What is the best management for a 50+ year old woman with asthma exacerbation secondary to viral infection?

Management of Asthma Exacerbation in a 50+ Year Old Woman

Immediately initiate triple therapy with oxygen (40-60% to maintain SaO2 >90%), nebulized short-acting beta-agonist (albuterol 5 mg or terbutaline 10 mg), and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV), then reassess at 15-30 minutes to determine need for hospital admission. 1

Initial Assessment and Risk Stratification

First, assess severity objectively rather than relying solely on symptoms, as patients frequently underestimate the severity of their exacerbations. 1, 2

Severe exacerbation features (any one indicates severe asthma): 1, 2

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow (PEF) <50% predicted or personal best
• Diminished breath sounds

Life-threatening features requiring immediate hospital transfer: 1, 2

• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, exhaustion, confusion, or coma
• PEF <33% predicted
• SaO2 <92% despite supplemental oxygen

Special consideration for this patient: Because she is over 50 years old, obtain baseline electrocardiogram and cardiac rhythm monitoring, as recommended specifically for patients in this age group with acute asthma. 1

Immediate Treatment Protocol

Primary Triple Therapy (Start Simultaneously)

1. Oxygen therapy: 1

• Administer via nasal cannula or mask to maintain SaO2 >90% (>95% if concurrent heart disease)
• Continue monitoring until clear response to bronchodilator therapy occurs

2. Nebulized short-acting beta-agonist: 1

• Albuterol 5 mg OR terbutaline 10 mg via oxygen-driven nebulizer
• Administer 3 treatments every 20-30 minutes in the first hour
• If no nebulizer available, use metered-dose inhaler with spacer: 2 puffs repeated 10-20 times 1

3. Systemic corticosteroids (choose one): 1

• Prednisolone 30-60 mg orally (preferred if patient can swallow)
• Hydrocortisone 200 mg IV (if vomiting or severely ill)
• Note: Oral and IV routes are equally effective; oral prednisolone 100 mg once daily is equivalent to hydrocortisone 100 mg IV every 6 hours 3

Reassessment at 15-30 Minutes

Measure PEF and clinical response after initial treatment. 1

If PEF >75% predicted and symptoms improved: 1

• Continue usual asthma medications
• Step up maintenance therapy
• Arrange follow-up within 48 hours
• Provide written asthma action plan

If PEF 50-75% predicted: 1

• Continue prednisolone course
• Repeat nebulized beta-agonist
• Reassess after 30 minutes
• Consider admission if multiple severe features present

If PEF <50% predicted or any severe features persist: 1, 2

• Arrange immediate hospital admission
• Continue oxygen and nebulized bronchodilators

Additional Therapy for Severe/Life-Threatening Exacerbations

Add ipratropium bromide: 1

• 0.5 mg nebulized with the beta-agonist
• Particularly important if life-threatening features present
• Repeat every 6 hours until improvement begins

Consider IV bronchodilator therapy if inadequate response: 1

• Aminophylline 250 mg IV over 20 minutes OR
• Salbutamol or terbutaline 250 mcg IV over 10 minutes
• Critical caveat: Do NOT give bolus aminophylline if patient already taking oral theophyllines 1

Magnesium sulfate infusion: 4

• Associated with fewer hospitalizations in severe exacerbations
• Consider in emergency department setting

Hospital Admission Criteria

Absolute indications for admission: 1, 2

• Any life-threatening features present
• Any severe features persist after initial treatment
• PEF <33% predicted after treatment

Lower threshold for admission if: 1, 2

• Exacerbation occurs in afternoon or evening (not morning)
• Recent nocturnal symptoms or worsening symptoms
• Previous severe attacks or recent hospital admission
• Patient expresses concern about their condition
• Concerns about social circumstances or ability to manage at home

Monitoring During Treatment

Frequency of nebulized bronchodilators: 1

• If improving: every 4 hours
• If not improving: every 15-30 minutes (up to continuous administration in severe cases)
• About 60-70% of patients respond sufficiently to initial 3 doses for discharge 1

Continue systemic corticosteroids: 1

• Prednisolone 30-60 mg daily OR
• Hydrocortisone 200 mg IV every 6 hours if seriously ill or vomiting
• Duration: minimum 5 days, typically 5-10 days total 2, 4

Discharge Planning

Criteria for safe discharge: 1, 2

• On discharge medications for 24 hours with stable response
• PEF >75% predicted or personal best
• PEF diurnal variability <25%
• Inhaler technique verified and documented

Discharge medications: 1, 2

• Continue prednisolone tablets (typically 3-10 day course)
• Initiate or continue inhaled corticosteroids
• Provide adequate supply of bronchodilators
• Provide peak flow meter

Follow-up: 1, 2

• Severe exacerbations: review within 24 hours
• Moderate exacerbations: review within 48 hours
• Clinic follow-up within 1-4 weeks

Important Caveats

Avoid these common errors: 1, 5

• Do NOT give antibiotics unless bacterial infection confirmed (viral trigger does not require antibiotics)
• Do NOT use sedation (contraindicated in acute asthma)
• Do NOT delay corticosteroids - they speed resolution of airflow obstruction 1
• Do NOT underestimate severity based on symptoms alone - always use objective measures 1, 2

Regarding steroid dosing: Lower doses are as effective as higher doses. Hydrocortisone 50 mg IV four times daily is equivalent to 200 mg or 500 mg doses for resolving acute severe asthma. 6 However, standard practice uses 200 mg doses, which remain appropriate. 1

Chest radiography: Not routine, but obtain if suspecting pneumonia, pneumothorax, pneumomediastinum, or congestive heart failure. 1 Given the viral trigger, consider if fever or purulent sputum present, though modest leukocytosis is common in asthma without infection. 1