What is the best course of treatment for a patient with a history of pneumonia and asthma, presenting with wheeze, cough, and sinus pressure?

Management of Wheeze, Cough, and Sinus Pressure in a Patient with History of Asthma and Pneumonia

This patient requires immediate assessment for acute asthma exacerbation severity, followed by concurrent treatment of both the asthma component and potential bacterial sinusitis/respiratory infection, with first-line therapy consisting of nebulized bronchodilators, systemic corticosteroids, and antibiotics if bacterial infection is suspected. 1, 2

Immediate Assessment of Asthma Severity

The presence of wheeze, cough, and inability to complete sentences (if present) must be objectively assessed immediately using the following criteria 1:

• Acute Severe Asthma is present if ANY of: Cannot complete sentences in one breath, pulse >110 beats/min, respirations >25 breaths/min, peak expiratory flow (PEF) <50% predicted or personal best, or diminished breath sounds 1
• Life-threatening features include: Silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, confusion, exhaustion, coma, or oxygen saturation <92% despite supplemental oxygen 1
• Measure respiratory rate, heart rate, oxygen saturation, and PEF immediately to stratify severity 2

The British Thoracic Society emphasizes that diminished breath sounds specifically predict severe airflow obstruction and warrant immediate intervention 1.

First-Line Treatment Protocol

For Moderate to Severe Exacerbation (PEF <50% predicted):

• Nebulized bronchodilators: Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 3, 1
• Systemic corticosteroids: Prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg immediately 3, 1
• Oxygen therapy: High-flow oxygen 40-60% to maintain saturation >92% 4
• Ipratropium bromide: Add 500 mcg to nebulized beta-agonist if severe features present or inadequate response at 15-30 minutes 3, 1

Reassess at 15-30 Minutes:

• If severe features persist after initial treatment, arrange immediate hospital admission 1
• Repeat nebulized bronchodilators every 15 minutes to 4 hours depending on response 3, 1
• Continue prednisolone for 5-10 days total 1, 4

Treatment of Concurrent Sinus Pressure and History of Pneumonia

The combination of sinus pressure with wheeze and cough in an asthmatic patient suggests upper airway cough syndrome (UACS) and possible bacterial sinusitis, which are common asthma triggers 3, 2:

• First-generation antihistamine-decongestant combination: Initiate immediately as diagnostic/therapeutic trial for UACS 3
• Antibiotic therapy: If fever, productive cough, or coarse breath sounds suggest bacterial infection, start amoxicillin as first-line (or azithromycin/clarithromycin if penicillin-allergic) 2, 5
• The American Thoracic Society states that fever with coarse breath sounds strongly suggests bacterial infection requiring antibiotics 2

Respiratory infections account for approximately 50% of acute asthma exacerbations, making concurrent treatment essential 2.

For Persistent Sinus Symptoms:

• Add intranasal corticosteroid spray if nasal symptoms persist after A/D therapy 3
• Consider sinus imaging (CT or plain films) if symptoms persist despite medical therapy to evaluate for acute or chronic sinusitis 3
• Mucosal thickening on imaging warrants presumptive antibiotic treatment in the context of chronic cough 3

Hospital Admission Criteria

Absolute criteria for admission 1:

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

Lower threshold for admission if 1:

• Symptoms occur in afternoon or evening
• Recent nocturnal symptoms or worsening symptoms
• Previous severe attacks or recent hospital admission
• Patient expresses concern about their condition

Common Pitfalls to Avoid

• Underestimating severity: Patients with severe asthma may not appear distressed initially; rely on objective measures (PEF, respiratory rate, oxygen saturation) rather than appearance alone 2
• Delaying corticosteroids: Systemic steroids take 6-12 hours to manifest benefits, so immediate administration is critical even if severity is uncertain 2
• Failing to treat concurrent infection: Asthmatic patients with fever, productive cough, or coarse breath sounds require antibiotics in addition to asthma therapy 2
• Ignoring UACS: Cough will not resolve until both asthma AND upper airway components are treated; chronic cough is frequently multifactorial 3
• Premature discharge: Do not discharge if wheezing persists or PEF remains <50% predicted, as incomplete resolution predicts early relapse 1

Discharge Planning and Follow-Up

For patients not requiring admission 1, 4:

• Continue prednisolone 30-60 mg daily for 5-10 days total 1
• Continue nebulized bronchodilators every 4-6 hours, spacing as tolerated 1
• Provide written asthma action plan with specific PEF thresholds for medication adjustment 4
• Verify correct inhaler technique 1
• Review within 24-48 hours for severe exacerbations, 48 hours for moderate exacerbations 1
• Ensure adequate supply of usual controller medications (inhaled corticosteroids) 1

The National Asthma Education and Prevention Program emphasizes that every patient must receive a written action plan distinguishing "relievers" from "preventers" 4.