What is the initial treatment for an asthma patient presenting with mucous plugging and scattered ground-glass opacities?

Initial Treatment for Asthma Patient with Mucous Plugging and Ground-Glass Opacities

The initial treatment for an asthma patient presenting with mucous plugging and scattered ground-glass opacities should include high-flow oxygen, nebulized beta-agonists (salbutamol 5-10 mg or terbutaline 10 mg), systemic corticosteroids, and consideration of ipratropium bromide. 1

Immediate Management

• Administer high-flow oxygen (40-60%) via face mask to maintain oxygen saturation >92% 1, 2
• Give nebulized salbutamol 5-10 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
• Administer systemic corticosteroids: either oral prednisolone 30-60 mg or intravenous hydrocortisone 200 mg (or both if patient is very ill) 1
• Consider adding ipratropium bromide 0.5 mg to the nebulizer if the patient is not improving after 15-30 minutes 1
• Obtain a chest radiograph to exclude pneumothorax and confirm the ground-glass opacities 1

Monitoring and Assessment

• Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment 1
• Use pulse oximetry to maintain SaO₂ >92% 1, 2
• Consider arterial blood gas measurement if:
  • PaO₂ <8 kPa (60 mm Hg) initially
  • PaCO₂ was normal or raised initially
  • Patient shows clinical deterioration 1
• Chart PEF before and after nebulized treatments 1

Subsequent Management

If patient is improving:

• Continue oxygen therapy
• Continue prednisolone 30-60 mg daily or intravenous hydrocortisone
• Continue nebulized beta-agonist every 4-6 hours 1

If patient is not improving after 15-30 minutes:

• Continue oxygen and corticosteroids
• Increase frequency of nebulized beta-agonist (every 15-30 minutes)
• Add ipratropium bromide 0.5 mg to nebulizer and repeat every 6 hours until improvement 1
• Consider admission to hospital 1

Special Considerations for Mucous Plugging

Mucous plugging represents significant airway obstruction that requires aggressive therapy. The combination of beta-agonists and anticholinergics (ipratropium) is particularly important in this scenario as it provides more effective bronchodilation through different mechanisms 2, 3.

Criteria for ICU Transfer

Transfer the patient to intensive care unit (accompanied by a doctor prepared to intubate) if there is:

• Deteriorating PEF
• Worsening or persistent hypoxia
• Confusion or drowsiness
• Exhaustion, coma, or respiratory arrest 1

Discharge Criteria

Patients should only be discharged when they:

• Have been on discharge medication for 24 hours with inhaler technique checked and recorded
• Have PEF >75% of predicted or best with variability <25%
• Are receiving appropriate treatment with oral and inhaled medications
• Have follow-up arranged with primary care within 1 week
• Have a follow-up appointment in respiratory clinic within 4 weeks 1

Medication Dosing

• Albuterol (salbutamol): 2.5 mg for adults and children weighing at least 15 kg, administered by nebulization 4
• For severe cases, higher doses (5-10 mg) may be used 1
• Corticosteroids: Even low doses of corticosteroids (hydrocortisone 50 mg IV every 6 hours) can be as effective as higher doses in resolving acute severe asthma 5

The presence of ground-glass opacities on imaging suggests significant inflammation that requires prompt anti-inflammatory treatment with corticosteroids in addition to bronchodilators 6, 3.