Management of a 68-Year-Old Male with Severe Asthma and COPD Presenting with Audible Wheeze
For a 68-year-old male with severe asthma and COPD presenting with audible wheeze, immediate treatment should include short-acting inhaled β2-agonists with or without short-acting anticholinergics, followed by systemic corticosteroids and consideration of antibiotics if there are signs of infection. 1
Initial Assessment and Classification
- This presentation likely represents an exacerbation of COPD with asthmatic features (sometimes called Asthma-COPD Overlap or ACO) 2, 3
- Classify the severity of the exacerbation based on symptoms, signs, and if possible, objective measurements 1:
- Mild: treated with short-acting bronchodilators only
- Moderate: requires short-acting bronchodilators plus antibiotics and/or oral corticosteroids
- Severe: requires hospitalization or emergency department visit 1
Immediate Management
Bronchodilator Therapy
- Administer short-acting inhaled β2-agonists (e.g., salbutamol 5 mg or terbutaline 10 mg) via nebulizer or spacer device 1
- Consider adding ipratropium bromide 500 μg (anticholinergic) if response to β2-agonist alone is inadequate 1
- Use air-driven nebulizers with supplemental oxygen via nasal cannulae if hypoxemia is present 1
Corticosteroid Therapy
- Administer systemic corticosteroids (oral or IV) - typically prednisolone 30-40 mg daily for 5-7 days 1
- Corticosteroids improve lung function, oxygenation, and shorten recovery time 1
Antibiotic Therapy
- Consider antibiotics if there are signs of bacterial infection (increased sputum purulence, increased sputum volume, increased dyspnea) 1
- Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
- First-line options include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 1
Oxygen Therapy
- Provide controlled oxygen therapy if hypoxemia is present, targeting SpO2 88-92% 1
- Monitor for CO2 retention, especially in patients with severe COPD 1
Monitoring and Reassessment
- Reassess within 30-60 minutes after initial treatment 1
- If improvement occurs, continue the same management
- If no improvement or worsening, consider hospital admission 1
Subsequent Management
For Patients Managed at Home
- Continue short-acting bronchodilators as needed 1
- Complete course of oral corticosteroids 1
- Complete antibiotics if prescribed 1
- Arrange follow-up within 1-2 weeks 1
For Hospitalized Patients
- Consider subcutaneous heparin for thromboprophylaxis 1
- Monitor fluid balance and nutrition 1
- Consider non-invasive ventilation (NIV) if respiratory failure develops 1
- Initiate maintenance therapy with long-acting bronchodilators before discharge 1
Long-term Management After Exacerbation
Pharmacological Management
- Initiate or adjust maintenance therapy with long-acting bronchodilators 1
- For patients with ACO features (asthma and COPD overlap), include inhaled corticosteroids in the regimen 2, 3
- Consider tiotropium (long-acting anticholinergic) which has been shown to reduce exacerbation rates 4
- Avoid methylxanthines due to side effects 1
Non-Pharmacological Management
- Smoking cessation counseling and support if patient is a smoker 1
- Consider pulmonary rehabilitation 1
- Ensure proper inhaler technique and adherence 1
- Annual influenza vaccination 1
Common Pitfalls to Avoid
- Don't rely solely on clinical features to differentiate between asthma and COPD exacerbations in patients with features of both conditions 5, 6
- Don't withhold systemic corticosteroids in COPD exacerbations due to concerns about side effects 1
- Don't prescribe antibiotics routinely without evidence of bacterial infection 1
- Don't delay initiation of maintenance therapy with long-acting bronchodilators 1
- Don't use nebulized therapy long-term without formal assessment of benefit 7