What dose of prednisolone should I give to a 16-year-old female with an acute asthma exacerbation?

Prednisolone Dosing for a 16-Year-Old with Acute Asthma Exacerbation

For a 16-year-old female with an acute asthma exacerbation, prescribe prednisolone 40–60 mg once daily for 5–10 days without tapering, continuing until peak expiratory flow reaches ≥70% of predicted or her personal best. 1

Dosing Algorithm Based on Severity

Moderate Exacerbation

• If the patient can speak in sentences, has respiratory rate <25/min, pulse <110/min, and SpO₂ >92% on room air: Start prednisolone 40 mg once daily 1
• Peak expiratory flow typically 40–69% of predicted 1

Severe Exacerbation

• If the patient has difficulty completing sentences, respiratory rate ≥25/min, pulse ≥110/min, or oxygen desaturation: Use prednisolone 60 mg once daily 1
• Peak expiratory flow <50% of predicted 1
• Consider adding ipratropium bromide 0.5 mg to nebulized bronchodilators 2

Life-Threatening Features

• If peak flow <33% predicted, silent chest, confusion, exhaustion, or cyanosis present: Give prednisolone 60 mg immediately OR switch to IV hydrocortisone 200 mg, then 200 mg every 6 hours 2, 1
• Arrange immediate intensive care consultation 2

Route Selection

Oral prednisolone is strongly preferred and equally effective as intravenous therapy when the patient can swallow and has intact gastrointestinal absorption. 1, 3, 4 Reserve IV hydrocortisone only for patients who are actively vomiting, severely ill, or unable to tolerate oral medication. 1

Duration and Tapering

• Continue treatment for 5–10 days until peak expiratory flow reaches ≥70% of predicted or personal best 1, 5
• No tapering is required for courses lasting 5–10 days, especially when the patient is concurrently using inhaled corticosteroids 1, 6
• Tapering short courses is unnecessary and may lead to underdosing during the critical recovery period 1

Essential Concurrent Therapy

• Nebulized salbutamol 5 mg (or via MDI with spacer) every 20 minutes for three doses, then every 1–4 hours as needed 2, 1
• Supplemental oxygen to maintain SpO₂ >92% 2, 1
• Continue or initiate inhaled corticosteroids at higher doses than pre-exacerbation 1
• Add ipratropium bromide 0.5 mg to nebulizer if not improving after 15–30 minutes 2, 1

Monitoring Response

• Measure peak expiratory flow 15–30 minutes after starting treatment 2, 1
• Reassess clinical status after 15–30 minutes; if no improvement, escalate care and increase bronchodilator frequency 2, 1
• Continue monitoring peak flow at least 4 times daily throughout treatment 2

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids while giving repeated bronchodilators alone—underuse of corticosteroids is a documented cause of preventable asthma deaths 2, 1
• Do not use doses higher than 60 mg—higher doses provide no additional benefit but increase adverse effects 1, 7
• Do not use weight-based dosing in adolescents—the standard 40–60 mg range applies regardless of body weight 1
• Never administer sedatives—they are contraindicated and potentially fatal in acute asthma 2
• Do not rely on clinical impression alone—always measure peak expiratory flow objectively 2, 1

Discharge Planning

Before discharge, ensure:

• Patient has been stable on discharge medications for ≥24 hours 2, 1
• Peak flow >75% of predicted with diurnal variability <25% 2, 1
• Inhaler technique verified and documented 2, 1
• Written asthma action plan provided 2, 1
• Peak flow meter prescribed 2, 1
• Follow-up arranged with primary care within 1 week and respiratory specialist within 4 weeks 2, 1