Post-Steroid Management for Cold in Asthma/COPD Patients
If a patient with asthma or COPD develops a cold while already on oral steroids, continue the current steroid course to completion (typically 5 days total) and do not extend beyond 7 days, as longer courses increase adverse effects without additional benefit. 1, 2
Treatment Algorithm for Acute Respiratory Symptoms
Initial Assessment and Bronchodilator Optimization
- Increase short-acting bronchodilators first - add or increase short-acting β2-agonists (salbutamol 2.5-5 mg nebulized or 200-400 µg via inhaler) and/or anticholinergics (ipratropium 500 µg) every 4-6 hours during the acute phase 1
- If single-agent bronchodilator provides inadequate response, combine β-agonist with ipratropium bromide, as these produce additive effects at submaximal doses 1
- Continue bronchodilators regularly every 4-6 hours during acute symptoms 1
Steroid Course Management
Do not extend or restart steroids unless specific criteria are met:
- Each new exacerbation should be treated on its own merits based on current severity, not timing of previous treatment 2
- Limit total steroid duration to 5-7 days maximum - extending beyond 7 days increases adverse effects (hyperglycemia, weight gain, insomnia) without providing additional clinical benefit 2
- Never use systemic corticosteroids for longer than 14 days for a single exacerbation 2
Criteria for Adding/Continuing Steroids
Add or continue oral steroids only if the patient meets severity criteria:
- Cannot complete sentences in one breath 1
- Respiratory rate >25/min 1
- Heart rate >110/min 1
- Failure of airflow obstruction to respond to increased bronchodilator doses 2
Standard dosing when indicated: Prednisolone 30-40 mg daily for 5 days total 2, 3
Antibiotic Consideration
Prescribe antibiotics only if 2 or more of the following are present: 1, 2
- Increased breathlessness
- Increased sputum volume
- Development of purulent sputum
First-line options include amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid for 7-14 days 1
Critical Limitations and Pitfalls
Do Not Use Steroids for Prevention Beyond 30 Days
- Systemic corticosteroids prevent hospitalization for subsequent exacerbations only within the first 30 days following the initial event 2
- Grade 1A recommendation (strong evidence) against using systemic corticosteroids to prevent exacerbations beyond 30 days after the initial event 2
- Long-term use carries risks of infection, osteoporosis, and adrenal suppression that far outweigh any benefits 2
Special Considerations for Elderly Patients
- β-agonists may precipitate angina in elderly patients - the first treatment should always be supervised 1
- Ipratropium can worsen glaucoma - consider using a mouthpiece rather than a face mask to minimize ocular exposure 1
- Ensure adequate support at home and verify patient/caregiver understands medication regimen and inhaler technique 2
Transition to Maintenance Therapy
Once acute symptoms improve:
- Change from nebulized to handheld inhaler therapy and observe for 24-48 hours 1
- Initiate or optimize maintenance therapy with long-acting bronchodilators (inhaled corticosteroid/LABA combination or long-acting anticholinergic) to prevent future exacerbations 2
- For stable COPD with chronic cough, ipratropium bromide reduces cough frequency and severity 1
- Discontinue oral corticosteroids after the acute episode unless a definite indication for long-term treatment exists 2