What is the immediate treatment for a 15-year-old experiencing an asthma exacerbation?

Immediate Treatment for Asthma Exacerbation in a 15-Year-Old

Begin immediate treatment with high-dose inhaled beta-2 agonist (salbutamol 5 mg via oxygen-driven nebulizer OR 10-20 puffs via MDI with spacer), high-flow oxygen to maintain SpO2 >92%, systemic corticosteroids (prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg), and add ipratropium 0.5 mg to the nebulizer if there are features of severe or life-threatening asthma. 1, 2

Initial Assessment of Severity

First, rapidly determine if this is a severe or life-threatening exacerbation by assessing the following clinical features:

Severe asthma features include: 1

• Too breathless to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow (PEF) <50% of predicted or personal best

Life-threatening features include: 1

• PEF <33% of predicted or personal best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma
• Normal or elevated PaCO2 (indicating impending respiratory failure)

Immediate Treatment Protocol (Begin AT ONCE)

1. High-Flow Oxygen

• Administer 40-60% oxygen via face mask immediately to maintain SpO2 >92% 1, 2, 3
• Continue oxygen throughout treatment and use it to drive nebulizers 2, 4

2. High-Dose Inhaled Beta-2 Agonist

Two equally effective delivery options: 2, 5

Option A - Nebulized:

• Salbutamol 5 mg via oxygen-driven nebulizer 1, 2
• Can repeat every 15-30 minutes if not improving 1

Option B - MDI with Spacer (preferred by many guidelines):

• 10-20 puffs (2 puffs repeated 5-10 times) of salbutamol via MDI into large volume spacer 1, 2
• MDI with spacer may result in lower admission rates and fewer cardiovascular side effects, particularly in severe exacerbations 2, 5

3. Systemic Corticosteroids (DO NOT DELAY)

Give immediately upon recognition of acute severe asthma: 1, 2

• Oral route (preferred if patient can swallow and not vomiting): Prednisolone 30-60 mg orally 1
• IV route (if vomiting, seriously ill, or unable to take oral): Hydrocortisone 200 mg IV, then 200 mg every 6 hours 1, 2, 4

4. Ipratropium Bromide

• Add ipratropium 0.5 mg to the nebulizer immediately if life-threatening features are present OR if patient fails to respond to initial beta-agonist treatment 1, 2, 4
• Repeat every 6 hours until improving 1, 2

Reassessment at 15-30 Minutes

Measure and document: 1, 2

• Peak expiratory flow
• Oxygen saturation (maintain continuous pulse oximetry)
• Clinical response (respiratory rate, heart rate, ability to speak)

If Patient is IMPROVING:

• Continue high-flow oxygen 1
• Continue prednisolone 30-60 mg daily 1
• Continue nebulized beta-agonist every 4-6 hours 1

If Patient is NOT IMPROVING:

• Continue oxygen and steroids 1
• Give nebulized beta-agonist more frequently (every 15-30 minutes) 1
• Add ipratropium 0.5 mg to nebulizer if not already given 1
• Consider IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 µg over 10 minutes 1
  • Critical pitfall: Do NOT give bolus aminophylline to patients already taking oral theophyllines 1

Hospital Admission Criteria

Immediate referral to hospital is required if: 1, 2

• Any life-threatening features present
• Features of severe attack persist after initial treatment
• PEF remains <50% predicted 15-30 minutes after treatment
• Afternoon or evening presentation (lower threshold for admission)
• Previous history of severe attacks with rapid onset
• Concern about patient's ability to assess severity or social circumstances

Critical Pitfalls to Avoid

Do not delay systemic corticosteroids - This is a major factor in preventable asthma deaths; give immediately, not after multiple failed doses of bronchodilators alone 2, 3

Do not underestimate severity - Respiratory acidosis or normal PaCO2 in a breathless asthmatic indicates life-threatening status requiring ICU-level care 4

Do not give sedatives of any kind - These can suppress respiratory drive 1

Do not use insufficient corticosteroid doses - A single 100 mg dose of hydrocortisone provides inadequate coverage; use 200 mg every 6 hours if IV route needed 4

Additional Investigations in Hospital

• Chest radiograph to exclude pneumothorax, consolidation, or pulmonary edema 1, 4
• Arterial blood gas if admitted to hospital (markers of life-threatening attack: normal or high PaCO2, PaO2 <8 kPa despite oxygen, low pH) 1, 4
• Plasma electrolytes, urea, and blood count 1

Transfer to ICU Criteria

Prepare for ICU transfer if: 1, 4

• Deteriorating PEF despite treatment
• Worsening or persistent hypoxia or hypercapnia
• Exhaustion, feeble respirations, confusion, or drowsiness
• Respiratory acidosis present