What is the most appropriate treatment for a 25-year-old patient with a history of intermittent Shortness Of Breath (SOB) who presents to the Emergency Room (ER) with SOB after exercise and has wheezing in all areas of the chest?

Management of Acute Asthma Exacerbation in a Young Adult

The most appropriate treatment for this 25-year-old patient with intermittent SOB history presenting with exercise-induced SOB and diffuse wheezing is inhaled salbutamol (option A).

Clinical Assessment and Diagnosis

This patient's presentation is consistent with an acute asthma exacerbation:

• 25-year-old with history of intermittent SOB
• Current SOB after exercise
• Wheezing in all areas of the chest

These findings strongly suggest exercise-induced bronchoconstriction (EIB) or an acute asthma exacerbation triggered by exercise.

Treatment Algorithm

First-Line Treatment

• Short-acting β2-agonist (SABA): Salbutamol (albuterol) should be administered immediately via nebulizer or metered-dose inhaler with spacer 1
  • Dosage: 5 mg via nebulizer or 4-10 puffs via MDI with spacer
  • This provides rapid bronchodilation within minutes

Assessment of Response

• Evaluate clinical response 15-30 minutes after initial treatment
• If significant improvement (PEF >75% predicted/best):
  • Continue with as-needed SABA
• If partial improvement (PEF 50-75% predicted/best):
  • Add oral corticosteroids (prednisolone 30-60 mg)
• If minimal improvement (PEF <50% predicted/best) or deterioration:
  • Add ipratropium bromide 500 μg to nebulizer
  • Consider hospital admission 1

Why Salbutamol (Option A) is Correct

1. Rapid onset of action: SABAs provide the fastest relief of bronchospasm in acute settings 1
2. Evidence-based first-line therapy: The American Thoracic Society strongly recommends SABAs as first-line treatment for EIB, noting that patients who received inhaled SABA had significantly less decline in FEV1 after exercise compared to placebo 1
3. Appropriate for intermittent symptoms: For patients with intermittent symptoms, as-needed SABA is the recommended initial approach 2

Why Other Options Are Not First-Line

• Inhaled fluticasone (Option B): Inhaled corticosteroids are maintenance therapy for persistent asthma, not for immediate relief of acute symptoms. They take hours to days to show effect 2

• IV cortisone (Option C): Systemic corticosteroids are indicated for moderate-to-severe exacerbations but not as first-line therapy before trying inhaled bronchodilators 1

• IV magnesium sulfate (Option D): Reserved for severe, life-threatening exacerbations not responding to initial bronchodilator therapy 1

Important Clinical Considerations

• If the patient shows features of severe asthma (inability to complete sentences, respiratory rate >25/min, pulse >110/min), consider adding systemic corticosteroids after initial bronchodilator treatment 1

• For patients with recurrent exercise-induced symptoms, prophylactic use of SABA 15 minutes before exercise can prevent EIB 1

• Regular follow-up is essential to assess asthma control and adjust therapy if needed 2

Pitfalls to Avoid

1. Delaying bronchodilator therapy: Immediate bronchodilation with SABA is crucial in acute wheezing 1

2. Overreliance on corticosteroids alone: Steroids should not be used as sole initial therapy without bronchodilators in acute settings 1

3. Failure to recognize severe asthma: Always assess for features of severe or life-threatening asthma that would require more aggressive intervention 1

4. Missing underlying chronic asthma: Patients with recurrent exercise-induced symptoms may need controller medications (like inhaled corticosteroids) in addition to as-needed bronchodilators 1, 2