What is the best course of action for managing a patient's respiratory symptoms and medication regimen, including albuterol inhaler, prednisone, and benzonatate, given their history of COVID-19, asthma, and COPD?

Management of Respiratory Symptoms in a COVID-19 Patient with Asthma and COPD

Continue the albuterol inhaler as needed for bronchospasm, taper and discontinue the prednisone 20 mg given the patient's current stable respiratory status (97% SpO2 on room air, clear lungs), and continue benzonatate for cough suppression while optimizing his chronic COPD management with proper inhaler technique assessment.

Immediate Assessment of Current Respiratory Status

Your patient presents with excellent oxygenation (97% SpO2 on room air) and clear lung fields, indicating resolution of the acute COVID-19 respiratory phase 1. This clinical picture does not support continued systemic corticosteroid therapy, which should be reserved for patients with moderate to severe breathlessness and hypoxemia 1.

• The prednisone 20 mg should be tapered and discontinued rather than continued, as systemic corticosteroids in the acute COVID-19 phase without severe respiratory compromise may adversely affect recovery 2
• The patient's clear lung examination and normal oxygen saturation indicate he is past the acute inflammatory phase where steroids would be beneficial 1

Albuterol Management in Post-COVID Context

The albuterol inhaler should be continued strictly as rescue therapy for his underlying asthma and COPD, not for COVID-19 symptoms 3.

• Albuterol has no evidence for relieving COVID-19 respiratory symptoms unless the patient has concurrent bronchospasm from asthma or COPD 3
• Given his dual diagnosis of asthma and COPD, the albuterol remains appropriate for bronchodilation 4
• Critical caveat: Assess his actual usage pattern—if he's using albuterol more than 2-3 times per week, his maintenance therapy needs escalation 5

Inhaler Technique Optimization - A Critical Priority

Before making any medication changes, directly observe and correct his inhaler technique at this visit, as 76% of COPD patients make critical errors with metered-dose inhalers that lead to increased hospitalizations 5.

• The American Thoracic Society emphasizes that inhaler technique must be checked before considering any medication adjustments 5
• If he cannot demonstrate correct MDI technique after instruction, switch to a dry powder formulation or add a spacer device 5
• This single intervention can prevent unnecessary medication escalation and reduce exacerbations 5

Chronic COPD Maintenance Therapy Assessment

Given his complex pulmonary history (asthma, COPD, atherosclerotic heart disease), evaluate whether his current maintenance regimen is adequate 6.

• For symptomatic COPD patients, long-acting bronchodilator monotherapy (LAMA preferred) should be the foundation 6
• If he has persistent breathlessness despite correct inhaler technique, escalate to dual bronchodilator therapy (LAMA/LABA combination) 6
• For patients with ≥2 moderate exacerbations or ≥1 severe exacerbation in the past year, consider triple therapy (LAMA/LABA/ICS) in a single inhaler device 5

Benzonatate Continuation

Continue benzonatate 100 mg for symptomatic cough relief as this is appropriate for post-COVID cough management 1.

• Non-opioid antitussives like benzonatate are reasonable for distressing cough 1
• Monitor for resolution; if cough persists beyond 4-6 weeks, consider alternative diagnoses

Medication Safety Review

Screen for contraindicated medications immediately, particularly beta-blockers (including eyedrop formulations), which must be avoided as they block albuterol's bronchodilatory effects 6, 4.

• Review his complete medication list for his multiple comorbidities (heart failure, hypertension, atherosclerotic heart disease) 6
• Beta-receptor blocking agents and albuterol inhibit each other's effects 4

Prednisone Tapering Protocol

Taper the prednisone over 5-7 days rather than abrupt discontinuation, given he's been on it since his ER visits 1.

• A reasonable taper: 15 mg daily × 2 days, 10 mg daily × 2 days, 5 mg daily × 2 days, then discontinue 1
• Monitor for return of respiratory symptoms during taper 1
• If respiratory symptoms worsen during taper with objective decline (oxygen saturation, increased work of breathing), this would indicate need for pulmonary specialist referral 2

Non-Pharmacological Interventions

Implement breathing techniques and positioning strategies to manage any residual breathlessness 1.

• Pursed-lip breathing: inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds 1
• Sitting upright and leaning forward with arms bracing increases ventilatory capacity 1
• These techniques reduce anxiety-related breathlessness amplification 1

Follow-Up Protocol

Schedule reassessment in 2-4 weeks to evaluate response to prednisone discontinuation and inhaler technique optimization 5.

• Re-check inhaler technique at this follow-up visit, as technique deteriorates over time and requires regular reinforcement 5
• Assess for persistent respiratory symptoms that might indicate post-COVID complications requiring specialist referral 2
• Verify smoking cessation status and reinforce cessation if applicable 6

Red Flags Requiring Urgent Re-evaluation

Watch for signs indicating need for immediate reassessment:

• Oxygen saturation declining below 94% on room air 1
• Increased work of breathing or respiratory rate >24 1
• Development of purulent sputum (would indicate bacterial superinfection requiring antibiotics) 1, 6
• Inability to complete sentences due to breathlessness 1