What is the treatment for a patient with a history of asthma and hypertension, presenting with cough and shortness of breath for 2 days, with chest X-ray showing no acute cardiopulmonary findings, Computed Tomography Angiography (CTA) chest revealing mild bilateral bronchial wall thickening, and laboratory results indicating elevated D-dimer, normal Brain Natriuretic Peptide (BNP), slightly elevated troponin, and urinalysis showing hematuria and bacteriuria?

From the Guidelines

Based on the clinical presentation and diagnostic findings, I recommend treating this patient with a short course of oral corticosteroids and a short-acting beta-agonist, as the patient's history of asthma and current symptoms of cough and shortness of breath suggest an asthma exacerbation with possible concurrent bronchitis. The patient's chest imaging shows mild bilateral bronchial wall thickening, which is consistent with inflammation, and the normal BNP rules out heart failure as a cause of symptoms 1. The elevated D-dimer is noted but the CTA chest did not mention pulmonary embolism, suggesting this is likely related to inflammation.

The treatment should include a short course of oral corticosteroids (prednisone 40mg daily for 5 days) and a short-acting beta-agonist like albuterol (2 puffs every 4-6 hours as needed for shortness of breath) 1. Consideration of an antibiotic such as azithromycin (500mg on day 1, then 250mg daily for 4 more days) may be necessary if bacterial infection is suspected. The blood in the urine warrants follow-up but is likely unrelated to the respiratory symptoms. Ensure proper inhaler technique, adequate hydration, and rest.

Key points to consider in the treatment plan include:

• The patient's history of asthma and high blood pressure
• The presence of bronchial wall thickening on chest imaging
• The normal BNP and troponin levels, which rule out heart failure and myocardial infarction as causes of symptoms
• The elevated D-dimer, which may be related to inflammation
• The presence of blood in the urine, which warrants follow-up but is likely unrelated to the respiratory symptoms

The patient should follow up in 3-5 days to reassess symptoms, or sooner if symptoms worsen. If the patient's asthma has been poorly controlled, consider adding or adjusting maintenance therapy with an inhaled corticosteroid/long-acting beta-agonist combination 1.

From the FDA Drug Label

WARNINGS As with other inhaled beta-adrenergic agonists, albuterol sulfate inhalation solution can produce paradoxical bronchospasm, which can be life threatening. The patient has a history of asthma and complains of cough and sob. Given the patient's symptoms and history, albuterol (INH) may be considered as a treatment option. However, it is essential to monitor the patient for potential paradoxical bronchospasm and cardiac effects. The patient's low lung volumes and mild bilateral bronchial wall thickening should also be taken into account when deciding on treatment.

• The patient's D-dimer, BNP, and troponin levels do not appear to indicate any acute cardiopulmonary issues that would contraindicate the use of albuterol.
• The patient's urinalysis results show RBC and bacteria, which may indicate a urinary tract infection, but this is not directly relevant to the treatment of the patient's respiratory symptoms. 2

From the Research

Patient Presentation

• The patient has a history of asthma and high blood pressure
• The patient complains of cough and shortness of breath (SOB) for 2 days
• Chest X-ray shows no acute cardiopulmonary findings, but low lung volumes are noted
• CTA chest reveals mild bilateral bronchial wall thickening, which may be congestive or related to infectious/inflammatory bronchitis
• Laboratory results:
  • D-dimer: 1.91
  • BNP: <10
  • Troponin: 0.02
  • Urinalysis: RBC 6-10, bacteria occ (0-10), blood urine moderate

Treatment Considerations

• The patient's symptoms and test results suggest a respiratory infection or exacerbation of asthma
• Azithromycin may be considered as a treatment option, as it has been shown to be effective in reducing symptoms and improving lung function in patients with chronic obstructive pulmonary disease (COPD) and acute exacerbation of chronic bronchitis 3
• However, a systematic review of azithromycin in asthma found no significant improvement in lung function or symptoms 4
• Combination therapy with fluticasone, azithromycin, and montelukast (FAM) has been shown to be effective in reducing corticosteroid exposure and improving lung function in patients with bronchiolitis obliterans syndrome after allogeneic hematopoietic cell transplantation 5, 6

Potential Treatment Options

• Azithromycin alone or in combination with other medications (e.g. salmeterol-fluticasone, tiotropium bromide) to treat the patient's respiratory symptoms and improve lung function 3
• FAM therapy to reduce corticosteroid exposure and improve lung function, although this may not be directly applicable to the patient's current condition 5, 6
• Further evaluation and monitoring of the patient's condition to determine the best course of treatment, as the current evidence does not provide a clear recommendation for treatment 4, 3