From the Guidelines
For a 74-year-old male with acute onset wheezing and no prior pulmonary history, the initial workup should include a thorough history, physical examination, and targeted diagnostic testing, prioritizing vital signs, chest X-ray, and spirometry with bronchodilator response if stable, as suggested by recent guidelines 1. The patient's vital signs, including oxygen saturation, should be assessed first, followed by a focused respiratory examination.
- A chest X-ray should be ordered to rule out pneumonia, heart failure, or mass lesions.
- Spirometry with bronchodilator response should be performed if the patient is stable enough.
- Laboratory tests, such as complete blood count to assess for infection or eosinophilia, basic metabolic panel, and BNP to evaluate for heart failure, should be considered.
- An ECG may be necessary to rule out cardiac causes. Initial management may include a short-acting beta-agonist like albuterol 2.5 mg via nebulizer or 2-4 puffs via MDI every 4-6 hours as needed for symptom relief, as well as supplemental oxygen to maintain saturation above 90% if hypoxic, and oral prednisone 40-60 mg daily for 5-7 days for moderate to severe symptoms, in line with the most recent and highest quality study available 1. This comprehensive approach is crucial because new-onset wheezing in an elderly patient without prior pulmonary issues raises concerns for several serious conditions, including COPD exacerbation, heart failure, pneumonia, pulmonary embolism, or even malignancy, and prompt evaluation helps distinguish between these possibilities and guides appropriate treatment, as emphasized in the management of asthma exacerbations 1.
From the Research
Initial Evaluation
The workup for acute onset of wheezing in a 74-year-old adult male without a history of pulmonary issues involves several steps:
- A thorough patient history to identify potential causes of wheezing, such as upper respiratory infections, exposure to allergens or irritants, and medication use 2
- Physical examination to assess for signs of respiratory distress, such as accessory muscle use, pulsus paradoxus, and decreased breath sounds 2
- Objective measures of airway obstruction, including peak flow or forced expiratory volume in 1 second, and pulse oximetry before oxygen administration 2
Diagnostic Testing
- Chest x-ray to evaluate for potential causes of wheezing, such as pneumonia or pulmonary edema 3
- Pulmonary function testing with bronchodilator challenge to assess for reversible airway obstruction 3
- Advanced imaging, such as computed tomography, may be considered in patients with a significant history of tobacco use and new-onset wheezing to evaluate for malignancy 3
Management
- A trial of short-acting beta agonists, such as albuterol, may be considered while awaiting formal evaluation 3
- However, paradoxical bronchoconstriction is a rare complication of bronchodilator therapy, and clinicians should be vigilant in monitoring for adverse effects 4
- Oral or parenteral corticosteroids may be administered to patients with acute severe asthma, as clinical benefits may not occur for several hours 2