CASE:

A 10-year-old girl with a history of poorly controlled asthma presents to the emergency
department with severe shortness of breath and audible inspiratory and expiratory wheezing. She
is pale, refuses to lie down, and appears extremely frightened. Her pulse is 120 bpm and
respirations 32/min. Her mother states that the girl has just recovered from a mild case of flu and
had seemed comfortable until this afternoon. The girl uses an inhaler (albuterol) but only when
really needed because her parents are afraid that she will become too dependent on medication.
She administered two puffs from her inhaler just before coming to the hospital, but the inhaler
doesnt seem to have helped.

. The patient has signs of imminent respiratory failure, including her refusal to lie down, her
fear, and her tachycardiawhich cannot be attributed to her minimal treatment with albuterol.
Critically important immediate steps are to administer high-flow oxygen and to start albuterol by
nebulization. Adding ipratropium (Atrovent) to the nebulized solution is recommended. A
corticosteroid (0.51.0 mg/kg of methylprednisolone) should be administered intravenously. It is
also advisable to alert the intensive care unit, because a patient with severe bronchospasm who
tires can slip into respiratory failure quickly, and intubation can be difficult.

This patient needs to be started on a long-term controller, especially an inhaled

corticosteroid, and needs instruction in an action plan for managing severe symptoms. This can be
as simple as advising her and her parents that if she has a severe attack that frightens her, she can
take up to four puffs of albuterol every 15 minutes, but if the first treatment does not bring
significant relief, she should take the next four puffs while on her way to an emergency department
or urgent care clinic. She should also be given a prescription for prednisone, with instructions to
take 4060 mg orally for severe attacks, but not to wait for it to take effect if she remains severely
short of breath even after albuterol inhalations.

1. Albuterol

Use: Bronchodilator
Route of Administration: Nebulization/Inhalation
Administration via nebulizer inhalation is contraindicated for children less than 2 years of age.
Dosage: (Usual)
For children 2-12 years old:
Less than 15 kg: 0.1 0.15 mg/kg/dose
15 kg or more: 2.5 mg, 3-4 times a day, over approx. 5-15 minutes
Adult: 2.5 mg, 3-4 times a day, over approx. 5-15 minutes

2. Ipratropium (Atrovent)

Use: Bronchodilator
Rout of Administration: Nebulization/Inhalation
Dosage: (Usual)
Children less than 12 years old: safety has not been established yet
12 years or older: 500 mcg, 3-4 times a day, with doses 6-8 hours apart
Adult: 500 mcg, 3-4 times a day, with doses 6-8 hours apart
 3. Methylprednisolone

Use: Steroid
Route of Administration: Intravenous
Dosage: 0.5-1.0 mg/kg (suggested in case)
0-11 years of age (usual): Initial dose: 0.8-1.6 mg/kg oral or IV, once a day or in 2 divided
doses until symptoms resolve.
Adult (usual): High dose therapy: 30 mg/kg IV over at least 30 minutes every 4 to 6 hours
until condition has stabilized

4. Prednisone

Use: Corticosteroid
Route of Administration: Oral
Dosage: 40-60 mg (suggested in case)
Less than 12 years (usual): Short-course "burst" therapy: 1 to 2 mg/kg orally in 2 divided
doses; maximum dose: 60 mg/day
Adult (usual): Short-course "burst" therapy: 40 to 80 mg orally once a day or in 2 divided
doses

References:

Albuterol. (n.d.). In Drugs.com. Retrieved from https://www.drugs.com/albuterol.html

Ipratropium. (n.d.). In Drugs.com. Retrieved from https://www.drugs.com/ipratropium.html

Katzung, BG. & Trevor, AJ. (2015). Basic and Clinical Pharmacology. 13th Ed. McGraw-Hill
Education:USA

Methylprednisolone. (n.d.). In Drugs.com. Retrieved from

https://www.drugs.com/methylprednisolone.html

Prednisone. (n.d.). In Drugs.com. Retrieved from https://www.drugs.com/prednisone.html