What is the role of inhaled corticosteroids (ICS) in managing a patient with post-influenza bronchitis and a history of Chronic Obstructive Pulmonary Disease (COPD) or asthma?

Inhaled Corticosteroids in Post-Influenza Bronchitis with COPD/Asthma History

In a patient with post-influenza bronchitis and underlying COPD or asthma, inhaled corticosteroids should be continued if already prescribed for the underlying disease, but should not be initiated solely for the acute bronchitis episode. 1

For Patients with Underlying COPD

When ICS Are Indicated in COPD

Continue existing ICS therapy if the patient meets established COPD criteria:

• FEV1 < 50% predicted with history of exacerbations (≥2 moderate exacerbations or ≥1 severe exacerbation requiring hospitalization in the past year) 2
• Triple therapy (LAMA/LABA/ICS) is specifically recommended for symptomatic COPD patients at high risk of future exacerbations 2
• ICS combined with long-acting bronchodilators reduces exacerbation frequency by 24% compared to LABA/LAMA alone 3

When ICS Should NOT Be Started

Do not initiate ICS for acute bronchitis in COPD patients who:

• Have stable disease without frequent exacerbations (≤1 exacerbation per year) 2
• Have FEV1 ≥ 50% predicted without exacerbation history 2
• Are experiencing their first acute bronchitis episode without prior exacerbation pattern 1

Acute Exacerbation Management

If the post-influenza bronchitis represents an acute COPD exacerbation:

• Prescribe prednisone 40 mg daily for 5-7 days (or 0.5 mg/kg/day) 1
• This systemic corticosteroid course improves lung function, oxygenation, and shortens recovery time 1
• After completing the systemic course, return to baseline inhaled therapy 1

For Patients with Underlying Asthma

ICS Are Essential in Asthma

Continue or initiate ICS/LABA combination therapy immediately for asthma patients:

• ICS plus inhaled bronchodilators should be started for any chronic cough due to asthma, regardless of whether cough is the sole symptom 4
• This carries Grade 1B evidence (very strong recommendation) 4
• Never use long-acting beta-agonist monotherapy without ICS, as this increases risk of serious asthma-related events 4

Escalation Strategy if Inadequate Response

Follow this stepwise approach:

1. First step: Increase the ICS dose before adding other agents 4
2. Second step: Add a leukotriene receptor antagonist to existing ICS/bronchodilator regimen after reconsidering alternative causes 4
3. Third step: Consider short course of oral corticosteroids (40-60 mg daily for 1-2 weeks in adults) only after above steps fail, then transition back to inhaled therapy 4

Critical Safety Considerations

Pneumonia Risk with ICS

Be aware that ICS therapy increases pneumonia risk in COPD:

• Pneumonia is a recognized class effect of all ICS-containing therapies 3
• The number needed to harm is 33 patients per year to cause one pneumonia case 3
• This must be balanced against the number needed to treat of 4 patients per year to prevent one moderate-to-severe exacerbation with triple therapy 3
• Monitor all patients on ICS for signs of pneumonia, oral candidiasis, and bone density if on high doses long-term 3

Dose-Response Relationship

Most benefit occurs at low-to-medium ICS doses:

• High doses show minimal additional improvement beyond medium doses 3
• The dose-response curve is relatively flat in COPD 3
• The ETHOS trial showed no significant difference in exacerbation reduction between 320 mg and 160 mg budesonide doses 3

Common Clinical Pitfalls to Avoid

Do not prescribe systemic corticosteroids for acute bronchitis in otherwise healthy adults without underlying lung disease, as evidence consistently shows no benefit 1

Do not withdraw ICS from patients with established asthma or COPD during or after acute bronchitis, as these remain clear indications for continued corticosteroid use 1

Do not use ICS monotherapy in COPD - always combine with long-acting bronchodilators for optimal efficacy 5

Do not jump directly to systemic steroids without trying inhaled therapy first in asthma patients, as this exposes patients to unnecessary systemic side effects 4