How to manage an asthma patient with shortness of breath, negative flu and COVID-19 tests, and leukocytosis?

Management of Asthma Patient with Shortness of Breath and Leukocytosis

This patient requires immediate assessment for acute severe asthma exacerbation with prompt initiation of high-dose bronchodilators and systemic corticosteroids, while simultaneously evaluating for possible bacterial respiratory infection given the leukocytosis.

Immediate Severity Assessment

First, objectively assess the severity of the asthma exacerbation using clinical criteria and peak expiratory flow (PEF) measurement:

Features of Severe Asthma Exacerbation 1:

• Inability to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• PEF <50% of predicted or personal best

Life-Threatening Features 2, 1:

• PEF <33% of predicted or personal best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma

Critical Pitfall: Never underestimate asthma severity by relying solely on clinical impression without objective PEF or spirometry measurements 1. The severity of attacks is frequently underestimated by patients, relatives, and physicians 2.

Immediate Treatment Protocol

For ANY Acute Asthma Exacerbation (Regardless of Severity) 2, 1:

1. High-dose inhaled β-agonist:

• Administer salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 2, 1
• Alternative: 2 puffs from metered-dose inhaler repeated 10-20 times into large spacer device 2
• Can be repeated every 20-30 minutes initially 3

2. Systemic corticosteroids immediately:

• Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 2, 1
• Never delay corticosteroid administration 1

3. High-flow oxygen (if available):

• Administer 40-60% oxygen 1

If Life-Threatening Features Present 2:

• Add ipratropium 0.5 mg nebulized to the β-agonist 2
• Consider IV aminophylline 250 mg over 20 minutes OR salbutamol/terbutaline 250 µg over 10 minutes 2
• Do NOT give bolus aminophylline if patient already taking oral theophyllines 2, 1

Addressing the Leukocytosis (WBC 13)

The elevated WBC count raises concern for bacterial respiratory infection superimposed on asthma:

Indications for Antibiotic Therapy 4:

• Consider antibiotics if bacterial infection is confirmed (fever, purulent/green sputum, focal consolidation) 1, 4
• First-line options: amoxicillin or tetracycline 4
• Alternatives: azithromycin or clarithromycin if penicillin allergy or high pneumococcal resistance 4

Important Caveat: The leukocytosis alone does NOT mandate antibiotics 1. Leukocytosis can occur from:

• Asthma exacerbation itself (eosinophilia, stress response) 5
• Systemic corticosteroid administration
• Bacterial infection requiring antibiotics

Look for these specific features suggesting bacterial infection 4:

• Fever
• Purulent or green sputum production
• Focal findings on chest examination (though your patient has clear chest X-ray)
• Systemic signs of infection

Since the chest X-ray is negative and flu/COVID tests are negative, this likely represents either viral-triggered asthma exacerbation with reactive leukocytosis or early bacterial bronchitis 4.

Reassessment at 15-30 Minutes Post-Treatment 2, 1

Measure PEF again and assess clinical response:

Criteria for Hospital Admission 2:

• Any life-threatening features persist
• Severe features persist after initial treatment
• PEF remains <33% of predicted or best after nebulization 2
• PEF 33-50% with inadequate clinical response

Criteria for Outpatient Management:

• PEF >50% predicted/best after treatment
• Symptoms significantly improved
• Patient can complete sentences comfortably
• Respiratory rate and heart rate normalizing

Disposition and Follow-up

If Discharging Home 4, 6:

• Continue prednisolone 30-60 mg daily for 5-7 days 2
• Prescribe albuterol inhaler or nebulizer solution for home use (2.5 mg three to four times daily) 3
• If bacterial infection suspected: Add antibiotic course 4
• Provide written asthma action plan 6
• Schedule follow-up within 24-48 hours 4, 6

Patient Instructions for Home Monitoring 4:

• Monitor peak flow twice daily
• Seek immediate care if:
  • Increasing shortness of breath
  • Inability to complete sentences in one breath
  • Peak flow drops below 50% of predicted/best
  • No improvement with bronchodilator use

If Admitting to Hospital 2:

• Continue oxygen to maintain saturation >92%
• Continue nebulized β-agonists regularly (every 4-6 hours or more frequently if needed)
• Continue systemic corticosteroids
• Monitor arterial blood gases if severe (PaCO2 5-6 kPa or higher indicates life-threatening attack) 2

Key Clinical Pitfalls to Avoid

• Never use sedation in acute asthma 1
• Never delay systemic corticosteroids during exacerbations 1
• Never discharge until PEF >75% of predicted/personal best and symptoms stable 6
• Avoid overreliance on bronchodilators without addressing underlying inflammation 6
• Do not prescribe antibiotics reflexively without evidence of bacterial infection 1