How to manage a 65-year-old with chest infection, productive cough, SOB (shortness of breath), and wheeze, with a history of asthma, hypertension, and hyperlipidemia, on salbutamol (albuterol), Amlodipine, chlorthalidone, Flixonase (fluticasone), rosuvastatin, aspirin, montelukast, quinapril, metformin, and Relvar Ellipta (fluticasone/vilanterol)?

Management of Acute Chest Infection with Wheeze in a 65-Year-Old with Asthma History

This patient requires immediate antibiotic therapy for bacterial chest infection, intensified bronchodilator therapy with nebulized salbutamol 5 mg plus ipratropium bromide 500 mcg every 4-6 hours, and a short course of oral corticosteroids (prednisolone 30 mg daily for 7-14 days). 1

Immediate Antibiotic Therapy

Start antibiotics immediately for this acute bacterial chest infection with purulent sputum. 1

• First-line choice: Amoxicillin or tetracycline unless previously used with poor response 1
• Second-line alternatives: Broad-spectrum cephalosporin or newer macrolides if inadequate response to first-line agents or more severe presentation 1
• The presence of green purulent sputum, night sweats, and bilateral crackles indicates bacterial infection requiring antimicrobial coverage 1

Intensified Bronchodilator Therapy

Escalate to nebulized bronchodilator therapy given the severity of symptoms with bilateral wheeze and crackles. 1

Nebulizer Regimen:

• Salbutamol 5 mg via air-driven nebulizer every 4-6 hours 1
• Add ipratropium bromide 500 mcg to the salbutamol given the moderate-to-severe presentation with bilateral signs 1
• Use air-driven nebulizers (not oxygen-driven) to avoid potential CO2 retention in patients with possible COPD 1
• Continue nebulized therapy for 24-48 hours or until clinical improvement, then step down to metered-dose inhalers 1

Critical Technical Points:

• Nebulize until approximately one minute after "spluttering" occurs (5-10 minutes total) 1
• Do NOT use "dryness" as the endpoint 1
• Tap the nebulizer cup toward the end of treatment 1

Systemic Corticosteroid Therapy

Initiate oral prednisolone 30 mg daily for 7-14 days. 1

• This is indicated for acute exacerbations with marked wheeze and bilateral chest signs 1
• Can use 100 mg hydrocortisone IV if oral route not possible 1
• Discontinue after the acute episode unless long-term benefit has been demonstrated during stable periods 1
• A corticosteroid trial during acute exacerbation does NOT automatically indicate need for long-term inhaled corticosteroids 1

Distinguishing Asthma vs COPD

The spirometry referral is appropriate and essential, but do not delay treatment. 1

Key Diagnostic Considerations:

• COPD criteria: FEV1 <80% predicted AND FEV1/VC ratio <70% with fixed obstruction 1
• Asthma features: Substantial bronchodilator reversibility (FEV1 increase ≥200 ml AND ≥15% from baseline) 1
• This patient's 4-year smoking cessation and history of asthma with previous good response to bronchodilators suggests asthma, but the ex-smoking history raises COPD possibility 1
• Many patients show overlap features, and 10-20% of COPD patients demonstrate some corticosteroid responsiveness 1

Monitoring and Reassessment

Reassess within 48 hours for home-managed exacerbations. 1

Signs Requiring Hospital Referral:

• Worsening breathlessness despite treatment 1
• Inability to complete sentences 1
• Respiratory rate >25/min 1
• Heart rate >110/min 1
• Oxygen saturation declining below 90% 1
• Development of confusion or drowsiness 1

Continuation of Existing Therapy

Continue all current medications without interruption. 1

• Maintain Relvar Ellipta (fluticasone/vilanterol) for baseline asthma control 1
• Continue salbutamol PRN, but frequency should decrease as infection resolves 2
• Keep montelukast 10 mg daily 1
• All cardiovascular medications (amlodipine, chlorthalidone, quinapril, rosuvastatin, aspirin) should continue 1

Blood Pressure Management

The elevated BP (157/92 mmHg) requires attention but is likely exacerbated by acute illness and bronchodilator therapy. 1

• Beta-agonists can precipitate tachycardia and hypertension 1
• Reassess BP after acute infection resolves before adjusting antihypertensive regimen 1
• Salt restriction as planned is appropriate 1

Common Pitfalls to Avoid

• Do not use albuterol alone for chronic cough not due to asthma - it is ineffective 1
• Do not rely on metered-dose inhalers during acute exacerbations - nebulizers deliver superior drug deposition when significant bronchospasm present 1, 2
• Do not use oxygen-driven nebulizers if COPD suspected - risk of CO2 retention 1
• Do not delay antibiotics - purulent sputum with systemic symptoms requires immediate antimicrobial therapy 1
• Avoid sedatives and hypnotics during acute exacerbation as they can suppress respiratory drive 1

Sputum Clearance

Encourage active coughing and adequate fluid intake. 1

• Consider home physiotherapy if sputum retention problematic 1
• Huffing technique may be taught as adjunct to coughing 1
• Chest physiotherapy has limited evidence in acute COPD exacerbations but may help with sputum clearance 1