In a 13-year-old with known asthma who tests positive for influenza B and has active wheezing, should systemic corticosteroids be given?

Systemic Corticosteroids for Asthma Exacerbation with Influenza B

Yes, give systemic corticosteroids—oral prednisone 1–2 mg/kg/day (maximum 60 mg) for 3–10 days—to this 13-year-old with asthma and active wheezing, regardless of the concurrent influenza B infection. 1, 2

Primary Recommendation

Administer oral prednisone or prednisolone at 1–2 mg/kg/day (maximum 60 mg/day) for 3–10 days without tapering. 1, 2 The presence of wheezing in a known asthmatic indicates an acute exacerbation requiring systemic anti-inflammatory therapy, and this takes priority over theoretical concerns about corticosteroids in influenza. 1

Rationale for Systemic Corticosteroids in Asthma Exacerbations

• Early administration of systemic corticosteroids shortens recovery time, reduces post-emergency-department relapse, and lowers the likelihood of hospitalization in pediatric asthma exacerbations. 1

• Corticosteroids must be given concurrently with initial short-acting beta-agonist (SABA) doses in moderate-to-severe cases rather than waiting for SABA failure, because corticosteroids exert clinical effects after 4–6 hours through genomic mechanisms. 1

• Oral steroids are as efficacious as intravenous steroids but are less invasive; therefore the oral route should be preferred. 1

• The FDA-approved dosing for pediatric asthma exacerbations is 1–2 mg/kg/day in single or divided doses, continued until peak expiratory flow reaches 80% of personal best or symptoms resolve, which usually requires 3–10 days. 2

Addressing the Influenza B Context

• The available evidence on corticosteroids in influenza is of very low quality and predominantly from observational studies with severe confounding by indication. 3 Most studies showing increased mortality with corticosteroids in influenza involved critically ill patients with pneumonia, not stable asthmatics with wheezing. 3

• One observational study of 89 patients with influenza A(H1N1)pdm09 found that systemic corticosteroids together with early antiviral agents in pneumonia patients with wheezing did not result in negative clinical outcomes and may prevent progression to severe pneumonia. 4 Patients with wheezing and a history of asthma were frequently treated with corticosteroids in this cohort. 4

• The risk-benefit calculation differs fundamentally in asthma exacerbations versus influenza pneumonia alone. In asthma, the primary pathology is airway inflammation and bronchospasm that responds to corticosteroids 5, 6, whereas concerns about corticosteroids in influenza relate to potential immunosuppression in viral pneumonitis. 3

• This patient has wheezing from asthma, not influenza pneumonia. The influenza infection is likely triggering the asthma exacerbation, but the immediate threat is bronchospasm and airway inflammation, which require standard asthma exacerbation management. 1

Complete Treatment Algorithm for This Patient

Immediate Bronchodilator Therapy

• Administer albuterol 4–12 puffs via metered-dose inhaler with spacer or nebulized solution every 20 minutes for three initial doses. 1

• Add ipratropium bromide 0.25–0.5 mg nebulized or 4–8 puffs via MDI combined with albuterol for moderate-to-severe exacerbations. 1

Systemic Corticosteroid Initiation

• Give oral prednisone 1–2 mg/kg/day (maximum 60 mg) starting with the first SABA dose, not after waiting for SABA response. 1, 2

• Continue for 3–10 days with no taper required for courses shorter than 10 days. 1, 2

Antiviral Therapy

• Although not the focus of this question, consider oseltamivir or other neuraminidase inhibitors for influenza B if within 48 hours of symptom onset, as this is standard care for influenza in high-risk patients (asthmatics qualify). 4

Oxygen Support

• Maintain oxygen saturation > 90% using nasal cannula or mask if needed. 1

Controller Therapy

• Resume or initiate daily inhaled corticosteroid controller therapy after the acute exacerbation to prevent future exacerbations. 1

Common Pitfalls to Avoid

• Do not delay systemic corticosteroids because of the influenza B diagnosis—the asthma exacerbation is the immediate life-threatening condition requiring anti-inflammatory therapy. 1

• Do not substitute high-dose inhaled corticosteroids for oral steroids during an acute exacerbation; high-dose ICS have insufficient evidence for rescue use. 1

• Do not taper the corticosteroid course if it is shorter than 10 days, especially with concurrent inhaled corticosteroid use. 1, 2

• Do not withhold corticosteroids based on observational data from critically ill influenza pneumonia patients, as this population differs fundamentally from a stable asthmatic with wheezing. 3

• Do not use SABA as scheduled regular therapy post-discharge; it should be used only as needed for symptom relief. 1

Evidence Quality Considerations

The recommendation for systemic corticosteroids in pediatric asthma exacerbations is based on high-quality guideline evidence from the National Heart, Lung, and Blood Institute and FDA labeling. 1, 2 In contrast, the evidence suggesting harm from corticosteroids in influenza is of very low quality with major confounding by indication, derived from observational studies of critically ill patients with influenza pneumonia. 3 When these two evidence bases are weighed in the context of a 13-year-old with asthma and wheezing triggered by influenza B, the established benefit of corticosteroids for asthma exacerbations takes clear precedence. 1