What is the best treatment plan for a patient with recurrent wheezing, suspected obesity-hypoventilation syndrome, and underlying cellulitis, who has never been treated with steroids for wheezing and is now presenting with shortness of breath and fever?

Management of Recurrent Wheezing with Underlying Cellulitis

For this patient with recurrent wheezing and underlying cellulitis, the recommended treatment plan is to provide bronchodilator nebulization therapy without systemic corticosteroids, as steroids could potentially worsen the existing cellulitis infection. 1

Assessment of Wheezing Pattern

• The patient presents with a history of recurrent wheezing triggered by smoke exposure and currently exacerbated by fever from cellulitis, suggesting a possible undiagnosed asthma or obesity-related breathing disorder 1, 2
• The patient's clinical presentation (speaking in full sentences, no tachycardia, prompt response to nebulization) indicates a mild-to-moderate exacerbation rather than severe respiratory distress 1
• The patient's obesity likely contributes to his respiratory symptoms, suggesting possible obesity hypoventilation syndrome as an underlying factor 3, 4

Recommended Treatment Approach

Immediate Management

• Continue bronchodilator therapy with albuterol nebulization as needed (2.5-5 mg) for symptom relief 1, 5
• Avoid systemic corticosteroids due to the active cellulitis infection, as steroids may impair the healing process and potentially worsen the infection 1
• Maintain appropriate antibiotic therapy for cellulitis (cephalexin 500 mg four times daily for 5 days is standard for non-purulent cellulitis) 6
• Monitor oxygen saturation and provide supplemental oxygen if saturation falls below 90% 1

Post-Acute Management

• Once the cellulitis has resolved, consider a formal evaluation for asthma with pulmonary function testing 1
• If asthma is confirmed, initiate step-based therapy according to severity:
  • For mild persistent asthma: low-dose inhaled corticosteroids 1
  • For moderate persistent asthma: low-to-medium dose inhaled corticosteroids plus long-acting beta-agonist 1

Evaluation for Obesity Hypoventilation Syndrome

• Given the patient's obesity and history of oxygen desaturation, evaluation for obesity hypoventilation syndrome is warranted 4, 2
• Consider arterial blood gas analysis when the patient is stable to assess for chronic hypercapnia 2
• Sleep study evaluation should be performed to assess for obstructive sleep apnea, which commonly coexists with obesity hypoventilation syndrome 3, 7

Rationale for Avoiding Steroids

• The Infectious Diseases Society of America guidelines note that systemic corticosteroids could be considered in non-diabetic adult patients with cellulitis (weak recommendation) 1
• However, in this case, the potential benefits of steroids for wheezing must be weighed against the risk of worsening the infection 1
• Since the patient responded well to bronchodilator therapy alone and has no history of requiring steroids for wheezing, the safest approach is to manage without steroids until the infection resolves 1

Long-term Management Considerations

• After resolution of the acute episode, a comprehensive evaluation for the underlying cause of recurrent wheezing is essential 1
• If asthma is diagnosed, a stepwise approach to therapy should be implemented based on symptom frequency and severity 1
• For patients with obesity hypoventilation syndrome, weight loss should be strongly encouraged, and evaluation for positive airway pressure therapy may be necessary 3, 2
• Smoking cessation counseling and avoidance of smoke exposure should be emphasized given the patient's reported trigger 1

Common Pitfalls to Avoid

• Don't automatically assume all wheezing is asthma, especially in obese patients who may have obesity hypoventilation syndrome 4, 7
• Avoid unnecessary use of systemic corticosteroids in patients with active infections when alternative treatments are effective 1
• Don't miss the opportunity to evaluate for underlying sleep-disordered breathing in obese patients with respiratory symptoms 3, 2
• Avoid prolonged or excessive use of short-acting beta-agonists without addressing the underlying cause of wheezing 1