What is the treatment for acute asthma in a patient with pneumonia?

Treatment of Acute Asthma in Patients with Pneumonia

Treat acute asthma in pneumonia patients with the standard acute asthma protocol: high-dose nebulized beta-agonists, systemic corticosteroids, and oxygen, while reserving antibiotics strictly for confirmed bacterial pneumonia. 1, 2

Immediate Treatment Protocol

The presence of pneumonia does not alter the fundamental management of acute asthma exacerbation. The treatment priorities remain:

First-Line Bronchodilator Therapy

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (40-60% oxygen) immediately 1, 2
• Repeat every 20-30 minutes for the first hour, then reassess 1, 2
• If no improvement after 15-30 minutes, increase frequency to every 15 minutes 1, 2
• Metered-dose inhalers with spacer devices are equally effective and may be used as an alternative delivery method 3, 4

Systemic Corticosteroids (Essential)

• Give prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg immediately 1, 2
• Continue hydrocortisone 200 mg every 6 hours if patient is seriously ill or vomiting 1
• Corticosteroids take 6-12 hours to show anti-inflammatory effects, making early administration critical 5, 6

Oxygen Therapy

• Deliver 40-60% oxygen to maintain SpO2 >92% 1, 6
• CO2 retention is NOT aggravated by oxygen therapy in asthma 1

When to Add Ipratropium and IV Medications

For Life-Threatening Features (PEF <33% predicted, silent chest, cyanosis, severe hypoxia PaO2 <8 kPa, or altered consciousness):

• Add nebulized ipratropium 0.5 mg to the beta-agonist 1, 2
• Repeat ipratropium every 6 hours until clear improvement 1, 2
• Consider IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 µg over 10 minutes 1, 2
• Do NOT give bolus aminophylline if patient is already taking oral theophyllines 1

Critical Decision Point: Antibiotics

This is where pneumonia becomes relevant to your treatment plan:

• Antibiotics should ONLY be given if bacterial infection is confirmed 1, 5
• The British Thoracic Society explicitly states antibiotics are unhelpful in acute asthma unless bacterial infection is present 1
• Evidence of bacterial pneumonia requiring antibiotics includes: consolidation on chest X-ray with fever, purulent sputum with positive bacterial cultures, or clinical signs of bacterial sinusitis 5
• Do NOT routinely prescribe antibiotics for acute asthma exacerbations, even with radiographic infiltrates that may represent atelectasis or viral pneumonia 5

Monitoring and Reassessment

Objective Measurements (15-30 minutes after initial treatment):

• Measure peak expiratory flow (PEF) before and after each bronchodilator dose 1, 6
• Maintain continuous oximetry targeting SpO2 >92% 1, 6
• Obtain arterial blood gases if PaO2 <8 kPa or if PaCO2 was initially normal/elevated 1, 6

Response-Based Treatment Escalation:

If improving: Continue oxygen, prednisolone 30-60 mg daily, and nebulized beta-agonist every 4-6 hours 1

If NOT improving after 15-30 minutes: Increase nebulized beta-agonist frequency to every 15 minutes, add ipratropium if not already given, and consider IV aminophylline or beta-agonist 1, 2

ICU Transfer Criteria

Transfer to intensive care with a physician prepared to intubate if:

• Deteriorating PEF despite maximal treatment 1, 6
• Worsening or persistent hypoxia (PaO2 <8 kPa) despite 60% oxygen 1
• Hypercapnia (PaCO2 >6 kPa) 1, 6
• Exhaustion, confusion, drowsiness, or coma 1, 6
• Respiratory arrest 1

Critical Pitfalls to Avoid

Absolute Contraindications:

• Never give sedatives of any kind in acute asthma 1, 2
• Sedation is absolutely contraindicated even in agitated patients 2

Unnecessary Interventions:

• Do not perform percussive physiotherapy 1, 2
• Do not routinely prescribe antibiotics without confirmed bacterial infection 1, 5

Common Errors Leading to Mortality:

• Underestimating severity by failing to obtain objective measurements (PEF, arterial blood gases) 2
• Delaying systemic corticosteroids 5, 6
• Inadequate frequency of nebulized bronchodilators in the first hour 2, 7

Discharge Criteria

Patients should NOT be discharged until:

• PEF >75% of predicted or personal best 1
• Diurnal PEF variability <25% 1
• No nocturnal symptoms 1
• Stable on discharge medications for 24 hours with verified inhaler technique 1
• Written self-management plan provided 1
• GP follow-up arranged within 1 week and respiratory clinic within 4 weeks 1