Zack, age 6, presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. He is accompanied by his mother, who is a good historian. She reports t

Zack, age 6, presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. He is accompanied by his mother, who is a good historian. She reports that her son started having symptoms of a viral upper respiratory infection 2 to 3 days ago, beginning with a runny nose, low-grade fever of 100.5ºF orally, and loose cough. Wheezing started on the day before the visit, so Zack’s mother administered albuterol metered-dose inhaler (MDI) two puffs before bed and then two puffs at around 2 a.m. The cough and wheezing appear worse today, according to the mother. Zack had difficulty taking deep-enough breaths to inhale this morning’s dose of albuterol, even using the spacer.

Zack has been a patient at the clinic since birth and is up to date on his immunizations. His growth and development have been normal, and he has been generally healthy except for mild intermittent asthma. His asthma is usually precipitated by a viral upper respiratory infection. He has required oral prednisone an average of two or three times per year for the past 3 years. He has an albuterol MDI at home with a spacer, which his parents are comfortable using. He is in first grade. This is the first asthma exacerbation of the school year, and his mother expresses a concern about sending him to school with an inhaler.

The patient’s assessment is as follows:

Zack is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes. He weighs 45 pounds. The examination is all within normal limits except for his breath sounds. He has diffuse expiratory wheezes and mild retractions. Pulse oximeter readings indicate oxygen saturation of 93%.

Answer the following questions. 

1. Which medications do you feel are safe and appropriate to utilize initially?
2. Which medications do you feel will be safe and appropriate to prescribe and/or recommend for chronic, ongoing management?

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