What is the management for an elderly female patient with a known history of asthma, presenting with mild fever, productive cough with green sputum, and mild shortness of breath (SOB), and generalized wheeze on exam?

Management of Asthma Exacerbation with Suspected Bacterial Infection

This elderly female patient with asthma presenting with fever, productive cough with green sputum, and generalized wheeze requires immediate treatment with nebulized bronchodilators, oral corticosteroids, and empiric antibiotics to cover both the acute asthma exacerbation and likely bacterial respiratory infection. 1, 2

Immediate Assessment and Severity Classification

Assess severity objectively before initiating treatment:

• Check if she can complete sentences in one breath - inability indicates severe exacerbation 3, 1
• Measure vital signs: respiratory rate >25/min, pulse >110/min, or oxygen saturation <92% indicate severe disease 3, 2
• Obtain peak expiratory flow (PEF): <50% of predicted/best = severe; <33% = life-threatening 3, 1
• Look for life-threatening features: silent chest, cyanosis, confusion, or exhaustion 3

The presence of fever and green sputum suggests bacterial infection complicating her asthma, which is a common trigger for exacerbations in elderly patients. 4

Immediate Pharmacological Management

Initiate the following treatments simultaneously within the first hour:

Bronchodilator Therapy

• Administer salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 3, 1, 2
• If nebulizer unavailable, give 2 puffs via large volume spacer and repeat 10-20 times 3
• Reassess 15-30 minutes after initial nebulization to determine response 3, 1

Systemic Corticosteroids

• Give prednisolone 30-60 mg orally immediately - do not delay as clinical benefits require 6-12 hours to manifest 3, 1, 2
• Alternative: IV hydrocortisone 200 mg if unable to take oral medication 3, 2

Antibiotic Therapy

• Initiate empiric antibiotics immediately given the fever and purulent sputum 4
• Recommended regimen: ceftriaxone plus azithromycin to cover typical and atypical bacterial pathogens 4
• The macrolide (azithromycin) provides dual benefit: antimicrobial coverage and anti-inflammatory effects in asthma 4
• Note: Antibiotics have no role in uncomplicated asthma exacerbations, but this case has clear signs of bacterial infection (fever + green sputum) 3, 4

Oxygen Therapy

• Administer 40-60% oxygen if available to maintain saturation >92% 3, 2

Response Assessment at 15-30 Minutes

If improvement occurs (PEF >50-75% predicted, able to speak in sentences):

• Continue prednisolone 30-60 mg daily for 5-7 days 1, 5
• Complete antibiotic course (typically 5-7 days) 4
• Step up inhaled corticosteroid therapy 1, 2
• Arrange follow-up within 24-48 hours 3, 1

If no improvement or severe features persist (PEF <50%, ongoing respiratory distress):

• Add ipratropium bromide 0.5 mg via nebulizer for additional bronchodilation through anticholinergic mechanism 3, 6
• Arrange immediate hospital admission 3, 1, 2
• Consider IV magnesium sulfate in hospital setting 1

Hospital Admission Criteria

Admit immediately if any of the following are present:

• PEF <33% predicted/best after initial treatment 3, 1
• Life-threatening features: silent chest, cyanosis, confusion, exhaustion 3, 1
• Inability to complete sentences after treatment 3, 1
• Oxygen saturation <92% on room air 1, 6
• Attack occurring in afternoon/evening (higher risk) 3
• Recent hospital admission or previous near-fatal asthma 3, 2
• Poor social circumstances or inability to self-manage 3

Outpatient Management (If Appropriate)

If patient can be managed at home after initial improvement:

• Prednisolone 30-60 mg daily for 5-7 days minimum - do not taper short courses 1, 5
• Complete antibiotic course (ceftriaxone/azithromycin for 5-7 days) 4
• Increase or initiate inhaled corticosteroid (e.g., fluticasone 250-500 mcg twice daily) 1, 2
• Continue short-acting beta-agonist as needed for symptom relief 1, 2
• Provide peak flow meter and written action plan 3, 1, 2
• Schedule follow-up within 24-48 hours with primary care 3, 1

Critical Pitfalls to Avoid

Common errors that increase morbidity and mortality:

• Underestimating severity - always use objective measures (PEF, vital signs), not just patient perception 3, 7
• Delaying corticosteroids - must be given within first hour as benefits take 6-12 hours 1, 2
• Withholding antibiotics when infection is evident - fever and purulent sputum warrant empiric coverage 4
• Overreliance on bronchodilators alone without anti-inflammatory treatment 2, 7
• Discharging too early - ensure PEF >75% predicted and patient stable on discharge medications for 24 hours before discharge if admitted 3, 1

Special Considerations in Elderly Patients

Age-related factors affecting management:

• Elderly patients may have coexisting COPD, making diagnosis challenging - wheezing with smoking history requires consideration of both conditions 3
• Higher risk of adverse effects from corticosteroids including hyperglycemia, fluid retention, and hypertension 5
• Increased susceptibility to respiratory infections as triggers for exacerbations 4
• Consider cardiac causes (heart failure) in differential diagnosis of dyspnea and wheeze 3