According to GINA guidelines, what medications should be prescribed for a 16‑year‑old female presenting with an acute asthma exacerbation?

Acute Asthma Exacerbation Management in a 16-Year-Old Female

For a 16-year-old female presenting with an acute asthma exacerbation, immediately administer high-dose inhaled short-acting β₂-agonist (albuterol 2.5–5 mg via nebulizer or 4–8 puffs via MDI with spacer every 20 minutes for three doses) together with oral prednisolone 40–60 mg as a single dose, while providing supplemental oxygen to maintain SpO₂ > 92%. 1, 2

Immediate Assessment and Treatment (First 15–30 Minutes)

Initial Severity Recognition

• Assess severity objectively using peak expiratory flow (PEF) or FEV₁ within the first few minutes, as subjective clinical impression frequently underestimates dangerous exacerbations. 1, 2
• Severe exacerbation features include inability to complete sentences in one breath, respiratory rate > 25 breaths/min, heart rate > 110 beats/min, and PEF < 50% of predicted or personal best. 1, 2
• Life-threatening signs requiring immediate ICU consideration include PEF < 33% predicted, silent chest, cyanosis, altered mental status (confusion, drowsiness), bradycardia or hypotension, and normal or elevated PaCO₂ ≥ 42 mmHg in a breathless patient. 1, 2

First-Line Pharmacologic Therapy

• Administer albuterol 2.5–5 mg via oxygen-driven nebulizer (or 4–8 puffs via MDI with spacer) every 20 minutes for three consecutive doses during the first hour. 1, 2
• Give oral prednisolone 40–60 mg immediately—do not delay corticosteroids while "trying bronchodilators first," as both must be given concurrently; anti-inflammatory effects require 6–12 hours to manifest. 1, 2
• Provide supplemental oxygen via nasal cannula or face mask to maintain SpO₂ > 92% (target > 95% if cardiac disease is present). 1, 2

Reassessment at 15–30 Minutes

• Measure PEF 15–30 minutes after the first bronchodilator dose to guide subsequent management decisions. 1, 2

Response-Based Treatment Algorithm

Good Response (PEF > 75% Predicted)

• Continue usual maintenance therapy with modest step-up if needed. 1, 2
• Arrange follow-up within 48 hours. 1, 2

Incomplete Response (PEF 50–75% Predicted)

• Continue nebulized albuterol every 4–6 hours. 1, 2
• Maintain oral prednisolone 40–60 mg daily for 5–10 days (no taper required for courses < 10 days, especially if already on inhaled corticosteroids). 1, 2
• Add ipratropium bromide 0.5 mg to each albuterol nebulizer every 4–6 hours, as the combination reduces hospitalization risk in moderate-to-severe exacerbations. 1, 2
• Consider hospital admission if severe features persist. 1, 2

Poor Response (PEF < 50% Predicted or Persistent Severe Features)

• Increase albuterol nebulization frequency to every 15–30 minutes. 1, 2
• Add ipratropium bromide 0.5 mg to each nebulizer dose (can be mixed in the same nebulizer). 1, 2
• Arrange immediate hospital admission. 1, 2

Escalation for Severe or Refractory Cases (After 1 Hour of Intensive Therapy)

Adjunctive Therapies

• Administer IV magnesium sulfate 2 g over 20 minutes for life-threatening features or severe exacerbations not responding after 1 hour of intensive treatment; this significantly increases lung function and decreases hospitalization necessity. 1, 2
• Consider continuous albuterol nebulization for markedly severe cases. 1, 2
• IV hydrocortisone 200 mg should be given if the patient is vomiting, severely ill, or unable to tolerate oral medication, followed by 200 mg every 6 hours. 1, 2

When to Avoid Aminophylline

• IV aminophylline 250 mg over 20 minutes may be considered for refractory severe asthma, but never give a bolus aminophylline to patients already taking oral theophylline due to heightened toxicity risk. 1, 3

Hospital Admission Criteria

Immediate admission is required for:

• Any life-threatening feature present (PEF < 33%, silent chest, altered mental status, respiratory acidosis). 1, 2
• Features of severe attack persisting after initial treatment. 1, 2
• PEF < 50% predicted after 1–2 hours of intensive treatment. 1, 2

Lower threshold for admission applies when:

• Presentation occurs in the afternoon or evening. 1, 2
• Recent nocturnal symptoms or worsening pattern. 1, 2
• History of previous severe attacks requiring intubation or ICU admission. 1, 2
• ≥ 2 hospitalizations or ≥ 3 emergency department visits in the past year. 1, 2
• Poor social circumstances or inadequate support systems. 1, 2

ICU Transfer Criteria

Transfer to intensive care when any of the following occur despite therapy:

• Deteriorating PEF. 1, 2
• Worsening or persistent hypoxia or hypercapnia. 1, 2
• Altered mental status (confusion, drowsiness, exhaustion). 1, 2
• Impending respiratory arrest. 1, 2

Discharge Planning (When Appropriate)

Discharge Eligibility

• PEF ≥ 70–75% of predicted or personal best. 1, 2
• Minimal or absent symptoms. 1, 2
• Stable oxygen saturation on room air. 1, 2
• Clinical stability for 30–60 minutes after the last bronchodilator dose. 1, 2

Discharge Medications

• Continue oral prednisolone 40–60 mg daily for 5–10 days (no taper needed for courses < 10 days). 1, 2
• Initiate or continue inhaled corticosteroids at a higher dose than pre-exacerbation. 1, 2
• Provide albuterol rescue inhaler with clear instructions for use. 1, 2

Patient Education and Follow-Up

• Verify correct inhaler technique and document competency before discharge. 1, 2
• Provide a written asthma action plan that includes individualized peak-flow zones with clear instructions for when to escalate treatment or seek urgent care. 1, 2
• Supply a peak-flow meter if the patient does not already have one. 1, 2
• Arrange primary-care follow-up within 1 week and respiratory-specialist review within 4 weeks. 1, 2

Critical Pitfalls to Avoid

• Never administer sedatives to patients with acute asthma exacerbation, as they are absolutely contraindicated and can precipitate respiratory failure. 1, 2
• Do not delay corticosteroid administration while "trying bronchodilators first"—both must be given immediately. 1, 2
• Do not rely solely on subjective clinical impression—objective PEF or FEV₁ measurement is essential to prevent under-recognizing severity, which is the most common preventable cause of asthma-related death. 1, 2
• Do not use unnecessarily high corticosteroid doses (> 60–80 mg prednisone-equivalent), as higher doses provide no additional clinical benefit but increase adverse-effect risk. 1
• Never discharge a patient without immediate access to a rescue bronchodilator—waiting until the next day is unacceptable. 1

Special Considerations for Adolescents

• Dosing for a 16-year-old follows adult regimens: prednisolone 40–60 mg daily (not weight-based), albuterol 2.5–5 mg nebulized (full adult dose). 1, 2
• Assess adherence carefully, as missing inhaler doses 2–3 times per week is a major contributor to poor asthma control in adolescents; provide education on technique and consider once-daily controller options to improve adherence. 1
• Evaluate for risk factors including previous intubation or ICU admission, recent hospitalization or emergency department visit within the past month, and poor perception of symptom severity. 1, 2

Ongoing Maintenance After Acute Episode

• GINA 2024 guidelines recommend that all adolescents with asthma receive ICS-containing medication and should not be treated with short-acting beta-agonist (SABA) alone. 4, 5
• Preferred Track 1 approach: as-needed combination low-dose ICS-formoterol as the reliever at all steps. 4, 5
• Alternative Track 2 approach: SABA as the reliever along with a separate daily ICS inhaler. 4, 5