What is the next best course of treatment for an elderly patient with a history of asthma, presenting with a 3-week history of unpredictable cough, green mucus, and chest pain that worsens at night?

Immediate Evaluation and Treatment for Suspected Respiratory Infection with Asthma Exacerbation

This elderly patient with asthma presenting with 3 weeks of productive cough with green sputum, chest pain, and nocturnal worsening requires immediate evaluation to rule out pneumonia, followed by treatment for both the suspected bacterial infection and asthma exacerbation. 1

Priority 1: Rule Out Pneumonia

Obtain a chest radiograph immediately to exclude pneumonia, which is a critical differential diagnosis in elderly patients with prolonged productive cough and chest pain. 1

• The 3-week duration of symptoms with green mucus production and chest pain raises significant concern for bacterial pneumonia or other serious pulmonary pathology. 1
• In elderly patients with asthma, the threshold for obtaining imaging should be lower, particularly when symptoms persist beyond the typical acute bronchitis timeframe (>3 weeks). 1
• Check vital signs: heart rate ≥100 beats/min, respiratory rate ≥24 breaths/min, or temperature ≥38°C significantly increase pneumonia likelihood. 1
• Examine for focal consolidation findings (rales, egophony, fremitus) which indicate pneumonia requiring antibiotic therapy. 1

Important caveat: Green or purulent sputum alone does NOT confirm bacterial infection—it can occur with viral infections or asthma exacerbations due to inflammatory cells and sloughed epithelial cells. 1

Priority 2: Treat the Asthma Exacerbation

Initiate high-dose bronchodilator therapy immediately, as nocturnal worsening and persistent cough for 3 weeks indicate poorly controlled asthma requiring escalation. 1

Immediate Bronchodilator Treatment:

• Administer salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen (if available) or via metered-dose inhaler with spacer (10-20 puffs). 1
• In elderly patients, the first treatment should be supervised due to rare risk of precipitating angina with β-agonists. 1
• Repeat every 4-6 hours if improving; if not improving within 15-30 minutes, add ipratropium bromide 500 µg to the β-agonist. 1

Systemic Corticosteroids:

Give prednisolone 30-60 mg orally immediately (or hydrocortisone 200 mg IV if unable to take oral medication). 1

• Oral steroids are equally effective as IV and should be continued until lung function returns to baseline, typically 7-21 days. 1
• No tapering is needed for courses up to 2 weeks—steroids can be stopped abruptly from full dose. 1
• The 3-week history of worsening symptoms with nocturnal exacerbation is a clear indication for rescue corticosteroids. 1

Priority 3: Antibiotic Decision

Give antibiotics ONLY if pneumonia is confirmed on chest radiograph or if there are clear signs of bacterial infection. 1

• The British Thoracic Society explicitly states: "Give antibiotics only if bacterial infection is present." 1
• Purulent sputum production alone is NOT an indication for antibiotics in the absence of pneumonia. 1
• If chest radiograph shows consolidation or clinical findings confirm pneumonia, initiate appropriate antibiotic therapy based on local guidelines for community-acquired pneumonia in elderly patients. 1

Additional Immediate Measures

Monitoring and Assessment:

• Measure peak expiratory flow 15-30 minutes after initial treatment and monitor response. 1
• Obtain baseline oxygen saturation and continue oxygen therapy to maintain SpO2 >90%. 1
• In elderly patients, check plasma electrolytes, urea, blood count, and ECG. 1

Criteria for Hospital Admission:

Consider immediate hospital referral if: 1

• Peak flow remains <33% predicted or personal best 15-30 minutes after treatment
• Patient cannot complete sentences due to breathlessness
• Respiratory rate >25/min or heart rate >110/min
• Symptoms seen in afternoon/evening (lower threshold for admission)
• History of previous severe attacks, especially with rapid onset
• Concern about patient's ability to assess severity or manage at home 1

Common Pitfalls to Avoid

• Do NOT withhold corticosteroids while waiting for diagnostic workup—the 3-week duration with nocturnal worsening mandates immediate steroid therapy. 1
• Do NOT prescribe antibiotics empirically without evidence of bacterial infection, as most prolonged cough in asthma patients is due to inadequate asthma control, not bacterial infection. 1
• Do NOT use sedation, which is contraindicated in asthma exacerbations. 1
• Do NOT rely on two puffs of inhaler as equivalent to nebulizer treatment—studies showing equivalence used 6-10 puffs sequentially. 2
• Do NOT assume this is simple bronchitis given the 3-week duration—cough lasting >3 weeks warrants evaluation for chronic conditions including poorly controlled asthma or cough-variant asthma. 1

Follow-Up Management

• Reassess within 24-48 hours to evaluate treatment response. 1
• If symptoms persist despite treatment, consider referral to respiratory specialist for evaluation of chronic asthma control and possible cough-variant asthma. 1
• Review and optimize maintenance asthma therapy, as frequent exacerbations indicate need for controller medication escalation (inhaled corticosteroids ± long-acting β-agonists). 1