In an 8-year-old with poorly controlled asthma who presents to the emergency department with a severe exacerbation, is non‑compliant with his inhaler (misses 2–3 doses per week) and is exposed to two household cats, what is the most appropriate next step in management?

Immediate Oral Corticosteroids for Acute Severe Asthma Exacerbation

In an 8-year-old presenting to the ED with a severe asthma attack, the most appropriate next step is to immediately administer oral corticosteroids (prednisolone 1–2 mg/kg, maximum 60 mg) alongside high-dose inhaled bronchodilators and oxygen. 1, 2, 3

Why Oral Corticosteroids Are the Priority

Systemic corticosteroids must be given immediately upon recognition of a severe exacerbation—not after "trying bronchodilators first." 1 The anti-inflammatory effects of corticosteroids require 6–12 hours to become clinically apparent, making early administration critical to prevent respiratory failure and reduce mortality. 1, 2, 4

• Under-use of systemic corticosteroids is a documented leading cause of preventable asthma deaths. 1, 3
• Delaying corticosteroid administration while giving repeated bronchodilator doses alone is a critical and common pitfall. 1, 2
• Oral prednisone/prednisolone is as effective as intravenous therapy when the child can tolerate oral intake, and is strongly preferred because it is less invasive. 1, 2, 4

Specific Dosing for This 8-Year-Old

Give prednisolone 1–2 mg/kg orally (maximum 60 mg) immediately. 1, 2, 3, 5 For an average 8-year-old weighing approximately 25–30 kg, this translates to 25–60 mg. 2 The maximum dose is capped at 60 mg regardless of weight. 2, 5

• Continue oral prednisolone 1–2 mg/kg/day for 3–10 days after stabilization; no taper is needed for courses less than 10 days, especially if the child is on inhaled corticosteroids. 1, 2, 3, 5
• If the child is vomiting or severely ill and cannot tolerate oral medication, use IV hydrocortisone 4 mg/kg initially. 2, 4

Concurrent Essential Therapy

While corticosteroids are the priority, they must be combined with:

• High-dose inhaled β₂-agonist: Salbutamol 5 mg (or half-dose 2.5 mg for children <15 kg) via oxygen-driven nebulizer, or 4–8 puffs via MDI with spacer, every 20 minutes for three doses. 1, 4, 3
• Supplemental oxygen: 40–60% via face mask to maintain SpO₂ >92%. 1, 4, 3
• Ipratropium bromide: Add 0.25–0.5 mg to nebulized salbutamol for severe exacerbations; this combination reduces hospitalizations. 1, 4, 3

Why the Other Options Are Insufficient

Option 2: Leukotriene Modifiers

Leukotrienes have no role in acute exacerbation management. 6 They are controller medications for chronic asthma, not rescue therapy. 6

Option 3: Inhaled Steroids Alone

While inhaled corticosteroids may reduce admissions when added to systemic steroids, they cannot replace oral corticosteroids in acute severe asthma. 7 The evidence for ICS alone in acute exacerbations is insufficient and conflicting. 7

Option 4: Environmental Control

Removing allergen exposure (the two cats) is critical for long-term asthma control but does nothing to address the immediate life-threatening exacerbation. 8 Environmental control must be addressed after stabilization, not during acute management. 1, 8

Addressing the Underlying Poor Control

Once the acute exacerbation is stabilized, the following must be addressed before discharge:

• Non-adherence: Missing inhaler doses 2–3 times per week is a major contributor to poor control. 1, 3 Provide education on inhaler technique, a written asthma action plan, and consider once-daily controller options to improve adherence. 1, 3
• Allergen exposure: The two household cats are likely significant triggers. 8 Recommend allergen avoidance strategies or rehoming the cats if feasible. 8
• Step-up controller therapy: Initiate or increase inhaled corticosteroid dose at discharge. 1, 2, 3
• Follow-up: Schedule primary-care follow-up within 1 week and respiratory specialist review within 4 weeks. 1, 4

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids while giving repeated bronchodilators alone. 1, 2
• Never administer sedatives to a child with acute asthma—this is absolutely contraindicated and may be fatal. 1, 4
• Do not rely on subjective clinical impression alone—measure peak expiratory flow or FEV₁ objectively to assess severity. 1, 4
• Do not discharge without ensuring the child has been stable on discharge medications for 24 hours, has a written action plan, and has verified inhaler technique. 1, 4, 3