In an 8-year-old child with poorly controlled asthma presenting to the emergency department with a severe exacerbation and non‑adherence to inhaled therapy, what is the most appropriate immediate management step?

Immediate Management: Oral Corticosteroids

For this 8-year-old presenting to the ED with a severe asthma exacerbation, the most appropriate next step is to administer oral corticosteroids (prednisolone 1–2 mg/kg, maximum 40–60 mg) immediately, as systemic corticosteroids are the cornerstone of acute severe asthma treatment and must not be delayed. 1, 2

Rationale for Immediate Systemic Corticosteroids

• Systemic corticosteroids target the underlying airway inflammation driving the severe exacerbation, not merely the bronchospasm. 2, 3
• Clinical benefit from corticosteroids may not appear for 6–12 hours, making early administration critical to prevent respiratory failure and reduce mortality risk. 2, 4
• Under-use or delayed administration of systemic corticosteroids is specifically identified as a leading cause of preventable asthma mortality. 2, 3
• Early corticosteroid use within 1 hour of ED presentation significantly reduces hospital admission rates (OR 0.40,95% CI 0.21–0.78), with a number needed to treat of 8. 5

Why This Takes Priority Over Other Options

Inhaled Steroids (Option 3)

• Inhaled corticosteroids are controller medications for long-term management, not acute exacerbation treatment. 2
• They have no role in the immediate ED management of a severe attack. 2, 3

Leukotriene Modifiers (Option 2)

• Leukotrienes are add-on controller therapies for chronic asthma, not acute exacerbation treatment. 6
• They have no established role in emergency management of severe attacks. 2, 3

Environmental Control (Option 4)

• While cat allergen exposure and medication non-adherence contribute to poor baseline control, addressing these factors does not treat the current life-threatening exacerbation. 2, 4
• Environmental interventions are important for long-term management but are irrelevant to immediate ED stabilization. 6

Complete Acute Management Protocol

Beyond the immediate corticosteroid administration, the full ED treatment includes:

• High-flow oxygen via face mask to maintain SpO₂ >92%. 1, 2, 3
• Nebulized salbutamol 5 mg (or 4–8 puffs via MDI with spacer) every 20 minutes for up to 3 doses in the first hour. 1, 2, 3
• Ipratropium bromide 100–250 mcg added to each salbutamol dose for the first hour, then every 6 hours. 1, 2, 3
• Reassessment 15–30 minutes after starting treatment, measuring peak expiratory flow and monitoring respiratory rate, heart rate, and work of breathing. 1, 2, 3

Critical Pitfall to Avoid

Do not delay systemic corticosteroids while giving repeated bronchodilator doses alone—this is a common error that worsens outcomes and increases mortality risk. 2, 3 The patient's poor medication adherence (missing inhaler 2–3 times per week) and cat allergen exposure explain his baseline poor control, but the immediate priority is treating the acute inflammatory crisis with systemic steroids. 2, 4

Discharge Planning After Stabilization

• Continue oral prednisolone 1–2 mg/kg daily for 3–10 days to prevent relapse. 2, 7
• Initiate or optimize inhaled corticosteroid controller therapy. 2, 8
• Provide written asthma action plan and address medication adherence barriers. 2, 9
• Arrange follow-up within 48 hours to reassess control and discuss environmental triggers (cat allergen removal). 2, 3