What is the next line of management for a 62-year-old female with bronchial asthma (BA) and a mouth polyp versus ulcer, who has partial relief from breathlessness with nebulization and oral pain with betadine (povidone-iodine) mouth gargle?

Management of Bronchial Asthma with Mouth Lesion

For this 62-year-old female with bronchial asthma experiencing partially relieved breathlessness and oral pain, the next line of management should include escalation of asthma therapy with oral corticosteroids (prednisolone 30-60mg) and referral for evaluation of the oral lesion.

Asthma Management

Assessment of Asthma Severity

• Evaluate severity based on objective measures: ability to complete sentences, respiratory rate, heart rate, and peak expiratory flow (PEF) 1
• If patient has features of severe asthma (can't complete sentences, respiratory rate >25/min, heart rate >110/min, PEF <50% of predicted/best), consider hospital admission 2
• If symptoms are partially relieved with nebulization but still present, this indicates inadequate control requiring treatment escalation 1

Immediate Management for Asthma

• Continue nebulized β2-agonist therapy (salbutamol 5mg or terbutaline 10mg) every 4-6 hours 2
• Add oral prednisolone 30-60mg as a single daily dose 2
• If response to β2-agonist is suboptimal, add ipratropium bromide 500μg to the nebulizer solution 2
• Ensure oxygen therapy if available and oxygen saturation is low 2

Follow-up Management for Asthma

• Provide a self-management plan with clear instructions for medication adjustment 1
• Schedule follow-up within 24-48 hours to assess response to treatment 1, 3
• Monitor symptoms and PEF using a peak flow chart 2
• Consider stepping up maintenance therapy if this represents a pattern of poor control 3
• Evaluate inhaler technique and medication adherence 1

Management of Oral Lesion

Assessment and Treatment of Oral Lesion

• While betadine (povidone-iodine) gargle has provided partial relief, the nature of the lesion (polyp vs. ulcer) requires proper diagnosis 1
• Refer for oral examination by a dental professional or otolaryngologist to determine the exact nature of the lesion
• Continue povidone-iodine gargle for symptomatic relief until definitive diagnosis and treatment 2
• Consider topical anesthetic (lignocaine 2%, 2-5ml or bupivacaine 0.25%, 2-5ml) for severe pain, preceded by β2-agonist via inhaler 2

Prescription Plan

Medications

1. Prednisolone 30-60mg orally once daily for 5-7 days 2
2. Salbutamol nebulization 5mg or terbutaline 10mg every 4-6 hours as needed 2
3. Add ipratropium bromide 500μg to nebulizer solution if response to β2-agonist alone is inadequate 2
4. Continue povidone-iodine gargle for oral pain relief 2
5. Consider topical anesthetic for severe oral pain 2

Additional Instructions

• Monitor and record PEF twice daily 2
• Return immediately if symptoms worsen or fail to improve 2
• Follow-up appointment within 24-48 hours 1
• Referral to oral specialist for evaluation of mouth lesion

Common Pitfalls to Avoid

• Underestimating the severity of asthma exacerbation can lead to inadequate treatment 1
• Failing to address both the respiratory and oral symptoms simultaneously 3
• Not providing clear follow-up instructions and a self-management plan 1
• Overlooking the need for specialist evaluation of the oral lesion 3
• Relying solely on bronchodilators without anti-inflammatory treatment 1