From the Guidelines
For a patient with a persistent upper respiratory infection and shortness of breath who hasn't responded to multiple treatments including doxycycline, Medrol Dosepak, nebulizer treatments, Advair, and albuterol inhaler, with a negative chest X-ray, I recommend further diagnostic evaluation before additional treatment. The next steps should include:
- Pulmonary function testing (PFT) to assess for underlying asthma, COPD, or restrictive lung disease, as suggested by the guidelines for the management of chronic obstructive pulmonary disease 1
- A high-resolution CT scan of the chest to detect subtle abnormalities not visible on plain radiographs, as recommended for patients with pulmonary symptoms in the consensus guidelines for evaluation and management of pulmonary disease in Sjögren's 1
- Consider testing for specific pathogens including influenza, COVID-19, Mycoplasma pneumoniae, and other atypical organisms with PCR testing of nasopharyngeal swabs
- If allergic components are suspected, allergy testing may be warranted
- For persistent bacterial infection concerns, a sputum culture could help identify resistant organisms While awaiting these results, consider a trial of a different antibiotic class such as a respiratory fluoroquinolone (levofloxacin 750mg daily for 5 days) if bacterial infection remains a concern, as suggested by the guidelines for the management of adult lower respiratory tract infections 1. The lack of response to multiple bronchodilators and anti-inflammatory medications suggests either a resistant infection, an alternative diagnosis such as pulmonary embolism, or a non-infectious inflammatory process that requires more targeted therapy based on specific diagnostic findings, as outlined in the expert panel report for the diagnosis and management of asthma 1.
From the Research
Next Steps for Patient with Upper Respiratory Infection (URI) and Shortness of Breath (SOB)
- The patient has not responded to doxycycline, Medrol Dosepak, nebulizer treatments, Advair, or albuterol inhaler, and has a negative chest X-ray (CXR) 2, 3, 4, 5, 6.
- Considering the patient's symptoms and lack of response to initial treatments, further evaluation of airway wall thickness and lung function may be necessary 5, 6.
- High-resolution computed tomography (HRCT) scans can help identify subsets of asthma patients who show rapid decline in lung function and can quantify air trapping 2.
- HRCT findings can be correlated with pulmonary function tests (PFTs) to assess airway obstruction and airflow limitation 2, 3, 4.
- Endobronchial ultrasound (EBUS) can also be used to assess bronchial wall thickness and may be more sensitive than HRCT in detecting differences in airway wall thickness between patients with obstructive lung diseases and controls 5.
- The relationship between airway wall thickness and lung function parameters, such as spirometric parameters and airway resistance, can provide valuable information for guiding further treatment 6.