What management plan should a patient with a history of asthma, managed with Ventolin (albuterol) and a preventer, follow if they are at risk of developing tonsillitis or Respiratory Syncytial Virus (RSV) infection?

Management Plan for Asthma Patient at Risk of Tonsillitis or RSV

For Maree's asthma management with potential respiratory infection risk, she should receive RSV vaccination if aged ≥60 years, maintain her current asthma controller therapy with proper inhaler technique verification, and understand that antibiotics are not indicated for viral tonsillitis unless specific bacterial criteria are met.

RSV Prevention Strategy

Vaccination Recommendation

• RSV vaccination is strongly recommended for adults aged ≥60 years with asthma, as they face 7-8 times higher risk of RSV-associated hospitalization compared to those without asthma 1, 2
• If aged 50-59 years with asthma as a risk factor, vaccination should still be prioritized given limited vaccine availability 3
• RSV vaccination prevents infection rather than treating established disease, making it the cornerstone of management 2

Why Vaccination Matters for Asthma Patients

• 49.5% of asthmatic patients hospitalized with RSV experience asthma exacerbations 2
• RSV is recognized as an important trigger for asthma exacerbations, making prevention critical 2

Asthma Maintenance Management

Current Controller Therapy Assessment

• Verify proper inhaler technique for both Ventolin (albuterol) and preventer medication 1
• Ensure she has a peak expiratory flow meter and knows how to use it 1
• She must have a written self-management plan that specifies when to increase treatment, call her doctor, or seek emergency care based on peak flow values and symptoms 1

Optimization of Reliever Therapy

• Consider switching from albuterol alone to a fixed-dose combination of albuterol-budesonide (180 μg/160 μg) as rescue medication, which reduces severe asthma exacerbation risk by 26% compared to albuterol alone 4
• This anti-inflammatory reliever approach addresses both bronchoconstriction and inflammation during symptom worsening 5

Monitoring Parameters

• Peak expiratory flow should remain above 75% of predicted or personal best 1
• Diurnal variability should be below 25% 1
• No nocturnal symptoms indicate adequate control 1

Tonsillitis Management Approach

When Antibiotics Are NOT Indicated

• Acute tonsillitis is usually viral and does not require antibiotics 1
• Antibiotics should be reserved for bacterial tonsillitis meeting specific clinical criteria 1

Bacterial Tonsillitis Diagnostic Criteria (When Antibiotics ARE Indicated)

Antibiotics are appropriate only when symptoms meet one of these patterns 1:

• Persistent symptoms >10 days without clinical improvement
• Severe symptoms: fever >39°C, purulent discharge, or facial pain for ≥3 consecutive days
• "Double sickening": worsening after initial improvement (new fever, headache, or increased discharge after typical viral URI was improving)

Antibiotic Selection If Bacterial Criteria Met

• First-line: Amoxicillin-clavulanate (preferred due to resistance patterns) 1
• Alternative: Doxycycline or respiratory fluoroquinolone 1
• Some guidelines support amoxicillin alone as first-line 1

Symptomatic Management for Viral Tonsillitis

• Analgesics (paracetamol or NSAIDs) for pain and fever 3, 6
• Adequate hydration 3
• Nasal saline irrigation for upper respiratory symptoms 3
• Single dose of corticosteroids may provide symptomatic benefit, with reassessment 6

Critical Asthma Exacerbation Recognition

When to Escalate Treatment Immediately

If respiratory infection triggers asthma worsening, she needs increased treatment when 1:

• Peak expiratory flow drops to 50-75% of predicted/best after nebulized bronchodilator
• Requires prednisolone 30-60 mg daily
• Must have objective confirmation of improvement before leaving medical supervision
• Follow-up within 48 hours is mandatory

Emergency Indicators Requiring Hospital Assessment

• Peak expiratory flow <50% of predicted after treatment 1
• Severe breathlessness with increasing tiredness 1
• Inability to complete sentences 1
• Confusion, drowsiness, or exhaustion 1

Infection Control Measures

RSV Prevention Beyond Vaccination

• Hand hygiene is the single most important measure to prevent RSV transmission 3, 7
• Avoid contact with individuals showing respiratory symptoms during RSV season (winter months) 7
• Avoid passive smoke exposure 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral tonsillitis based solely on throat appearance or patient request 1
• Do not use corticosteroids routinely for RSV bronchiolitis if it develops 3
• Do not stop or reduce inhaled corticosteroids during respiratory infections unless asthma is worsening 1
• Do not rely on albuterol alone without addressing inflammation during symptom escalation 4, 5
• Do not discharge or reassure without objective peak flow measurement and written action plan 1