What is the initial management for a patient with asthma and pneumonia?

Management of Asthma with Pneumonia

Treat both conditions simultaneously: initiate immediate bronchodilator therapy with nebulized salbutamol 5 mg and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV), provide supplemental oxygen to maintain saturation >92%, and add appropriate antibiotics for community-acquired pneumonia based on local resistance patterns. 1, 2, 3

Initial Assessment and Severity Stratification

Assess asthma severity first to determine the intensity of bronchodilator therapy needed:

• Severe asthma features: inability to complete sentences, respiratory rate >25/min, heart rate >110/min, peak expiratory flow (PEF) <50% predicted 4, 1, 3
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, confusion, or exhaustion 4, 1, 3
• Pneumonia confirmation: obtain chest radiography to document infiltrates and exclude complications like pneumothorax 4, 3

Immediate Bronchodilator Management

Administer high-dose inhaled beta-agonists immediately:

• Nebulized salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer 1, 2, 3
• Dosing frequency: every 20 minutes for 3 doses initially, then every 1-4 hours as needed 2, 5
• Alternative if no nebulizer available: 4-8 puffs via metered-dose inhaler with spacer every 20 minutes for up to 3 doses 1, 2

For moderate-to-severe presentations, add ipratropium bromide:

• Dose: 0.5 mg nebulized every 20 minutes for 3 doses, then every 4-6 hours 1, 2
• This combination reduces hospitalizations, particularly in severe airflow obstruction 2

Systemic Corticosteroid Therapy

Administer corticosteroids early and aggressively - this is critical for both asthma exacerbation and pneumonia-associated inflammation:

• Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 4, 1, 3
• Continue for 5-10 days with no taper needed for courses <10 days 2, 6
• Lower doses (hydrocortisone 50 mg IV every 6 hours) are as effective as higher doses for acute severe asthma 7

Oxygen Therapy

Maintain adequate oxygenation throughout treatment:

• Target: oxygen saturation >92% (>95% in pregnant patients or those with cardiac disease) 2, 3
• Delivery: 40-60% oxygen via face mask or nasal cannula 1, 3
• Monitor continuously via pulse oximetry 2

Antibiotic Selection for Pneumonia

Initiate empiric antibiotics for community-acquired pneumonia while awaiting culture results:

• Typical pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 8, 9
• Atypical coverage: Consider azithromycin or levofloxacin to cover Mycoplasma pneumoniae and Chlamydophila pneumoniae 8, 9
• Dosing examples: Azithromycin 500 mg daily or levofloxacin 750 mg daily 8, 9

Important caveat: Asthma patients on inhaled corticosteroids, particularly fluticasone propionate, have increased pneumonia risk compared to those on budesonide 10. This does not contraindicate ICS use but warrants heightened clinical vigilance.

Monitoring and Reassessment

Reassess 15-30 minutes after initial treatment:

• Measure PEF before and after bronchodilator administration 1, 2
• Clinical response: assess respiratory rate, heart rate, oxygen saturation, ability to speak 1, 3
• If improving: continue oxygen, corticosteroids, and nebulized beta-agonist every 4-6 hours 1, 3
• If NOT improving: increase nebulizer frequency to every 15-30 minutes and add/continue ipratropium 1, 3

Admission Criteria

Strongly consider hospital admission if:

• More than one severe asthma feature persists after initial treatment 4
• PEF remains <50% predicted after 1-2 hours of treatment 2
• Any life-threatening features present 4, 1, 3
• Pneumonia with significant hypoxemia or multilobar involvement 9
• Social factors that may impede outpatient management 4, 3

ICU transfer indications:

• Deteriorating PEF despite treatment 3
• Worsening hypoxia despite supplemental oxygen 3
• Exhaustion, confusion, drowsiness, or altered mental status 3
• Respiratory arrest or impending respiratory failure 2, 3

Critical Pitfalls to Avoid

Never administer sedatives to patients with acute asthma exacerbation, regardless of anxiety level 1, 3

Do not delay antiviral therapy if influenza is suspected - early antiviral treatment (≤2 days of admission) is associated with better outcomes in asthma patients with influenza pneumonia 11

Avoid underestimating severity - deaths from asthma are often associated with underestimation of severity and underuse of corticosteroids 3

Do not give bolus aminophylline to patients already taking oral theophyllines without checking levels 4

Discharge Planning (Once Stabilized)

Criteria for discharge:

• PEF ≥70% predicted or personal best 2
• Minimal symptoms and stable oxygen saturation on room air 2
• Adequate oral intake and ability to use inhalers correctly 2

At discharge, ensure:

• Continue oral corticosteroids for 5-10 days total 2, 6
• Complete antibiotic course for pneumonia (typically 5-10 days depending on agent) 8, 9
• Initiate or optimize inhaled corticosteroids for long-term asthma control 2
• Provide written asthma action plan and review inhaler technique 2
• Arrange follow-up within 24 hours with primary care and within 1 week with pulmonology if severe 4