Treatment of 12-Year-Old with Common Cold and Mild Wheezing
For a 12-year-old with a common cold and mild wheezing, provide as-needed albuterol (short-acting beta-agonist) for symptomatic relief of wheezing, along with supportive care for cold symptoms—antibiotics should not be prescribed, and daily controller therapy is not indicated unless this represents a pattern of persistent asthma. 1, 2
Immediate Management of Wheezing
- Administer albuterol via nebulizer or metered-dose inhaler at 2.5 mg (one vial of 0.083% solution) three to four times daily as needed for wheezing episodes 2
- The wheezing in this context is likely virus-induced bronchospasm from the common cold, which is self-limited and does not require daily controller therapy 3, 4
- Albuterol provides bronchodilation and symptomatic relief but does not modify the underlying viral illness 2
Common Cold Management
- Do not prescribe antibiotics—they are ineffective for viral upper respiratory infections and increase risk of adverse effects without benefit 1
- Symptomatic therapy is appropriate and may include analgesics for pain, antipyretics for fever, and decongestants tailored to symptoms 1
- Advise the family that cold symptoms typically last up to 2 weeks, and to follow up if symptoms worsen or exceed expected recovery time 1
Critical Distinction: Viral Wheeze vs. Asthma
This clinical scenario requires distinguishing between isolated virus-induced wheeze and underlying persistent asthma:
- If this is an isolated episode of wheezing only during a viral URI with no symptoms between infections, this represents episodic viral wheeze that does not require daily controller therapy 1, 4
- If there is a pattern of recurrent wheezing (>2 days/week), nocturnal symptoms (>2 nights/month), or wheezing triggered by exercise/allergens apart from colds, this indicates persistent asthma requiring daily inhaled corticosteroids 1, 5, 4
- Children with atopic dermatitis plus wheezing apart from colds are at particularly high risk for persistent asthma and should be started on daily low-dose inhaled corticosteroids 5
When to Escalate to Controller Therapy
Initiate daily inhaled corticosteroid therapy if any of the following are present: 1, 5
- Symptoms >2 days per week or >2 nights per month between viral infections
- History of multiple wheezing episodes (≥3 in past year)
- Wheezing triggered by exercise, laughing, or allergen exposure independent of viral infections
- Personal history of atopic dermatitis or strong family history of asthma
- Prolonged recovery from respiratory infections (taking >1 week to fully resolve respiratory symptoms)
Common Pitfalls to Avoid
- Do not delay bronchodilator treatment while waiting for formal pulmonary function testing—a therapeutic trial of albuterol is appropriate and diagnostic 5, 6
- Do not prescribe inhaled corticosteroids for isolated viral wheeze—the 2020 NAEPP guidelines conditionally recommend starting a short course of daily ICS at the onset of respiratory tract infections in children 0-4 years with intermittent wheeze, but this does not apply to a 12-year-old with a single episode 1
- Do not use over-the-counter cough and cold medications as primary therapy, as evidence for benefit is limited and potential for harm exists 7
- Do not assume this is allergic rhinitis—while the child may have concurrent seasonal allergies, the acute wheezing is related to the viral URI, not allergic inflammation 1, 4
Follow-Up Strategy
- Reassess within 4-6 weeks to evaluate response to therapy and determine if a pattern of persistent asthma is emerging 5
- If wheezing recurs with subsequent viral infections or symptoms persist between infections, formal evaluation for persistent asthma with consideration of daily controller therapy is warranted 1, 5
- Provide written action plan for when to use albuterol and when to seek urgent care (e.g., no improvement with albuterol, increased work of breathing, inability to speak in full sentences) 5