What is the appropriate management for a 74-year-old asthmatic woman presenting with a sore throat, productive cough, nasal congestion, wheezing, and diarrhea?

Management of Acute Lower Respiratory Tract Infection in an Elderly Asthmatic Patient

This 74-year-old asthmatic woman presenting with productive cough, nasal congestion, wheezing, and diarrhea most likely has an acute lower respiratory tract infection (LRTI) with an asthma exacerbation, and should be treated with nebulized bronchodilators, systemic corticosteroids, and supportive care, while antibiotics should be withheld unless bacterial infection is clearly documented. 1, 2

Initial Assessment and Severity Stratification

The clinical presentation requires immediate evaluation of asthma severity to determine the appropriate treatment setting:

• Assess ability to complete sentences in one breath - if unable, this indicates severe asthma requiring urgent intervention 2
• Measure respiratory rate - rates >25 breaths/min indicate severe asthma 2
• Obtain peak expiratory flow (PEF) - values <50% of predicted indicate severe asthma requiring aggressive treatment 1, 2
• Check heart rate - tachycardia >110 beats/min suggests severe disease 2
• Evaluate for life-threatening features including silent chest, cyanosis, weak respiratory effort, exhaustion, or confusion 2

Immediate Bronchodilator Therapy

Regardless of whether this patient requires hospitalization, bronchodilator therapy should be initiated immediately:

• Administer nebulized salbutamol 5 mg with oxygen or deliver via metered-dose inhaler with large volume spacer device 1, 2
• Reassess PEF 30 minutes after bronchodilator administration to determine response 1
• Consider adding ipratropium bromide (short-acting muscarinic antagonist) if response to beta-agonist alone is limited 2

Systemic Corticosteroid Administration

Given the one-week duration of symptoms with productive cough and wheezing in an asthmatic patient, systemic corticosteroids are indicated:

• Administer prednisolone 30-60 mg orally immediately 1, 2
• Alternatively, give hydrocortisone 200 mg intravenously if oral route is not feasible 2
• Corticosteroids address both the asthma exacerbation and the underlying airway inflammation from the LRTI 2

Antibiotic Decision-Making

The key clinical pitfall here is inappropriate antibiotic prescribing. The presence of yellow phlegm alone does not mandate antibiotic therapy:

• Antibiotics should only be given if bacterial infection is clearly present, not routinely for respiratory symptoms or sputum production 3, 2
• The European guidelines on LRTI management emphasize judicious use of antimicrobials 1
• Yellow sputum can occur with viral infections and does not reliably distinguish bacterial from viral etiology 1

Diagnostic Workup

If the patient shows features of severe asthma or fails to respond to initial therapy:

• Obtain chest radiography to exclude pneumonia, pneumothorax, or pulmonary edema 3
• Measure oxygen saturation - values <92% on room air indicate need for hospitalization 2
• Check arterial blood gases if severe asthma features are present at hospital admission 2
• Consider complete blood count and electrolytes in complicated cases 3

Management of Concurrent Diarrhea

The new-onset loose stools likely represent a viral gastroenteritis concurrent with the respiratory infection:

• Ensure adequate hydration given the combination of respiratory illness and diarrhea
• Monitor electrolytes if diarrhea is severe or prolonged 3
• The diarrhea does not change the respiratory management approach

Disposition and Follow-Up

Hospitalization criteria include:

• PEF <50% of predicted or best after initial bronchodilator therapy 2
• Inability to complete sentences in one breath 2
• Oxygen saturation <92% on room air 2
• Persistent severe symptoms despite emergency treatment 1

If discharged home, the patient requires:

• Close follow-up within 24-48 hours to reassess response 1
• Contact with the patient's primary care physician to ensure continuity 1
• Written action plan for worsening symptoms 4
• Continuation of inhaled corticosteroids at appropriate dosage 3

Critical Safety Considerations

Absolutely avoid sedatives - any sedation is contraindicated in acute asthma as it can worsen respiratory depression and is potentially fatal 3, 4, 2

The one-week duration of symptoms suggests this is not the catastrophic sudden-severe asthma variant, but vigilance is still required as elderly patients with asthma can deteriorate rapidly 1.