How to manage a patient with an asthma flare-up, productive cough, vomiting, fever, sore throat, rhinitis, and a viral infection?

Management of Viral-Triggered Asthma Exacerbation

Immediately initiate systemic corticosteroids (prednisolone 30-60 mg in adults or 1-2 mg/kg in children, maximum 40 mg) along with high-dose inhaled β2-agonists (salbutamol 5 mg or terbutaline 10 mg nebulized), while recognizing that antibiotics have no role in uncomplicated viral-triggered asthma. 1

Initial Assessment and Severity Classification

Assess severity immediately upon presentation by evaluating:

• Ability to complete sentences in one breath - inability indicates severe asthma 1, 2
• Respiratory rate >25 breaths/min - indicates severe exacerbation 1, 3
• Heart rate >110 beats/min - suggests severe disease 1, 3
• Peak expiratory flow (PEF) <50% of predicted or personal best - defines severe asthma requiring aggressive treatment 1, 2, 3

Life-threatening features requiring immediate intensive care consideration include silent chest, cyanosis, poor respiratory effort, confusion, exhaustion, bradycardia, or PEF <33% of predicted. 1, 2

Immediate Pharmacological Management

Bronchodilator Therapy

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer as first-line bronchodilator therapy 1, 3
• If no nebulizer available, give 2 puffs of β-agonist via large volume spacer, repeating 10-20 times (maximum 20 puffs) 1
• Reassess PEF 15-30 minutes after initial bronchodilator administration to guide further management 1
• If inadequate response, increase frequency of nebulized β-agonists up to every 15 minutes 1

Systemic Corticosteroid Therapy

• Give prednisolone 30-60 mg orally immediately in adults - do not delay administration 1, 2
• In children, administer prednisolone 1-2 mg/kg (maximum 40 mg) orally 1
• Alternative: intravenous hydrocortisone 200 mg if patient is vomiting or severely ill 1
• Continue daily prednisolone until two days after control is established, then stop or taper 1
• Clinical benefits may not occur for 6-12 hours, emphasizing the importance of early administration 4

Oxygen Therapy

• Administer high-flow oxygen 40-60% in all cases to maintain adequate oxygenation 1

Role of Antibiotics in Viral-Triggered Asthma

Antibiotics have no place in the management of uncomplicated asthma and should only be given if bacterial infection is clearly present. 1, 5 This is a critical pitfall to avoid - the presence of fever, productive cough, and elevated inflammatory markers in the context of a viral infection does not warrant antibiotic therapy unless bacterial superinfection is documented. 1, 5

Additional Therapeutic Considerations

Ipratropium Bromide

• Add nebulized ipratropium 0.5 mg if response to β-agonists is inadequate after initial treatment 1, 3
• Benefits are primarily in the emergency department setting and are not sustained after hospital admission 4

Aminophylline

• Consider intravenous aminophylline 250 mg over 20 minutes only if progress remains unsatisfactory despite maximal bronchodilator therapy 1
• Do not give bolus aminophylline to patients already taking oral theophyllines - this is a critical safety consideration 1

Management of Associated Symptoms

Vomiting

• If vomiting prevents oral medication, switch to intravenous hydrocortisone 200 mg every 6 hours 1
• Continue oxygen therapy and nebulized bronchodilators 1

Productive Cough and Rhinitis

• These symptoms are part of the viral trigger and do not require specific additional therapy beyond asthma management 1
• Antihistamines have proved disappointing in clinical practice for asthma management 1

Criteria for Hospital Admission

Consider immediate hospital referral if any of the following persist after initial treatment:

• Any life-threatening features present 1, 2
• PEF remains <33% of predicted or best value 15-30 minutes after nebulization 1
• Features of severe attack persist after initial treatment 1
• Lower threshold for admission if seen in afternoon/evening, recent nocturnal symptoms, previous severe attacks, or concerns about patient's ability to assess severity 1

Critical Pitfalls to Avoid

• Never use sedatives - they are absolutely contraindicated in acute asthma and can worsen respiratory depression 1, 3, 5
• Do not delay systemic corticosteroids - early administration is crucial even though benefits take 6-12 hours to manifest 2, 4
• Avoid overreliance on bronchodilators without anti-inflammatory treatment - this represents inadequate management 2
• Do not prescribe antibiotics for uncomplicated viral-triggered asthma - they provide no benefit and contribute to resistance 1, 5
• Percussive physiotherapy is unnecessary in acute asthma management 1

Follow-Up Management

• Review patient within 24-48 hours after acute exacerbation to ensure adequate recovery 2
• Continue prednisolone for 1-3 weeks (or longer in chronic asthma) according to written action plan 1
• Increase inhaled corticosteroid dosage higher than pre-exacerbation levels 1
• Provide written self-management plan with clear instructions for recognizing worsening symptoms and adjusting medications 2
• Monitor PEF regularly to assess response to treatment 1, 3, 5