What is the acute management and dosing for a 1.5‑year‑old child with dyspnea?

Management of Breathlessness in a 1.5-Year-Old Child

Immediately administer high-flow oxygen via face mask to maintain oxygen saturation >92%, nebulized salbutamol 2.5 mg (or 4-8 puffs via MDI with spacer) every 20 minutes for three doses, and oral prednisolone 2 mg/kg (maximum 40-60 mg) as a single dose. 1, 2

Initial Assessment and Severity Recognition

Assess for features indicating severe respiratory distress:

• Too breathless to feed – a critical indicator in infants requiring immediate intervention 1, 2
• Respiratory rate >50 breaths/minute – exceeds the threshold for severe distress in this age group 1, 2
• Heart rate >140 beats/minute – signals significant physiologic stress 1, 2
• Use of accessory muscles – indicates substantial respiratory effort 1, 2
• Oxygen saturation <92% – represents severe hypoxemia requiring urgent treatment 2, 3

Life-threatening features requiring immediate escalation include silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, or agitation. 1, 2

Immediate Treatment Protocol (First Hour)

Oxygen Therapy

• Administer high-flow humidified oxygen via face mask to maintain SpO₂ >92% 1, 2
• Continue oxygen throughout treatment and monitor continuously with pulse oximetry 2, 3

Bronchodilator Therapy

• Give salbutamol 2.5 mg via oxygen-driven nebulizer every 20 minutes for three consecutive doses in the first hour 1, 2, 4
• Alternative delivery: 4-8 puffs via metered-dose inhaler (MDI) with large-volume spacer every 20 minutes for three doses – this method is equally effective and may result in lower admission rates with fewer cardiovascular side effects 1, 2, 3, 4
• For infants who cannot tolerate spacers, nebulizer remains the preferred route 1

Systemic Corticosteroids

• Administer oral prednisolone 2 mg/kg immediately (maximum 40-60 mg) as a single dose 1, 2, 5
• If the child is vomiting or critically ill, give IV hydrocortisone 100 mg every 6 hours instead 1, 2
• Do not delay corticosteroids while giving repeated bronchodilator doses alone – this is a common cause of treatment failure and preventable mortality 2, 3

Additional Bronchodilator for Severe Cases

• Add ipratropium bromide 100-250 mcg to the nebulizer immediately if initial bronchodilator treatment fails or if the child presents with severe features 1, 2, 3
• Repeat ipratropium every 6 hours until improvement begins 1, 2

Reassessment at 15-30 Minutes

• Measure respiratory rate, heart rate, and oxygen saturation after the first set of bronchodilator doses 2, 3
• Observe for clinical improvement: ability to feed, decreased work of breathing, improved oxygen saturation 2, 3

Response-Guided Management

Good Response (improving symptoms, SpO₂ >92%, able to feed):

• Continue salbutamol every 4 hours as needed 1, 2
• Continue prednisolone 2 mg/kg daily for 3-5 days total (no taper needed if course <10 days) 2, 5
• Arrange follow-up within 48 hours 1

Incomplete Response (persistent symptoms, ongoing respiratory distress):

• Maintain high-flow oxygen 2, 3
• Continue prednisolone daily 2, 3
• Continue nebulized salbutamol every 4 hours 2, 3
• Strongly consider hospital admission 2, 3

Poor Response (worsening distress, SpO₂ <92%, exhaustion):

• Increase nebulized salbutamol frequency to every 15-30 minutes 1, 2
• Ensure ipratropium is added if not already given 2, 3
• Arrange immediate hospital admission 2, 3

Escalation for Refractory Cases

If no improvement after initial intensive treatment:

• Consider IV aminophylline: loading dose 5 mg/kg over 20 minutes, then maintenance infusion 1 mg/kg/hour 1
• Omit loading dose if the child is already on oral theophylline 1
• Prepare for ICU transfer if deterioration continues 1, 2

Hospital Admission Criteria

Admit immediately if any of the following are present:

• Life-threatening features (silent chest, cyanosis, altered consciousness) 2, 3
• Persistent severe distress after initial intensive treatment 2, 3
• SpO₂ <92% despite oxygen therapy 2, 3
• Too breathless to feed after treatment 2, 4
• Parents unable to manage at home 3
• Evening presentation with concerning features 3

ICU Transfer Criteria

Transfer to intensive care for:

• Worsening respiratory effort despite maximal treatment 1, 2
• Persistent or worsening hypoxia (SpO₂ <92%) 2, 3
• Exhaustion, feeble respirations, or altered consciousness 1, 2, 3
• Rising PaCO₂ (≥42 mmHg signals impending respiratory failure) 2, 3

Critical Pitfalls to Avoid

• Never use sedatives in acute respiratory distress – they can depress respiratory function and are absolutely contraindicated 1, 2, 3
• Do not delay systemic corticosteroids – underuse of corticosteroids is a leading cause of preventable asthma mortality 2, 3
• Do not give aminophylline loading dose to children already on theophylline 1
• Do not use antibiotics unless bacterial infection is confirmed – viral infections are the most common trigger in this age group 1, 6, 7

Special Considerations for Bronchiolitis

If the clinical picture suggests viral bronchiolitis (first episode of wheeze, viral prodrome, age <2 years):

• Supportive care with oxygen and fluids is the mainstay of treatment 6, 8, 7, 9
• Bronchodilators may be ineffective in pure bronchiolitis but a trial is reasonable if there is significant respiratory distress 6, 8, 7
• Nebulized epinephrine may provide short-term benefit (0.5 ml/kg of 1:1000 solution) 1, 7, 9
• Ribavirin is not routinely used and has not been shown to reduce hospital stay or need for ventilation 1
• Hypertonic saline (3%) may decrease length of hospital stay when given with a bronchodilator 7, 9

Discharge Planning (When Stable)

Discharge is appropriate when:

• Stable on medication for ≥24 hours with minimal symptoms 1, 2
• SpO₂ >92% on room air 2, 3
• Able to feed adequately 2, 4

Discharge prescriptions:

• Complete prednisolone course (total 3-5 days at 2 mg/kg daily) 2, 5
• Salbutamol via MDI with spacer for ongoing symptom relief 2, 3
• Provide written action plan detailing when to increase bronchodilators and when to seek emergency care 3, 4

Follow-up:

• Arrange primary care follow-up within 1 week 2, 3
• Consider respiratory specialist referral within 4 weeks if recurrent episodes 2, 3