What is the appropriate management for a patient presenting with a chronic cough, shortness of breath, and a history of relief with albuterol, who is concerned about pneumonia or COVID-19?

Management of Chronic Cough with Shortness of Breath and Albuterol Response

This patient requires albuterol refill, COVID-19 testing, and close monitoring for worsening symptoms, with empiric treatment for reactive airway disease given the clear response to bronchodilators. 1

Immediate Assessment and Testing

COVID-19 testing is mandatory given the patient's recent travel, cough, shortness of breath, and fatigue, even though fever is absent. 2 The combination of respiratory symptoms with known travel history increases the likelihood of COVID-19 infection. 1

• RT-PCR swab test should be obtained to confirm or exclude COVID-19 diagnosis, as this is the gold standard for diagnosis. 2
• If RT-PCR is unavailable or delayed, chest radiography (CXR) can help assess for viral pneumonia patterns, though CXR is insensitive in mild or early COVID-19 infection. 2
• The patient should be considered potentially infected until COVID-19 is definitively ruled out. 2

Bronchodilator Management

Refill albuterol immediately as the patient has demonstrated clear symptomatic relief with this medication and has run out of supply. 3

• Proper inhaler technique must be reinforced, as correct use is critical for managing shortness of breath. 1
• The action of albuterol may last up to six hours; instruct the patient not to use it more frequently than recommended without medical consultation. 3
• Albuterol should be used with caution given the patient's symptoms, but the clear response suggests reactive airway disease or asthma component. 3

Symptom Management and Home Care

Position optimization and supportive measures can help manage the cough and breathing difficulty while awaiting test results. 1

• Avoid lying flat on back as this makes coughing ineffective; recommend sitting upright or leaning forward with arms bracing a chair for breathlessness. 1
• Vick's vapor rub application to chest at night may help with cough and congestion through aromatherapy effects. 1
• Maintain adequate hydration (no more than 2 liters per day). 1
• Pursed-lip breathing techniques can help manage breathlessness. 1

Pneumonia Considerations

Empiric antibiotics are NOT routinely indicated at this stage given the absence of fever, the productive sputum that has resolved, and the clear response to bronchodilators suggesting a reactive airway component rather than bacterial pneumonia. 2

• If COVID-19 is confirmed, empirical antibacterial coverage is not required in all patients with confirmed COVID-19-related pneumonia unless bacterial superinfection cannot be ruled out. 2
• Procalcitonin testing, if available, could help guide the decision to withhold antibiotics in confirmed COVID-19 with less severe disease. 2
• The patient's initial yellow sputum production does not mandate antibiotic treatment in the absence of fever, worsening symptoms, or confirmed bacterial infection. 2

Red Flag Symptoms Requiring Emergency Care

Establish clear instructions for when to seek immediate medical attention: 1

• Worsening shortness of breath or increasing respiratory distress
• Persistent chest pain
• Confusion or altered mental status
• Bluish discoloration of lips or face
• Inability to maintain adequate oxygen saturation

Follow-up Plan

Schedule reassessment in 7-10 days to evaluate symptom progression and treatment efficacy. 1

• Monitor for symptom progression, particularly increasing shortness of breath, which may indicate COVID-19 progression. 1
• If fever develops, recommend paracetamol over NSAIDs for symptom relief in the context of possible COVID-19. 1
• Continue albuterol as needed for shortness of breath and cough, using proper technique. 1, 3

Critical Pitfalls to Avoid

• Do not delay COVID-19 testing based on absence of fever alone, as many patients with COVID-19 present without fever. 2
• Do not withhold albuterol refill given the patient's clear symptomatic response and current shortage of medication. 3
• Do not empirically prescribe antibiotics without evidence of bacterial superinfection, as this contributes to antibiotic resistance and is not indicated in viral respiratory illness with bronchospasm. 2
• Do not assume pneumonia is absent based solely on clinical presentation; if symptoms worsen or fever develops, reassessment with imaging may be warranted. 2