Anaesthesia and Intensive Care, Vol. 33, No. 2, April 2005 Anaesth Intensive Care 2005; 33: 261-265 Case Reports A Teenager with Severe Asthma Exacerbation Following Ibuprofen G. M. PALMER* Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Parkville, Victoria SUMMARY Aspirin-sensitive asthma, aspirin-intolerant asthma, aspirin- (or non-steroidal anti-inflammatory drug [NSAID]) exacerbated respiratory disease are terms for a disorder commonly described as affecting adults aged >30y. With this perception, ibuprofen was administered for postoperative pain management to a 17-year-old boy with allergic rhinitis and previous severe asthma (at a time when well controlled), who then had a severe asthma exacerbation. Analysis of the literature in response to this case highlights four points: 1) NSAID-exacerbated asthma is not only a disorder of adults; it occurs in up to of 2% in asthmatic children, approaching probably 30% in older children with severe asthma and nasal disease. 2) The asthmatic reaction is dose-dependent and can occur with sub-therapeutic doses. Oral NSAID/aspirin challenge should be conducted in an environment where a severe asthma exacerbation can be appropriately managed. 3) The therapeutic use of non-selective [COX-1 preferential] NSAIDs should be avoided when sensitivity is known or suspected in adults and teenagers with severe asthma and chronic rhinosinusitis or nasal polyps. Use of these agents in younger children with mild episodic wheeze is probably safe. 4) Paracetamol use is probably safe, but aspirin-exacerbated respiratory disease may occur with clinical doses in a subgroup of aspirin-exacerbated respiratory disease patients. COX-2 selective inhibitors are probably safe, although this is controversial. Opioids and tramadol are suitable analgesic alternatives for patients with known or suspected susceptibility. Key Words: ASTHMA: aspirin-sensitive, aspirin-intolerant, non-steroidal anti-inflammatory drugs (NSAID) Aspirin-sensitive asthma, aspirin-intolerant asthma, and most recently, aspirin- (or non-steroidal anti- inflammatory drug [NSAID]) exacerbated respira- tory disease (AERD/NSAID-ERD) are multiple terms for the same disorder 1-3 . Previously, AERD was understood to be a disease affecting adults 4 , usually females, commonly in their third to fourth decades 2,5 . Based upon this perception, a male asthmatic teen- ager who recently presented was given therapeutic ibuprofen for day surgery analgesia, following which he had a severe asthma exacerbation. High cross- sensitivity exists between ibuprofen and aspirin for AERD and ibuprofen has been implicated in pre- vious adult case reports 1 . AERD has also been re- ported to occur in children 1,2 . There has previously been a single report of ibuprofen-associated exacer- bation of asthma in a young child 6 . CASE REPORT A 17-year-old 47 kg male asthmatic presented for elective inguinal hernia repair. In his early teens he had regular emergency department presentations and five hospital admissions for asthma, including three intensive care unit (ICU) stays. Previously described as a brittle asthmatic, he had often required week- or month-long courses of oral steroids every few months. His asthma was managed at a tertiary paediatric hospital by a respiratory paediatrician. He did not *F.F.M.A.N.Z.C.A., F.A.N.Z.C.A., M.B.B.S., Paediatric Anaesthetist and Pain Management Specialist/Deputy Head, Children’s Pain Management Service, Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Melbourne. Address for reprints: Dr G. M. Palmer, Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Flemington Road, Parkville, Vic. 3052. Accepted for publication on November 17, 2004.
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