What is the initial management for a 10-year-old patient presenting with wheezing?

Initial Management of a 10-Year-Old with Wheezing

Immediately administer inhaled bronchodilator therapy using either a metered-dose inhaler (MDI) with large volume spacer (4-8 puffs of salbutamol every 20 minutes for up to 3 doses) or nebulized salbutamol 5 mg, along with oral prednisolone 1-2 mg/kg (maximum 40 mg), and assess peak expiratory flow if the child can perform the maneuver. 1

Immediate Assessment and Recognition

Assess severity immediately upon presentation:

• Measure peak expiratory flow (PEF) if the child can use a peak flow meter (most children over 5 years can) 2
• Look for features of severe asthma: too breathless to talk or feed, respiratory rate >50 breaths/minute, pulse >140 beats/minute, PEF <50% predicted 1
• Identify life-threatening features: PEF <33% predicted, poor respiratory effort, silent chest, cyanosis, exhaustion, altered consciousness, or agitation 1
• Determine trigger: wheezing with recent viral upper respiratory symptoms suggests viral-triggered exacerbation, the most common trigger in this age group 1

Initial Treatment Protocol

For all presentations, regardless of severity:

Bronchodilator Therapy (Choose One Delivery Method)

Option 1 - MDI with Spacer (Preferred):

• Salbutamol 4-8 puffs via MDI with large volume spacer every 20 minutes for up to 3 doses in the first hour 1
• This method is equally effective to nebulization and may result in lower admission rates, particularly in more severe exacerbations, with fewer cardiovascular side effects 1, 3, 4

Option 2 - Nebulizer:

• Salbutamol 5 mg via oxygen-driven nebulizer every 20 minutes for up to 3 doses 1
• Use half doses (2.5 mg) only in very young children 2

Systemic Corticosteroids (Essential)

• Oral prednisolone 1-2 mg/kg as a single dose (maximum 40 mg) 2, 1
• Give immediately upon recognition - do not delay while continuing repeated bronchodilator doses alone 1
• Continue for up to 5 days if needed 2

Oxygen Therapy

• High-flow oxygen via face mask to maintain oxygen saturation >92% 2, 1

Reassessment After Initial Treatment

Measure PEF 10-15 minutes after initial bronchodilator treatment: 2, 1

• If PEF <50% predicted: treat as severe attack and consider hospital admission 2
• If PEF 50-75% predicted: continue treatment and reassess 2
• If PEF >75% predicted and improving: consider discharge with appropriate follow-up 1

When to Escalate Treatment

Add ipratropium bromide 100 mcg to nebulizer immediately and repeat every 6 hours if: 1

• Initial beta-agonist treatment fails (lack of response to two doses within 24 hours) 1
• Features of severe asthma persist 1

This provides additional bronchodilation through a different mechanism of action. 1

Hospital Admission Criteria

Admit to hospital if any of the following are present: 2, 1

• Failure to respond to or early deterioration after initial bronchodilator treatment 2
• PEF <50% predicted 10 minutes after treatment 2
• Persistent features of severe asthma after initial treatment 1
• Inability of the child or parents to give appropriate treatment at home 2
• Severe breathlessness and increasing tiredness 2

Common Pitfalls to Avoid

Critical errors that worsen outcomes:

• Do not delay systemic corticosteroids while continuing to give repeated doses of albuterol alone - if the patient has already failed two doses, escalation is needed 1
• Do not use antibiotics unless bacterial infection is confirmed - clear rhinorrhea and viral prodrome do not suggest bacterial infection 1
• Do not use aminophylline in children at home - this is no longer recommended 2
• Ensure proper inhaler technique and age-appropriate device before escalating therapy - most 10-year-olds cannot achieve coordination for unmodified MDI use 1

Discharge Planning (If Appropriate)

Before discharge, ensure: 1

• Child has been on discharge medication for 24 hours 1
• PEF >75% of predicted 1
• Treatment includes oral steroids and inhaled steroids in addition to bronchodilators 1
• Provide written action plan detailing when to increase bronchodilators and when to seek immediate care 1
• Arrange GP follow-up within 1 week 1
• Schedule respiratory clinic follow-up within 4 weeks 1

Ongoing Home Management

If treated at home: 2

• Relief treatment can be repeated 2-4 hourly 1
• Continue oral prednisolone for up to 5 days 2
• Immediate referral to hospital if no improvement after 5 days 2
• Improvement requires objective confirmation (repeat PEF measurement) 2
• Review in surgery within 48 hours 2