What is the appropriate treatment and management plan for a 35-year-old female with symptoms of hyperinflated lungs, sneezing allergies, and breathlessness during exertion, suspected to have allergic bronchitis or asthma?

Management of Allergic Bronchitis/Asthma in a 35-Year-Old Female

For a 35-year-old female with hyperinflated lungs, sneezing allergies, and exertional breathlessness, start with salbutamol (short-acting β2-agonist) 2 puffs as needed up to 4 times daily, along with a low-dose inhaled corticosteroid twice daily, and montelukast 10mg once daily.

Diagnosis Confirmation

Before finalizing treatment, confirm the diagnosis with:

1. Spirometry testing - Essential for objective confirmation of asthma 1

   • Look for FEV1 <80% predicted with FEV1/VC ratio <70%
   • Test for reversibility with bronchodilator (≥20% improvement)

2. Peak flow monitoring - To assess variability

   • Calculate amplitude % best = (highest – lowest)/highest × 100
   • Variability ≥20% with minimum change of 60 L/min suggests asthma 1

3. Rule out other conditions:

   • Vocal cord dysfunction
   • COPD
   • Tuberculosis - Consider CBNAAT testing before starting steroids if TB is suspected

Treatment Plan

Immediate Relief

• Salbutamol (short-acting β2-agonist):
  • 2 puffs (200μg) as needed for symptom relief
  • Use before exercise to prevent exertional symptoms
  • Maximum 4 times daily
  • Particularly effective for exercise-induced symptoms 2

Controller Medications

1. Inhaled Corticosteroid (ICS):

   • Start with low-dose ICS twice daily
   • Most effective anti-inflammatory treatment for persistent asthma
   • Continue for at least 3 months to evaluate response

2. Montelukast 10mg:

   • Take once daily in the evening
   • Effective for both asthma and allergic symptoms
   • Not for acute asthma attacks 3
   • Monitor for neuropsychiatric side effects

3. Consider adding levocetirizine:

   • Particularly if allergic rhinitis symptoms are prominent
   • Take once daily
   • Treating upper airway symptoms may improve lower airway control 4

Additional Considerations

• Oral corticosteroids:

  • Not indicated for initial management without severe symptoms
  • Reserve for acute exacerbations with significant symptoms
  • Short course (5-7 days) of prednisolone may be used if symptoms are severe 5

• LAMA (Long-Acting Muscarinic Antagonist):

  • Not first-line for allergic asthma
  • Consider adding only if symptoms persist despite optimal ICS therapy

Monitoring and Follow-up

1. Peak flow monitoring:

   • Measure morning and evening
   • Record in diary to assess variability and treatment response

2. Follow-up visit in 2-4 weeks:

   • Assess symptom control
   • Review inhaler technique
   • Consider step-up or step-down therapy based on response

3. Long-term management:

   • Continue montelukast for at least 3 months
   • ICS duration depends on symptom control
   • Aim for lowest effective dose of all medications

Important Caveats

• Differentiate between asthma and other conditions: Symptoms like cough, wheeze, and dyspnea can be misattributed to asthma when they may be due to other causes 6

• Consider allergic rhinobronchitis: The link between upper and lower airway symptoms is well-established, and treating both components is important 4

• Exercise-induced symptoms: May require pre-treatment with salbutamol 15 minutes before exercise 2, 7

• Eosinophilic bronchitis: Consider this diagnosis if cough is prominent with eosinophilic inflammation but without variable airflow obstruction 8

• Montelukast precautions: Not for acute attacks; patients should have rescue medication available; monitor for neuropsychiatric events 3