What is the best course of action for a 48-year-old non-asthmatic, non-COPD patient with a 3-week history of dry cough, runny nose, and breathing difficulties, who has had to use a short-acting beta-agonist (SABA) inhaler, such as albuterol, for acute relief of symptoms?

Management of Suspected New-Onset Asthma in a 48-Year-Old Adult

This patient requires immediate initiation of short-acting beta-agonist (SABA) therapy with albuterol 200-400 mcg (2-4 puffs) via metered-dose inhaler with spacer every 4-6 hours as needed, combined with urgent spirometry to confirm the diagnosis of asthma before committing to long-term controller therapy. 1, 2

Immediate Management

Prescribe albuterol MDI with spacer for symptomatic relief:

• Start with 200-400 mcg (2-4 puffs) every 4-6 hours as needed for breathlessness and cough 1, 2
• The patient's current use of a borrowed "blue inhaler" (likely albuterol) with symptom relief strongly suggests reversible airway obstruction 1
• MDI with spacer is equally effective as nebulizer therapy when proper technique is used and is the preferred first-line delivery method 1, 2

Key safety point: While the patient has been using a relative's inhaler with apparent benefit, this practice should be discontinued and replaced with a properly prescribed inhaler with documented technique instruction 1

Diagnostic Confirmation Required

Spirometry is mandatory before starting long-term therapy:

• Measure FEV1 and peak expiratory flow (PEF) to document airflow obstruction 1, 3, 4
• Perform bronchodilator reversibility testing: administer albuterol 400 mcg via MDI with spacer and repeat spirometry after 15 minutes 1
• Look for ≥15% improvement in FEV1 (and ≥200 mL absolute change) or ≥20% improvement in PEF (and ≥60 L/min absolute change) to confirm asthma 1
• If spirometry is normal between symptomatic episodes, consider serial PEF monitoring at home for 2 weeks, looking for ≥20% diurnal variability 1

Clinical features supporting asthma diagnosis in this patient:

• Three-week duration of dry cough and rhinorrhea (viral trigger) 1
• Exercise-induced breathlessness requiring mid-session cessation (exercise-induced bronchoconstriction) 1
• Nocturnal symptoms requiring rescue inhaler use (classic asthma pattern) 1
• Symptomatic response to borrowed SABA inhaler (suggests reversible obstruction) 1

Differential Diagnosis Considerations

Rule out COPD despite no smoking history:

• COPD can occur in never-smokers, though less common 3, 4
• Spirometry showing post-bronchodilator FEV1/FVC <0.70 with minimal reversibility suggests COPD rather than asthma 1, 4
• The acute 3-week onset and lack of chronic progressive dyspnea makes COPD less likely 4

Consider post-viral reactive airway disease:

• Viral respiratory infections commonly trigger transient airway hyperreactivity that can persist for weeks 1
• If symptoms completely resolve within 6-8 weeks and spirometry normalizes, this may represent temporary post-viral bronchospasm rather than chronic asthma 1

Escalation Criteria

If symptoms worsen or fail to respond to as-needed SABA:

• Increase SABA frequency to every 2-4 hours if needed 2
• Add oral prednisolone 30-40 mg daily for 5-7 days if symptoms are moderate-to-severe 1
• Initiate inhaled corticosteroid (ICS) controller therapy if using SABA >2 days per week (excluding pre-exercise use) 1

Red flags requiring urgent evaluation:

• Inability to complete sentences in one breath 1
• Respiratory rate >25 breaths/minute 1
• Heart rate >110 beats/minute 1
• PEF <50% predicted or personal best 1
• These features indicate acute severe asthma requiring emergency department evaluation with oxygen, nebulized bronchodilators, and systemic corticosteroids 1

Long-Term Management Plan

If asthma is confirmed by spirometry:

• Start low-dose ICS (e.g., budesonide 200-400 mcg daily or equivalent) as controller therapy 1
• Continue as-needed SABA for symptom relief 1
• Recent evidence supports as-needed albuterol-budesonide combination therapy as an alternative to daily ICS plus as-needed SABA in mild asthma, showing 47% reduction in severe exacerbations 5
• Schedule follow-up in 4-6 weeks to assess control and adjust therapy 1

Patient education priorities:

• Demonstrate and verify proper MDI with spacer technique 1, 2
• Explain that increasing SABA use (>2 days/week) signals poor control requiring medical re-evaluation 1, 2
• Provide written action plan for symptom worsening 1

Common Pitfalls to Avoid

Do not prescribe home nebulizer therapy without specialist assessment:

• Nebulizers are reserved for acute exacerbations or patients who cannot use MDIs despite proper instruction 1, 6
• Formal evaluation by respiratory specialist is required before prescribing home nebulizer 1, 6

Do not use regular scheduled SABA as monotherapy:

• Regular scheduled albuterol without ICS provides no benefit over as-needed use and may mask deteriorating control 1, 7
• Frequent SABA use indicates need for controller therapy, not increased SABA dosing 1

Do not assume this is "just a cold":

• Three weeks of symptoms with exercise limitation and nocturnal awakening exceeds typical viral illness duration 1
• The symptomatic response to SABA strongly suggests reversible airway obstruction requiring formal diagnosis 1