What is the appropriate management for a patient with a history of asthma presenting with wheezing, sore throat, fever, and productive cough?

Management of Asthma Patient with Acute Respiratory Infection

This patient requires immediate nebulized bronchodilator therapy with albuterol 2.5-5 mg (or terbutaline 10 mg) plus oral prednisolone 30-60 mg, while antibiotics should be avoided as they have no role in uncomplicated asthma exacerbations. 1

Initial Assessment and Risk Stratification

The combination of asthma history with wheezing, productive cough, and fever suggests an acute asthma exacerbation triggered by a viral respiratory infection, which is one of the most common precipitants of acute asthma. 1, 2 The key is to distinguish this from pneumonia, which would alter management significantly.

Clinical features to assess immediately:

• Ability to complete sentences in one breath 1
• Respiratory rate (>25 breaths/min indicates severe asthma) 1
• Pulse rate (>110 beats/min indicates severe asthma) 1
• Peak expiratory flow if available (<50% predicted indicates severe asthma) 1
• Presence of focal chest findings (rales, egophony, fremitus suggesting pneumonia) 1
• Vital sign abnormalities (heart rate ≥100 beats/min, respiratory rate ≥24 breaths/min, or temperature ≥38°C increase pneumonia likelihood) 1

Critical point: Purulent sputum does NOT indicate bacterial infection requiring antibiotics—it simply reflects inflammatory cells and can occur with viral infections. 1

Immediate Treatment Algorithm

If Features of Acute Severe Asthma Present:

Administer immediately:

• Oxygen 40-60% if available (CO₂ retention is not aggravated by oxygen in asthma) 1
• Nebulized albuterol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1, 3
• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1

Reassess 15-30 minutes after nebulizer treatment: 1

• If improving (PEF >50-75% predicted): Continue prednisolone daily, step up usual asthma treatment, arrange follow-up within 48 hours 1
• If not improving: Repeat nebulized bronchodilator every 15-30 minutes, add ipratropium 0.5 mg to nebulizer, consider hospital admission 1

If No Severe Features Present:

Treat at home with:

• Nebulized albuterol 2.5-5 mg (entire 3 mL vial of 0.083% solution) 3
• Prednisolone 30-60 mg if PEF 50-75% predicted or symptoms persist 1
• Step up regular inhaled corticosteroid therapy 1
• Follow-up within 24-48 hours 1

The Antibiotic Question: A Critical Pitfall

Antibiotics have absolutely no place in the management of uncomplicated asthma exacerbations. 1, 4 This is one of the most important clinical pearls, as both patients and physicians often mistakenly believe that fever and productive cough mandate antibiotic therapy.

The evidence is clear:

• Viral respiratory infections are the most common trigger for acute asthma 2, 5
• Purulent sputum reflects inflammation, not bacterial infection 1
• Antibiotics provide no benefit in acute bronchitis with productive cough 1
• In fact, bronchodilators are MORE effective than antibiotics (erythromycin) for acute bronchitis symptoms 6

Only consider antibiotics if:

• Focal consolidation on chest examination suggests pneumonia 1
• Chest radiograph confirms pneumonia (though radiography is only needed if vital signs are abnormal or focal findings present) 1

Corticosteroid Therapy: Timing and Duration

Systemic corticosteroids should be started immediately because clinical benefits require 6-12 hours to manifest. 2 The British Thoracic Society provides clear guidance:

Indications for oral prednisolone: 1

• Symptoms and PEF progressively worsening day by day
• PEF falls below 60% of patient's best
• Sleep disturbed by asthma
• Morning symptoms persist until midday
• Diminishing response to inhaled bronchodilators

Dosing:

• Adults: 30-60 mg prednisolone daily until 2 days after control established, then stop (no taper needed for short courses) 1
• Children: 1-2 mg/kg body weight for 1-5 days, no tapering required 1

Monitoring and Follow-Up

Essential monitoring parameters:

• Peak expiratory flow before and after each bronchodilator treatment 1
• Oxygen saturation (maintain >92%) 1
• Response to treatment at 15-30 minute intervals 1

Discharge criteria:

• PEF >75% predicted with variability <25% 1
• Patient on discharge medications for 24 hours with verified inhaler technique 1
• Written self-management plan provided 1
• GP follow-up within 1 week, respiratory clinic within 4 weeks 1

Common Pitfalls to Avoid

1. Prescribing antibiotics for purulent sputum without evidence of pneumonia 1
2. Delaying corticosteroids while waiting to see if bronchodilators alone work 2
3. Underestimating severity because patient appears comfortable (severe asthma patients may not show distress) 1
4. Failing to provide written action plan for future exacerbations 1
5. Not addressing environmental triggers, particularly smoking exposure 1, 4

Special Consideration: Cough-Variant Asthma

If cough persists beyond 3 weeks without wheezing, consider cough-variant asthma, which requires methacholine challenge testing or therapeutic trial of bronchodilators. 1 However, in the acute setting with wheezing present, this is standard asthma exacerbation management.