What is the next step in managing a 68-year-old female patient with worsening shortness of breath (SOB), fever, and diffuse wheezes, who has a history of asthma managed by albuterol, fluticasone (fluticasone), and salmeterol, and had a clear chest X-ray (CXR) two days ago?

Management of Acute Asthma Exacerbation in a 68-Year-Old Female

The appropriate next step is to initiate treatment with oxygen therapy, nebulized bronchodilators, and systemic corticosteroids, followed by hospital admission as this patient has signs of acute severe asthma exacerbation. 1, 2

Assessment of Severity

This patient presents with multiple features of acute severe asthma:

• Speaking in four-word sentences (inability to complete sentences in one breath)
• Dyspnea with diffuse wheezes throughout all lung fields
• Oxygen saturation of 91% on supplemental oxygen
• Low-grade fever (99°F)
• Worsening symptoms despite previous treatment with steroids

According to British Thoracic Society guidelines, the presence of these features indicates acute severe asthma that requires immediate intervention and likely hospital admission 1.

Immediate Management Algorithm

1. Oxygen therapy:

   • Administer high-flow oxygen (40-60%) to maintain SaO₂ > 92% 1, 2
   • Continue pulse oximetry monitoring

2. Bronchodilator therapy:

   • Administer nebulized salbutamol (albuterol) 5 mg via oxygen-driven nebulizer 1, 2
   • Add ipratropium bromide 0.5 mg to the nebulizer 1, 2
   • Repeat nebulized treatment every 15-30 minutes as needed based on response

3. Corticosteroid therapy:

   • Administer prednisolone 30-60 mg orally or intravenous hydrocortisone 200 mg 1, 2

4. Monitoring:

   • Assess response to treatment after 15-30 minutes 1
   • Monitor vital signs, oxygen saturation, and work of breathing continuously

Decision for Admission

This patient should be admitted to the hospital because:

• She has features of acute severe asthma (speaking in short sentences, diffuse wheezes, hypoxemia)
• She has had a progressive deterioration despite outpatient treatment
• She has failed previous treatment with steroids
• She is an older patient (68 years) with likely comorbidities
• She requires continuous monitoring and potentially escalation of therapy

Imaging Considerations

• Repeat CXR is indicated at this time despite the normal CXR two days ago, as her clinical condition has deteriorated and she now has fever, which raises concern for possible pneumonia or other complications 1
• CT chest is not indicated as the initial next step in this acute situation but may be considered later if there are specific concerns for complications or alternative diagnoses after initial stabilization

Antibiotic Considerations

• Initiating Augmentin is not the appropriate first step in this scenario
• While the patient has rhinorrhea and fever, the presentation is most consistent with an asthma exacerbation
• Antibiotics should be considered only if there is clear evidence of bacterial infection, which is not apparent from the current presentation

Common Pitfalls to Avoid

• Delay in treatment: Immediate bronchodilator and corticosteroid therapy is essential; do not wait for imaging results before initiating treatment 1, 2
• Underestimating severity: Patients with severe asthma may not appear as distressed as their physiological parameters would suggest 2
• Inadequate monitoring: Continuous monitoring is essential as patients can deteriorate rapidly 1, 2
• Failure to admit: Lower the threshold for admission in patients with previous severe attacks or recent treatment failure 1

This patient requires immediate treatment for acute severe asthma followed by hospital admission for continued management and monitoring. Repeat CXR is appropriate after initial stabilization, but the priority is treating the acute exacerbation.