What is the appropriate treatment plan for a patient with a chest infection, asthma, and previous gastric surgery, presenting with chest burning, cough, fever, and shortness of breath?

Management of Chest Infection in a Patient with History of Asthma

The patient should be treated with antibiotics (amoxicillin or tetracycline) for lower respiratory tract infection, along with bronchodilator therapy and close monitoring for asthma exacerbation. 1

Assessment of Current Presentation

• The patient presents with symptoms consistent with a lower respiratory tract infection (LRTI): chest burning, cough with green phlegm, fever, and shortness of breath 1
• History of asthma (long-standing but inactive) and previous esophageal gastrectomy (2022) are important comorbidities to consider in management 1
• Current vital signs show tachycardia (pulse 125) but normal blood pressure, oxygen saturation, and temperature 1
• Respiratory examination shows good air entry with vesicular breath sounds and no wheeze or crackles, suggesting the absence of severe bronchospasm at present 1

Diagnostic Considerations

• Green sputum and fever indicate a likely bacterial infection requiring antibiotic therapy 1
• The patient's history of asthma puts them at risk for exacerbation triggered by the respiratory infection 1
• Differential diagnoses to consider include:
  • Bacterial LRTI (most likely given presentation) 1
  • Asthma exacerbation (may be developing secondary to infection) 1
  • Post-surgical complications related to previous gastric surgery 1

Treatment Plan

Immediate Management

1. Antibiotic therapy:

   • First-line: Tetracycline or amoxicillin as recommended for LRTI 1
   • Alternative if allergic or in areas with high pneumococcal resistance: Azithromycin or clarithromycin 1
   • Recommended dosing: Amoxicillin/clavulanate 875/125 mg every 12 hours for 7-10 days 2

2. Bronchodilator therapy:

   • Prescribe albuterol (salbutamol) inhaler for as-needed use 3
   • Instruct on proper inhaler technique and frequency (2 puffs every 4-6 hours as needed) 3
   • Consider nebulized albuterol 2.5 mg three to four times daily if symptoms worsen 3

3. Anti-inflammatory treatment:

   • If respiratory symptoms worsen or signs of asthma exacerbation develop, add oral prednisolone 30-60 mg daily 1
   • Consider starting inhaled corticosteroids if asthma symptoms persist beyond the acute infection 1

Monitoring Plan

• Provide peak flow meter for home monitoring of respiratory function 4
• Instruct patient to monitor symptoms and peak flow readings twice daily 4
• Advise to seek immediate medical attention if:
  • Increasing shortness of breath 1
  • Inability to complete sentences in one breath 1
  • Peak flow drops below 50% of predicted/best 1
  • Symptoms not improving within 48 hours of starting antibiotics 1

Follow-up Plan

• Schedule follow-up appointment within 48 hours to assess response to treatment 1
• Consider referral to respiratory specialist if:
  • Poor response to initial treatment 4
  • History of asthma with current exacerbation 4
  • Recurrent chest infections 1

Special Considerations

• Post-gastric surgery: Patients with previous esophageal surgery may have increased risk of aspiration, which can complicate respiratory infections 5
• Smoking history: Former smoker status (quit 20 years ago) is relevant but less concerning than if currently smoking 5
• Vaccination: Recommend influenza vaccination once current infection resolves to prevent future respiratory infections 1

Patient Education

• Explain the difference between infection symptoms and asthma symptoms 4
• Provide clear instructions on medication use, including when to increase bronchodilator use 4
• Advise on warning signs that should prompt urgent medical attention 1
• Discuss importance of completing full course of antibiotics 1

Potential Pitfalls

• Underestimating severity of respiratory infections in patients with asthma history 4
• Overreliance on bronchodilators without addressing underlying infection 4
• Delayed recognition of developing asthma exacerbation 4
• Failing to provide clear follow-up instructions 1