What is the best treatment approach for an elderly patient with a history of childhood asthma, currently presenting with cough and wheeze without fever, and taking metoprolol (beta blocker) chronically?

Management of Cough and Wheeze in an Elderly Patient on Metoprolol

Immediately discontinue or switch the metoprolol to an alternative antihypertensive agent, as beta-blockers—even cardioselective ones—can precipitate bronchospasm in patients with underlying reactive airway disease, and initiate treatment with an inhaled short-acting beta-agonist (albuterol/salbutamol) plus a short course of oral corticosteroids (prednisolone 30-40 mg daily for 5-7 days). 1, 2, 3

Critical First Step: Address the Beta-Blocker

The metoprolol is likely contributing to or exacerbating the bronchospasm. Even cardioselective beta-blockers like metoprolol can cause significant airway obstruction in patients with asthma or reactive airway disease. 1

• In patients with reversible airways disease, wheezing can develop following small, potentially subtherapeutic doses of either non-selective or cardioselective beta-blockers, and the response is unpredictable. 1
• One study showed that patients with reversible obstruction developed wheezing with metoprolol doses as low as 37.5 mg, demonstrating that cardioselectivity provides negligible practical benefit in this population. 1
• Coordinate with the prescribing physician to switch to an alternative antihypertensive (such as an ACE inhibitor, ARB, or calcium channel blocker) that does not affect bronchial smooth muscle. 1

Immediate Pharmacologic Management

Bronchodilator Therapy

Initiate inhaled short-acting beta-agonist immediately:

• Administer albuterol/salbutamol 2.5-5 mg via nebulizer or 2-4 puffs via metered-dose inhaler every 4-6 hours as needed. 3, 2
• If symptoms are severe (respiratory distress, accessory muscle use, inability to speak in full sentences), give nebulized treatments every 20 minutes for the first hour. 2

Anti-Inflammatory Therapy

Add systemic corticosteroids for this acute presentation:

• Prescribe oral prednisolone 30-40 mg daily for 5-7 days (no taper needed for short courses). 2, 3
• Systemic corticosteroids require 6-12 hours to manifest clinical benefits, so early administration is critical. 4
• If the patient cannot tolerate oral medication or has severe distress, consider intravenous hydrocortisone. 2

Consider Adding Anticholinergic

If response to beta-agonist alone is inadequate:

• Add ipratropium bromide 100-500 mcg nebulized every 6 hours, which provides additive bronchodilation. 2, 5

Assessment of Severity

Evaluate for features of acute severe asthma that would require urgent hospital admission:

• Peak expiratory flow <50% of predicted or patient's best (if measurable). 2
• Inability to complete sentences in one breath. 2
• Respiratory rate >25 breaths/minute, heart rate >110 bpm. 2
• Silent chest on auscultation (indicating severely reduced air movement). 2

Life-threatening features requiring immediate intensive care consultation include:

• Peak flow <33% predicted, cyanosis, poor respiratory effort, altered consciousness, or exhaustion. 2, 5

Long-Term Controller Therapy

Once the acute episode resolves, initiate daily inhaled corticosteroid therapy:

• This patient has a history of childhood asthma and is now presenting with recurrent symptoms, indicating persistent asthma requiring controller medication. 2
• Prescribe low-to-medium dose inhaled corticosteroid such as fluticasone 100-250 mcg twice daily or budesonide 200-400 mcg twice daily via dry powder inhaler or metered-dose inhaler with spacer. 2, 3
• Inhaled corticosteroids are the preferred first-line controller therapy, demonstrating superior efficacy in reducing symptoms and exacerbations compared to alternative medications. 2, 5

If symptoms persist despite inhaled corticosteroids:

• Consider adding a long-acting beta-agonist (LABA) such as salmeterol or formoterol to the inhaled corticosteroid regimen. 2
• Combination inhalers (fluticasone/salmeterol or budesonide/formoterol) improve adherence and are preferred for moderate persistent asthma. 2

Diagnostic Considerations

Confirm the diagnosis and rule out alternative causes:

• The absence of fever makes acute infection less likely, but consider post-viral reactive airway disease if there was a recent upper respiratory infection. 2, 4
• Obtain spirometry with bronchodilator reversibility testing when the patient is stable to confirm asthma diagnosis (≥12% and ≥200 mL improvement in FEV1 post-bronchodilator). 6
• Consider chest X-ray to exclude pneumonia, heart failure, or other structural abnormalities if the clinical picture is atypical. 2

Critical Pitfalls to Avoid

Do not rely on short-acting bronchodilators alone:

• Beta-agonists provide only symptom relief and do not modify disease progression or prevent future exacerbations. 5
• Patients requiring rescue bronchodilators more than twice weekly need daily controller therapy. 3

Do not delay treatment waiting for objective testing:

• Empiric therapy with bronchodilators and corticosteroids is appropriate given the classic presentation and history of childhood asthma. 7
• Spirometry can be performed once acute symptoms improve to guide long-term management. 6

Do not prescribe antibiotics:

• The absence of fever and purulent sputum makes bacterial infection unlikely. 2
• Antibiotics have no role in uncomplicated asthma management and should only be considered if there is clear evidence of bacterial superinfection. 7

Follow-Up Strategy

Reassess within 1-2 weeks to evaluate treatment response:

• Document symptom frequency, nighttime awakenings, activity limitation, and rescue inhaler use. 4, 6
• Measure peak expiratory flow or repeat spirometry to assess objective improvement. 2
• Adjust controller medication dose based on asthma control, aiming for minimal symptoms and normal activity levels. 6

Provide a written asthma action plan:

• Include instructions for recognizing worsening symptoms (increased cough, wheeze, shortness of breath, decreased peak flow). 8
• Specify when to increase inhaled corticosteroid dose, when to start oral corticosteroids, and when to seek emergency care. 7, 8