What is the appropriate treatment plan for a patient with ongoing respiratory illness, asthma exacerbation, and bilateral otitis media?

Treatment Plan for Ongoing Respiratory Illness with Asthma Exacerbation and Bilateral Otitis Media

The patient requires immediate treatment with high-dose albuterol via nebulizer (5 mg) or multiple actuations via metered-dose inhaler with spacer, oral prednisone 30-60 mg daily for 5-10 days, and amoxicillin-clavulanate for bilateral otitis media. 1, 2, 3

Assessment of Asthma Exacerbation Severity

Based on the clinical presentation, this patient has a persistent moderate asthma exacerbation with:

• Expiratory wheeze throughout chest
• Productive cough with yellow sputum
• Sleep disturbance due to breathing difficulties
• Persistent symptoms despite previous treatment with prednisolone and roxithromycin

The patient does not demonstrate severe features as they are able to speak in full sentences, have normal oxygen saturation, and heart rate is 78 bpm (not >110 bpm) 2.

Treatment Plan

1. Asthma Exacerbation Management

• Bronchodilator therapy:

  • Administer high-dose albuterol: Either 5 mg via nebulizer or 2 puffs via metered-dose inhaler with spacer repeated 10-20 times 2, 1
  • Consider adding ipratropium bromide 0.5 mg nebulized every 6 hours for additional bronchodilation 1

• Corticosteroid therapy:

  • Prescribe oral prednisone 30-60 mg daily for 5-10 days (no need to taper if course is less than 10 days) 2, 1
  • Continue current inhaled corticosteroid (Brio inhaler) but ensure proper technique and adherence 2

• Monitoring:

  • Assess response to initial bronchodilator treatment within 15-30 minutes and repeat if improvement is inadequate 2, 1
  • Monitor symptoms, peak expiratory flow if available, and oxygen saturation 2

2. Otitis Media Management

• Antibiotic therapy:

  • Prescribe amoxicillin-clavulanate 875/125 mg twice daily for 10 days for bilateral otitis media 3
  • This regimen is preferred over the 500/125 mg three times daily regimen due to lower incidence of severe diarrhea (1% vs 2%) 3

• Symptomatic relief:

  • Consider adding a decongestant to improve eustachian tube function 2

3. Consideration of Underlying Allergic Component

Given the co-existence of asthma and otitis media, there may be an allergic component:

• Consider adding montelukast 10 mg daily, which has shown benefit in both asthma control and improvement of otitis media with effusion in patients with co-existing disease 4, 5
• Montelukast may be particularly beneficial as studies have shown 60% resolution of otitis media with effusion in asthmatic patients after 30 days of therapy compared to 36% with inhaled medications alone 5

Discharge Plan

1. Medications:

   • Prednisone 30-60 mg daily for 5-10 days
   • Amoxicillin-clavulanate 875/125 mg twice daily for 10 days
   • Continue Brio inhaler 1 puff daily
   • Salbutamol inhaler 2 puffs as needed for relief
   • Consider montelukast 10 mg daily

2. Written action plan:

   • Provide clear instructions on medication use
   • Signs of worsening that require medical attention
   • Peak flow monitoring if appropriate 2

3. Follow-up:

   • Schedule follow-up within 24-48 hours to assess response to treatment 2
   • Plan for longer-term follow-up to adjust maintenance therapy 2

Important Considerations and Pitfalls

• Medication interactions: Monitor for potential side effects of amoxicillin-clavulanate, particularly diarrhea which occurs in approximately 9% of patients 3

• Neuropsychiatric events: Be aware that montelukast can cause neuropsychiatric events including agitation, depression, and sleep disturbances; instruct patient to report any such symptoms 4

• Incomplete response: If symptoms persist despite treatment, consider:

  1. Eosinophilic otitis media, which is more common in asthmatic patients and may require more aggressive treatment 6
  2. Evaluation for allergic triggers that may be exacerbating both conditions 7
  3. Assessment of inhaler technique and medication adherence 1

• Avoid monotherapy with long-acting beta-agonists: Ensure the patient continues to use inhaled corticosteroids with any long-acting beta-agonist due to increased risk of asthma-related deaths when used alone 1