What is the management plan for a 21-year-old patient with a history of reactive airway disease (asthma) on budamate (budesonide/formoterol) inhaler presenting with breathlessness after a stressful event?

Management of Acute Asthma Exacerbation Triggered by Stress

For a 21-year-old patient with reactive airway disease experiencing breathlessness after a stressful call, immediate treatment with a short-acting beta-agonist followed by assessment of severity is required, with consideration for increasing the budesonide/formoterol dose as both maintenance and reliever therapy. 1, 2

Initial Assessment and Management

• Assess severity of breathlessness by checking if the patient can complete sentences in one breath, respiratory rate (>25 breaths/min indicates severe attack), and peak expiratory flow (PEF) if available (<50% of predicted indicates severe attack) 1

• For immediate symptom relief, administer the patient's budesonide/formoterol (Budamate) inhaler, which can serve as both maintenance and reliever therapy 2, 3

• If symptoms are mild to moderate and improve with initial treatment, continue using budesonide/formoterol as needed for symptom control 3

Management Based on Severity

If symptoms are mild and improve quickly:

• Continue using budesonide/formoterol inhaler as needed for symptom relief 3
• Instruct patient to monitor symptoms and peak flow (if available) 1
• Ensure proper inhaler technique is being used 1
• Identify and address the stress trigger that precipitated the attack 1

If symptoms are moderate to severe:

• Administer high-dose inhaled beta-agonist: 5-10 mg salbutamol or terbutaline via nebulizer or multiple actuations of metered-dose inhaler with spacer 1
• Add oral prednisolone 30-60 mg immediately 1
• Consider adding ipratropium bromide 0.5 mg to nebulizer if response is inadequate 1
• Monitor response after 15-30 minutes; if not improving, repeat beta-agonist treatment and arrange hospital transfer 1

Hospital Referral Criteria

Refer to hospital immediately if any of the following are present:

• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, confusion, or exhaustion 1
• Severe symptoms persisting after initial treatment 1
• PEF <33% of predicted or best value after treatment 1
• History of previous severe attacks, especially with rapid onset 1
• Inadequate social support or inability to monitor condition at home 1

Follow-up Management

• Schedule follow-up within one week with primary care provider 1
• Consider increasing the maintenance dose of budesonide/formoterol temporarily 3, 4
• Provide a written asthma action plan that includes when to increase medication and when to seek emergency care 1
• Educate patient about stress as an asthma trigger and discuss stress management techniques 1

Special Considerations for Budesonide/Formoterol Users

• The combination of budesonide/formoterol can be used as both maintenance and reliever therapy (MART approach), which has been shown to reduce exacerbation risk compared to using separate maintenance and reliever medications 4
• During periods of increased symptoms, patients can temporarily increase their budesonide/formoterol dosage, which provides both immediate symptom relief and increased anti-inflammatory effect 2
• This approach may reduce the need for oral corticosteroids and emergency department visits 3

Cautions

• Avoid sedatives as they are contraindicated in asthma exacerbations 1
• Monitor for signs of systemic corticosteroid effects if increasing inhaled corticosteroid dose significantly 5
• Be alert for paradoxical bronchospasm with inhaled medications, which would require immediate discontinuation and alternative therapy 5

Remember that stress-induced asthma exacerbations are real physiological responses and require appropriate medical management alongside addressing the psychological trigger 1.