What is the plan of care for a patient with asthma, who recently completed a round of antibiotics (abx) and steroids, and now presents with upper respiratory symptoms, including runny nose, congestion, cough with colored sputum, and wheezing, after possible mold exposure, currently taking Zyrtec (cetirizine)?

Plan of Care for Asthma Exacerbation with Post-Viral Symptoms and Possible Mold Exposure

This patient requires a rescue course of oral corticosteroids (prednisolone 30-60 mg daily) for 1-3 weeks, increased inhaled corticosteroids, and continued short-acting beta-agonists, while avoiding antibiotics unless bacterial infection is confirmed. 1

Immediate Management

Initiate Rescue Steroid Course

• Start prednisolone 30-60 mg daily immediately and continue until 2 days after control is established 1
• This patient meets criteria for rescue steroids: worsening symptoms with wheezing, productive cough, and recent rebound after completing prior treatment 1
• The colored sputum alone does not indicate bacterial infection requiring antibiotics 1

Optimize Bronchodilator Therapy

• Continue short-acting beta-agonist (albuterol/salbutamol) as needed for wheezing 1
• If wheezing persists despite rescue inhalers, consider nebulized beta-agonist (2.5-5 mg salbutamol) every 4-6 hours until symptoms improve 1
• Monitor response 15-30 minutes after each treatment 1

Increase Inhaled Corticosteroid Dose

• Increase inhaled corticosteroid to a higher dose than baseline 1
• This should be maintained throughout the exacerbation and adjusted based on symptom control 1

Critical Decision: Antibiotics Are NOT Indicated

Do not prescribe antibiotics - the British Thoracic Society explicitly states that antibiotics have no place in the management of uncomplicated asthma and should only be given if bacterial infection is confirmed 1. The green/brownish sputum in this context represents inflammatory cells and mucus plugging typical of asthma exacerbation, not bacterial infection 1.

Address Mold Exposure

Environmental Control

• Immediate removal from mold exposure is essential - patients with mold allergy have significantly worse asthma control and more frequent exacerbations requiring systemic corticosteroids 2
• Mold-allergic asthma patients have an odds ratio of 2.11 for developing bronchial asthma and require higher daily doses of inhaled steroids 2
• Arrange professional mold remediation of the new residence before patient returns 2

Consider Allergy Testing

• Perform skin prick testing or serum-specific IgE for mold allergens (particularly Alternaria alternata) to confirm sensitization 2
• This is recommended for patients with persistent asthma taking daily medications 1

Optimize Current Antihistamine Therapy

Continue Cetirizine (Zyrtec)

• Cetirizine should be continued as it has demonstrated beneficial effects in asthma management beyond just treating allergic rhinitis 3, 4
• Cetirizine reduces asthma symptoms, has bronchodilatory effects, and may have corticosteroid-sparing effects 3, 4
• It works through both H1-receptor antagonism and anti-inflammatory effects independent of histamine blockade 4

Monitoring and Follow-Up

Peak Flow Monitoring

• Provide peak flow meter and establish written action plan 1
• Measure peak flow twice daily (morning and evening before treatment) plus 30 minutes after morning bronchodilator 1
• Patient should increase treatment if peak flow falls below 60% of personal best 1
• Seek urgent care if peak flow remains <60% despite treatment 1

Discharge Criteria

• Continue current regimen until peak flow >75% of predicted/best value 1
• Diurnal variability should be <25% 1
• No nocturnal symptoms 1

Follow-Up Schedule

• See patient within 1 week to assess response to rescue steroids 1
• Schedule follow-up every 1-6 months depending on control achieved 1
• Consider referral to respiratory specialist if symptoms persist despite high-dose inhaled steroids or if this represents recurrent exacerbations 1

Critical Pitfalls to Avoid

Do Not Prescribe Antibiotics

• The recent completion of antibiotics followed by symptom rebound strongly suggests viral trigger with asthma exacerbation, not bacterial infection 1
• Overuse of antibiotics in asthma is explicitly discouraged by guidelines 1

Do Not Withhold Steroids

• Despite recent steroid course, this patient requires another rescue course given persistent wheezing and productive cough 1
• Exception: If patient is from or has traveled to areas endemic for Strongyloides stercoralis, test for parasitic infection before giving steroids 5
• Steroids in Strongyloides-infected patients can cause hyperinfection syndrome and death 5

Do Not Rely Solely on Bronchodilators

• Many asthma deaths are associated with overreliance on bronchodilators without adequate anti-inflammatory treatment 1
• The inflammatory component requires corticosteroid therapy 1

Long-Term Management Adjustments

Step Up Maintenance Therapy

• After acute exacerbation resolves, reassess baseline asthma control 1
• If patient was previously on low-dose inhaled steroids alone, consider adding long-acting beta-agonist or leukotriene modifier for better control 6
• Mold-allergic patients typically require higher maintenance doses of inhaled corticosteroids 2

Self-Management Education

• Provide written asthma action plan with specific peak flow thresholds for increasing treatment 1
• Train on proper inhaler technique 1
• Educate on difference between "reliever" (bronchodilator) and "preventer" (inhaled steroid) medications 1