Discharge Instructions for a 52-year-old Male with Asthma Treated for Pneumonia
Patients with asthma who have been treated for pneumonia should be discharged only when their symptoms have stabilized, with peak expiratory flow (PEF) above 75% of predicted value or their best level, diurnal variability below 25%, and no nocturnal symptoms. 1
Medication Recommendations at Discharge
- Prescribe prednisolone tablets (30 mg daily) for one to three weeks according to a written action plan 1
- Increase inhaled steroids to a higher dosage than before admission 1
- Continue inhaled β-agonists for use "as necessary" 1
- Consider oral theophylline, long-acting β-agonists, or inhaled ipratropium if required based on severity of asthma 1
- Antibiotics should be prescribed only if bacterial infection is present and continued until completion of the course 1
- Caution regarding azithromycin if prescribed: monitor for rare but serious side effects including allergic reactions and QT prolongation, especially in patients with cardiac conditions 2
Self-Management and Monitoring
- Provide a peak expiratory flow meter and teach the patient how to use it properly 1
- Develop a written self-management plan that includes:
- When to increase treatment based on PEF values
- When to call their doctor
- When to return to the hospital 1
- Ensure the patient has been on discharge medication for at least 24 hours before leaving the hospital 1
- Verify and document proper inhaler technique 1
- Replace nebulizers with standard inhaler devices 24-48 hours before discharge unless the patient requires a nebuliser at home 1
Follow-up Arrangements
- Schedule follow-up with primary care physician within one week of discharge 1, 3
- Arrange follow-up appointment with a respiratory physician within 4 weeks 1
- Monitor blood theophylline concentrations if the patient is on oral xanthines 1
Warning Signs and When to Seek Medical Attention
- Return to the emergency department if experiencing:
- Be vigilant for signs of secondary infection or pneumonia recurrence 4
Investigation of Precipitating Factors
- Review potential triggers that may have contributed to the pneumonia or asthma exacerbation:
- Allergen exposure
- Viral infections
- Environmental factors
- Medication compliance 1
- Assess if there was an avoidable precipitating cause 1
- Evaluate if the patient was complying with regular treatment, and address barriers if not 1
Common Pitfalls to Avoid
- Never stop prednisolone abruptly or reduce the dose if asthma symptoms are worsening 1
- Avoid discharging patients too early before adequate stabilization of symptoms 3, 4
- Ensure inhaled steroid treatment is started at least 48 hours before discharge 1
- Avoid sedatives as they are contraindicated in asthma 1
- Do not discharge patients in the evening without ensuring adequate support and understanding of the management plan 3
Special Considerations for Asthma with Pneumonia
- Monitor closely for signs of respiratory deterioration as patients with asthma may have more severe presentations of pneumonia 5
- Be aware that inflammation from asthma can potentiate postobstructive pneumonia with unusual organisms in some cases 6
- Consider stepping up asthma maintenance therapy to prevent future exacerbations 4