What is the recommended management for a patient with asthma and Upper Respiratory Tract Infection (URTI)?

Management of Asthma with Upper Respiratory Tract Infection

For patients with asthma and URTI, optimize bronchodilator therapy with inhaled β-agonists as needed, increase or initiate inhaled corticosteroids, and avoid antibiotics unless bacterial infection is clearly documented. 1

Initial Assessment and Monitoring

Assess asthma severity immediately to determine if outpatient management is appropriate or if hospital referral is needed:

• Measure peak expiratory flow (PEF) to objectively quantify airflow obstruction 1, 2
• Evaluate ability to speak in complete sentences - inability indicates severe exacerbation requiring hospitalization 2, 3
• Check respiratory rate (>25 breaths/min suggests severe disease) and heart rate (>110 bpm indicates severity) 2, 3
• Assess oxygen saturation - values <92% on room air require hospital admission 3

Bronchodilator Therapy

Intensify short-acting β-agonist use as the cornerstone of acute symptom management:

• Administer salbutamol 5 mg or terbutaline 10 mg via nebulizer every 4 hours if symptoms are mild to moderate 1, 2
• Alternatively, use MDI with spacer (1 puff every few seconds up to 20 puffs) which may be equally effective 1
• Increase frequency to every 15-30 minutes if initial response is inadequate 1, 3
• Consider adding ipratropium bromide 0.5 mg to each nebulized treatment for additional bronchodilation in severe cases 2, 3

Corticosteroid Management

Initiate or increase corticosteroid therapy as URTI-triggered asthma exacerbations respond well to early anti-inflammatory treatment:

• Start oral prednisolone 30-60 mg daily for patients with moderate to severe symptoms or PEF <50-75% predicted 1, 2, 3
• Continue for 1-3 weeks (not just 5-6 days, as shorter courses lead to relapse) 3
• Increase inhaled corticosteroid dose for patients already on maintenance therapy 1, 4
• Consider early initiation of inhaled budesonide at high doses (0.2 mg four times daily for 3 days, then taper) at the first sign of URTI, as this can attenuate exacerbations and reduce emergency visits 5

The evidence shows that corticosteroids take 6-12 hours to manifest anti-inflammatory effects, making early administration critical 3. Research demonstrates that inhaled steroids started early during URTI can significantly improve PEF and reduce emergency room visits 5.

Antibiotic Use: A Critical Pitfall

Do not prescribe antibiotics unless bacterial infection is clearly documented - this is explicitly stated as "unhelpful treatment" in guidelines:

• URTIs triggering asthma are typically viral, not bacterial 6
• Antibiotics should only be given if bacterial infection is present (e.g., consolidation on chest X-ray, purulent sputum with fever) 1, 2, 3
• Evidence does not support routine antibiotic use in acute asthma exacerbations 6

Additional Management Considerations

Avoid contraindicated treatments that worsen outcomes:

• Never use sedatives - they are absolutely contraindicated and can cause respiratory depression 7, 2, 3
• Avoid percussive physiotherapy - it provides no benefit 1

Follow-Up and Self-Management

Ensure close monitoring and patient education:

• Provide or reinforce peak flow meter use with written action plan 1, 3
• Schedule follow-up within 1 week with primary care and within 4 weeks with respiratory specialist if symptoms persist 1, 3
• Verify inhaler technique before discharge or at follow-up 1
• Continue monitoring for 48 hours if managed at home to confirm objective improvement 1

Hospital Referral Criteria

Refer immediately to hospital if any of the following are present:

• PEF <50% predicted after initial bronchodilator treatment 1, 2, 3
• Inability to complete sentences in one breath 2, 3
• Oxygen saturation <92% on room air 3
• Life-threatening features: silent chest, cyanosis, weak respiratory effort, exhaustion, confusion, or altered consciousness 1, 2
• Symptoms seen in afternoon/evening (lower threshold for admission) 1