What is the most appropriate management for a school-aged child with asthma, presenting to the emergency room with an acute exacerbation, oxygen saturation (SpO2) of 95%, peak flow at 60% of best, able to complete full sentences, with a history of taking two puffs of salbutamol (albuterol) at home, and mild wheeze on auscultation?

Management of School-Aged Child with Acute Asthma Exacerbation

The most appropriate management is D) Give salbutamol by spacer then reassess. This child presents with a moderate exacerbation (PEF 60%, able to complete sentences, SpO2 95%, mild wheeze) that requires immediate bronchodilator therapy with reassessment before deciding on hospitalization or additional interventions.

Severity Classification

This child's presentation indicates a moderate exacerbation, not severe asthma:

• Speech normal (can complete full sentences) 1
• SpO2 95% (acceptable, not life-threatening) 1
• Peak flow 60% of best (>50% threshold for severe asthma) 1
• Mild wheeze on auscultation 1

The British Thoracic Society guidelines define severe asthma as requiring inability to complete sentences, pulse >110 bpm, respiratory rate >25/min, and PEF <50% predicted or best 1. This child does not meet these criteria.

Immediate Treatment Approach

Step 1: Administer bronchodilator and reassess

• Give salbutamol via metered-dose inhaler (MDI) with spacer: 2 puffs repeated 10-20 times if needed, or nebulized salbutamol 5 mg 1
• The guideline specifically states: "If there is no nebuliser give 2 puffs of β agonist via a large volume spacer and repeat 10-20 times" 1
• Monitor response 15-30 minutes after treatment 1

Step 2: Reassess after bronchodilator

After 15-30 minutes, measure peak flow and clinical status 1:

• If PEF improves to >75% predicted/best: Step up usual treatment and arrange outpatient follow-up within 48 hours 1
• If PEF 50-75% predicted/best: Give prednisolone 30-40 mg orally, step up usual treatment, and arrange follow-up within 48 hours 1
• If PEF remains <50% or severe features develop: Consider hospitalization 1

Why Other Options Are Incorrect

Option A (Start oral corticosteroids and hospitalize immediately) is premature:

• Hospitalization criteria include life-threatening features or features of acute severe asthma present after initial bronchodilator treatment 1
• The child must first receive bronchodilator therapy and be reassessed before deciding on admission 1
• Corticosteroids may be needed based on post-treatment PEF, but hospitalization is not automatic 1

Option B (Add salmeterol and hospitalize) is inappropriate:

• Salmeterol is a long-acting beta-agonist (LABA) used for chronic control, not acute exacerbations 2, 3
• LABAs have no role in emergency management of acute asthma 2, 3
• This represents a dangerous misunderstanding of controller versus reliever medications 2

Option C (Add ipratropium) is reserved for more severe presentations:

• Ipratropium is added when life-threatening features are present or when severe asthma features persist after initial bronchodilator treatment 1, 4
• This child has moderate, not severe or life-threatening asthma 1
• Recent evidence shows that in severe exacerbations, combined salbutamol-ipratropium via MDI with spacer is effective 5, but this should be reserved for appropriate severity levels

Evidence Supporting MDI with Spacer

MDI with spacer is as effective as nebulization in acute asthma:

• Multiple studies demonstrate equivalent efficacy between MDI with spacer and nebulization for mild-to-moderate exacerbations 6, 7
• One study in severe exacerbations showed MDI with spacer was actually superior to nebulization, with lower hospitalization rates (5.8% vs 27.5%, P=0.003) 5
• The British Thoracic Society explicitly endorses spacer delivery when nebulizers are unavailable 1

Critical Pitfall to Avoid

The most common error is underestimating severity or overestimating severity without objective reassessment:

• Deaths from asthma are associated with failure to assess severity objectively and underuse of corticosteroids 1, 4
• However, premature hospitalization without reassessment after bronchodilator therapy wastes resources and may not benefit the patient 1
• The key principle is: treat, then reassess in 15-30 minutes 1

Disposition Algorithm

After salbutamol administration and 15-30 minute reassessment 1:

1. Improved (PEF >75%): Discharge with stepped-up maintenance therapy, follow-up <48 hours 1
2. Partial response (PEF 50-75%): Give oral prednisolone 30-40 mg, discharge with close follow-up <48 hours 1
3. Poor response (PEF <50% or worsening): Repeat bronchodilator, add ipratropium, give systemic corticosteroids, and hospitalize 1, 4