What is the treatment for a patient with a history of asthma, showing wheezing over bilateral lungs, and normal laboratory results, including a computed tomography angiography (CTA) scan showing no acute intrathoracic findings, a complete blood count (CBC) and comprehensive metabolic panel (CMP) within normal limits, a troponin level indicating no myocardial infarction, and a d-dimer level indicating no thrombotic activity?

From the Guidelines

For a patient with wheezing over bilateral lungs, normal CTA, history of asthma, and normal lab values, I recommend immediate treatment with a short-acting beta-agonist such as albuterol via nebulizer (2.5-5 mg) or metered-dose inhaler (4-8 puffs with spacer) to address the acute bronchospasm, as suggested by the guidelines for managing asthma 1. This approach is supported by the most recent evidence, which emphasizes the importance of achieving optimal asthma control through a stepwise approach to pharmacological treatment 1. The patient's history of asthma and normal lab values, including a normal D-dimer and troponin, suggest that this is likely an asthma exacerbation rather than a pulmonary embolism or cardiac issue. Key considerations in managing this patient include:

• Identifying and controlling environmental triggers, as emphasized in the guidelines for managing asthma 1
• Monitoring pulmonary function and adjusting treatment accordingly, with the goal of achieving well-controlled asthma 1
• Using a combination of short-acting beta-agonists and systemic corticosteroids to address acute bronchospasm and reduce airway inflammation
• Ensuring the patient has appropriate maintenance therapy with an inhaled corticosteroid with or without a long-acting beta-agonist, and reviewing proper inhaler technique and asthma action plan to prevent future exacerbations. It is also important to consider the potential for overlapping disorders that can present with symptoms indistinguishable from asthma, as well as lifestyle and environmental factors that may contribute to poor control 1. By taking a comprehensive approach to managing this patient's asthma, we can reduce the risk of exacerbations and improve quality of life.

From the FDA Drug Label

As with other beta-agonists, inhaled and intravenous albuterol may produce a significant hypokalemia in some patients, possibly through intracellular shunting, which has the potential to produce adverse cardiovascular effects. Albuterol, as with all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias and hypertension, in patients with convulsive disorders, hyperthyroidism or diabetes mellitus and in patients who are unusually responsive to sympathomimetic amines WARNINGS As with other inhaled beta-adrenergic agonists, albuterol sulfate inhalation solution can produce paradoxical bronchospasm, which can be life threatening. If it occurs, the preparation should be discontinued immediately and alternative therapy instituted.

The patient has a history of asthma and is presenting with wheezing over bilateral lungs. Given the patient's symptoms and history, albuterol may be considered as a treatment option. However, it should be used with caution due to the patient's potential cardiovascular risks and the possibility of paradoxical bronchospasm. The patient should be monitored closely for any adverse effects, and alternative therapy should be considered if necessary 2, 2.

From the Research

Treatment for Asthma

• The patient's history of asthma and current symptoms of wheezing over bilateral lungs suggest the need for asthma treatment 3, 4.
• Short-acting beta-agonists (SABAs) are no longer recommended as the preferred reliever for patients with symptomatic asthma, and should not be used as monotherapy due to safety concerns and poor outcomes 4.
• Instead, a combined inhaled corticosteroid-fast acting beta agonist is recommended as a reliever for patients with asthma 4.
• Long-acting beta-agonists (LABAs) such as salmeterol and formoterol can provide more prolonged bronchodilation and greater reduction of symptoms, but should be used in combination with inhaled corticosteroids, not as a replacement for them 3.

Use of Ipratropium Bromide

• Ipratropium bromide has been shown to be effective in combination with albuterol for the treatment of chronic obstructive pulmonary disease (COPD) 5, 6, 7.
• However, the addition of ipratropium bromide to albuterol for the prehospital treatment of reactive airways disease does not appear to result in significant clinical outcome improvements 5.
• In patients with COPD, maintenance therapy with ipratropium bromide and albuterol provides better bronchodilation than either therapy alone, without increasing side effects 6, 7.

Treatment Approach

• Based on the patient's history of asthma and current symptoms, a treatment approach that includes a combined inhaled corticosteroid-fast acting beta agonist as a reliever, and possibly a LABA in combination with an inhaled corticosteroid for long-term control, may be appropriate 3, 4.
• The use of ipratropium bromide in combination with albuterol may also be considered, although its effectiveness in this patient population is not well established 5, 6, 7.