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) immediately 1, 3, 4
• Continue daily dosing for 3-5 days or until complete remission for at least 3 days 3, 2
• Do not exceed 40 mg daily maximum in pediatric patients, even if weight-based calculation suggests higher 3

Bronchodilator Therapy (Must Be Combined with Steroids):

• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children) 1
• Administer every 4 hours initially 1
• If not improving after 15-30 minutes, increase frequency to every 15-30 minutes 1, 2

Add Ipratropium Bromide:

• Add ipratropium 100 mcg (or 250 mcg) to nebulizer if patient not improving after initial bronchodilator treatment 1, 2
• Repeat every 6 hours until improvement begins 1, 2

Oxygen Therapy:

• High-flow oxygen via face mask to maintain oxygen saturation >92% 1, 2
• This is critical even if the child appears comfortable, as hypoxia may not be clinically apparent 2

Clinical Decision Point: Inpatient vs Outpatient Management

Hospital Admission Indicated If:

• Failure to respond to or early deterioration after inhaled bronchodilators 1
• Inability of child to take, or parents to give, appropriate treatment 1
• Severe breathlessness and increasing tiredness 1
• PEF <50% of expected value 10 minutes after treatment 1
• Presentation in afternoon/evening when close follow-up is difficult 2

Outpatient Management Acceptable If:

• Objective improvement documented after initial treatment 1, 2
• Parents capable of administering treatment at home 1
• PEF improves to >50-75% predicted after treatment 1

Critical caveat: Never discharge without objective confirmation of improvement before leaving the patient. 1

Monitoring Response to Treatment

Reassess at 15-30 Minutes After Initial Treatment:

• Measure PEF before and after bronchodilator administration 1
• Monitor for decreased work of breathing, improved air entry, and decreased wheezing 2

If Patient Improving:

• Continue high-flow oxygen 1
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg) 1
• Continue nebulized β-agonist every 4 hours 1

If Patient NOT Improving:

• Continue oxygen and steroids 1
• Increase nebulized β-agonist frequency to every 15-30 minutes 1, 2
• Add ipratropium to nebulizer if not already done 1, 2
• Refer to hospital immediately if no improvement after combination therapy 2

Addressing the Nasal Congestion Component

The new onset nasal congestion likely represents a viral upper respiratory infection triggering the asthma exacerbation. The primary focus should remain on aggressive asthma management with systemic corticosteroids and bronchodilators, as treating the underlying airway inflammation will provide the most significant benefit to both the asthma and associated upper respiratory symptoms. 2

Intranasal corticosteroids are not contraindicated but are secondary to systemic management in this acute setting. The systemic prednisolone will provide anti-inflammatory effects throughout the respiratory tract.

Discharge Planning (If Outpatient Management Chosen)

Before Discharge Ensure:

• Patient on discharge medications for 24 hours with proper inhaler technique verified 1, 3
• PEF >75% of predicted or personal best (if measurable) 1, 3
• Written asthma action plan provided with clear instructions 3, 2

Follow-Up Requirements:

• Schedule primary care follow-up within 48 hours if treated at home 2
• GP follow-up within 1 week mandatory 1, 3
• Specialist respiratory follow-up within 4 weeks 1

Alternative Steroid Regimen: Single-Dose Dexamethasone

For mild-to-moderate exacerbations (not severe), a single dose of dexamethasone 0.3-0.6 mg/kg offers equivalent efficacy to 5 days of prednisolone with superior compliance. 5, 6 However, given the question specifies "severe asthma," the traditional prednisolone regimen is more appropriate and better studied in severe cases. 1

Common Pitfalls to Avoid

• Underuse of corticosteroids is a major factor in preventable asthma deaths 1
• Do not use ideal body weight for significantly overweight adolescents; use actual weight up to the 40 mg maximum 3
• Never discharge immediately after treatment without objective confirmation of improvement 1
• Do not taper steroids after short courses (3-10 days); there is no evidence this prevents relapse 4
• Blood gas estimations are rarely helpful in deciding initial management in children 1