Management of Mild Acute Asthma Exacerbation in a School-Aged Child
The most appropriate management is D) Give salbutamol by spacer then reassess. This child presents with a mild exacerbation (able to speak full sentences, SpO2 95%, PEF 60% of best, mild wheeze) and requires immediate bronchodilator therapy followed by reassessment before determining need for additional interventions or hospitalization.
Severity Classification
This child does not meet criteria for acute severe asthma based on the clinical presentation 1:
- Speech: Can complete full sentences (severe = cannot complete sentences) 1
- Pulse: Not documented but likely <110 bpm given overall mild presentation (severe = >110 bpm) 1
- Respiratory rate: Not documented but mild wheeze suggests <25/min (severe = >25/min) 1
- Peak flow: 60% of best (severe = <50% of predicted/best) 1
- Oxygen saturation: 95% (life-threatening = <92% despite oxygen) 2
Immediate Treatment Algorithm
Step 1: Administer Bronchodilator
- Give salbutamol via metered-dose inhaler with spacer (2 puffs repeated 10-20 times if no nebulizer available) 1
- This is equally effective as nebulization for mild-to-moderate exacerbations 3, 4
- The child already took 2 puffs at home, which is insufficient dosing for an acute exacerbation 1
Step 2: Reassess at 15-30 Minutes
- Measure peak expiratory flow again 1, 5
- Check vital signs (respiratory rate, heart rate, ability to speak) 1, 5
- Assess oxygen saturation 5
Step 3: Decision Based on Response
If PEF improves to >75% predicted/best:
- Step up usual maintenance treatment 1
- Arrange follow-up within 48 hours 1
- Discharge home with self-management plan 1
If PEF remains 50-75% predicted/best:
- Give prednisolone 30-40 mg orally 1
- Continue bronchodilator therapy 1
- Consider discharge with close follow-up or short observation period 1
If features of acute severe asthma persist:
- Arrange hospital admission 1
- Add ipratropium bromide 0.5 mg to next nebulizer dose 5, 6
- Give systemic corticosteroids 1
Why Other Options Are Incorrect
Option A (Start oral corticosteroids and hospitalize): Premature without reassessment after adequate bronchodilator therapy. The British Thoracic Society guidelines clearly state that response to treatment must be assessed before making admission decisions 1. Corticosteroids may be needed based on reassessment, but immediate hospitalization is not indicated for this mild presentation 1.
Option B (Add salmeterol and hospitalize): Salmeterol is a long-acting beta-agonist used for maintenance therapy, not for acute exacerbations 7. It has no role in emergency management and would be inappropriate 7.
Option C (Add ipratropium): While ipratropium reduces hospitalization rates in severe exacerbations 5, 8, 6, it should be reserved for patients with severe airflow obstruction or those not responding to initial beta-agonist therapy 5. The American Thoracic Society recommends adding ipratropium when salbutamol fails to produce adequate response 5. This child has not yet received adequate dosing of salbutamol in the emergency department 1.
Critical Pitfalls to Avoid
- Inadequate bronchodilator dosing: Two puffs at home is insufficient; emergency treatment requires repeated doses (up to 10-20 puffs via spacer) 1
- Premature admission decisions: Always reassess 15-30 minutes after treatment before determining disposition 1, 5
- Underuse of corticosteroids: If PEF remains 50-75% after bronchodilator therapy, systemic corticosteroids should be given to prevent deterioration 1
- Relying solely on clinical appearance: Patients may not appear distressed despite significant airflow obstruction; objective measures (PEF, oxygen saturation) are essential 1, 2