What treatment should be given to a 25.6 kg pediatric patient with a history of asthma, presenting with cough and wheezing for 2 days?

Management of Pediatric Asthma Exacerbation

Immediately administer nebulized salbutamol 5 mg (or 4-8 puffs via MDI with spacer), oral prednisolone 25-50 mg (1-2 mg/kg), and assess for severity features requiring escalation to emergency care. 1, 2

Immediate First-Line Treatment

Bronchodilator therapy:

• Administer salbutamol 5 mg via nebulizer (or 4-8 puffs via MDI with large volume spacer) immediately 3, 1, 2
• Repeat every 20 minutes for up to 3 doses in the first hour if needed 2, 4
• MDI with spacer is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects 1, 2

Systemic corticosteroids:

• Give oral prednisolone 1-2 mg/kg (maximum 40-60 mg) immediately 3, 1, 2, 5
• For a 25.6 kg child, this equals approximately 25-50 mg prednisolone 5
• Do not delay corticosteroids—they are critical for addressing airway inflammation and take 6-12 hours to manifest effects 2
• Continue for 3-5 days; no tapering needed in children 3, 5

Severity Assessment

Evaluate for features requiring immediate escalation:

• Respiratory rate >50 breaths/min 3
• Pulse >140 beats/min 3
• Too breathless to talk or feed 3
• Use of accessory muscles or intercostal retractions 1
• Peak expiratory flow <50% predicted (if measurable) 3

Life-threatening features requiring emergency transfer:

• Silent chest, cyanosis, or poor respiratory effort 3
• Exhaustion, altered consciousness, or agitation 3
• Oxygen saturation <92% 3, 1

Reassessment After Initial Treatment

Monitor response 15-30 minutes after starting therapy:

• Repeat clinical assessment and measure peak flow if child can cooperate 3, 1, 2
• If improving: continue bronchodilators every 4 hours and prednisolone daily 3
• If not improving: increase bronchodilator frequency to every 30 minutes and add ipratropium 3, 1

When to Add Ipratropium

Add ipratropium bromide 100 mcg to nebulizer if:

• Patient fails to respond to initial salbutamol doses 3, 1
• Severe exacerbation features are present 1, 2
• Repeat every 6 hours until improvement starts 3
• The combination of beta-agonist plus ipratropium reduces hospitalizations, particularly in severe airflow obstruction 1, 4

Criteria for Emergency Department or Hospital Admission

Transfer immediately if:

• Persistent severe features after initial treatment 3, 1
• Peak flow remains <50% predicted 15-30 minutes after treatment 3, 4
• Oxygen saturation <92-94% after 1 hour of treatment 4
• Deteriorating clinical status, worsening exhaustion, or persistent hypoxia 3

At hospital, severe cases require:

• High-flow oxygen via face mask to maintain SaO₂ >92% 3, 1
• Intravenous hydrocortisone if unable to take oral medications or vomiting 3, 1
• Consider IV aminophylline 5 mg/kg over 20 minutes if life-threatening features present 3

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids while giving repeated bronchodilator doses alone—underuse of corticosteroids is a leading cause of preventable asthma mortality 1, 2
• Do not use antibiotics unless bacterial infection is confirmed; viral triggers are most common in this age group 3, 1
• Avoid sedatives of any kind in acute asthma as they depress respiratory function 1
• Do not use theophylline as first-line therapy 2

Home Management Plan

If mild exacerbation without severe features:

• Continue salbutamol 4-8 puffs via MDI with spacer every 4 hours as needed 3
• Complete the 3-5 day course of prednisolone 3, 5
• Seek immediate care if symptoms worsen, child becomes too breathless to talk, or fails to improve within 1-2 hours 1, 2

Follow-up:

• Arrange GP follow-up within 1 week 3
• Ensure child has written asthma action plan 3
• Review inhaler technique and ensure appropriate controller therapy is prescribed 3, 1