What treatment should a patient with asthma, currently experiencing sore throat, body aches, congestion, and runny nose, and already using albuterol (albuterol) inhaler twice a day, follow to manage their symptoms?

Management of Asthma Patient with Upper Respiratory Symptoms

Continue albuterol on an as-needed basis rather than scheduled dosing, add symptomatic treatment for the viral upper respiratory infection, and closely monitor for signs of asthma exacerbation requiring escalation of therapy. 1, 2

Albuterol Management Strategy

The current twice-daily scheduled albuterol use should be transitioned to as-needed dosing. 1, 2

• Evidence from the Beta Agonist Study (BAGS) demonstrates that regularly scheduled albuterol in mild asthma is neither beneficial nor harmful compared to as-needed use, with no differences in peak flow, symptoms, or quality of life. 1, 2
• The National Asthma Education and Prevention Program incorporated this evidence into recommendations that as-needed short-acting beta-agonist use is the appropriate approach for symptom control. 1
• For acute symptom relief, the patient should use 2 inhalations of albuterol as needed, which can be repeated based on symptom response. 3

Assessment for Asthma Exacerbation

Objectively assess asthma severity to avoid underestimating the attack, as increased albuterol use over 3-4 days may signal worsening asthma. 1

The patient does NOT currently meet criteria for severe asthma, which would include: 1

• Inability to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow <50% of predicted or best

However, the British Thoracic Society guidelines emphasize that a lower threshold for concern is appropriate when: 1

• Symptoms are seen in the afternoon or evening (as in this case)
• Recent onset of nocturnal symptoms or worsening symptoms is present
• There is increased rescue bronchodilator requirement

Treatment Recommendations

Symptomatic Management of URI

• Continue over-the-counter symptomatic treatment (Alka-Seltzer) for congestion and runny nose as the patient finds helpful
• Antibiotics are NOT indicated unless bacterial infection is confirmed. 1

Monitoring Parameters

The patient should monitor for features requiring immediate medical attention: 1

• Worsening breathlessness or inability to speak in full sentences
• Increased respiratory rate or heart rate
• Decreased response to albuterol
• Need for albuterol more frequently than every 4 hours

Consider Controller Therapy Escalation

If the patient requires albuterol more than twice weekly for symptom control (beyond this acute illness), this indicates inadequate asthma control requiring initiation of daily inhaled corticosteroid therapy. 1, 4

• For patients 12 years and older with mild persistent asthma, options include either daily low-dose inhaled corticosteroids OR intermittent inhaled corticosteroid-SABA combination therapy (e.g., 2-4 puffs of albuterol followed by 80-250 μg beclomethasone equivalent every 4 hours as needed). 1
• Recent evidence shows that as-needed combination albuterol-budesonide (180 μg/160 μg) reduces severe exacerbation risk by 26% compared to albuterol alone in patients with moderate-to-severe asthma. 5

Critical Pitfalls to Avoid

Do NOT underestimate asthma severity during viral respiratory infections. 1

• The severity of asthma attacks is often underestimated by patients and physicians due to failure to make objective measurements
• Viral upper respiratory infections are common triggers for asthma exacerbations

Do NOT continue scheduled albuterol dosing without reassessment. 1, 2

• If the previously effective dosage regimen fails to provide usual relief, this is a sign of seriously worsening asthma requiring therapy reassessment. 3

Do NOT use sedating medications, as sedation is contraindicated in asthma. 1

• Be cautious with OTC cold medications containing sedating antihistamines or other sedating components