What is the indication for systemic steroids in an elderly female patient with a history of asthma presenting with an acute exacerbation?

Systemic Steroids in Acute Asthma Exacerbation

Systemic corticosteroids should be administered immediately to this elderly female patient with acute asthma exacerbation, as they are the only treatment effective for the inflammatory component of asthma and are a cornerstone of acute management. 1, 2

Clear Indications for Systemic Steroids

The British Thoracic Society guidelines establish that systemic steroids are indicated immediately when any of the following are present 1:

• Severe or life-threatening features (PEF <50% predicted, inability to complete sentences, respiratory rate >25/min, pulse >110/min)
• Features of acute severe asthma that persist after initial bronchodilator treatment
• Peak expiratory flow 15-30 minutes after nebulization <50% of predicted or best value
• Progressive worsening of symptoms day by day
• Sleep disturbance from asthma
• Morning symptoms persisting until midday
• Diminishing response to inhaled bronchodilators

Recommended Dosing Algorithm

For Adults (Including Elderly Patients)

Immediate administration: 1, 3, 4

• Prednisolone 30-60 mg orally as a single morning dose or in 2 divided doses
• OR Hydrocortisone 200 mg IV if patient is vomiting, severely ill, or unable to tolerate oral medications 1, 3

Continue treatment: 3, 4

• Same daily dose until peak expiratory flow reaches 70% of predicted or personal best
• Typical duration: 5-10 days without tapering
• For hospitalized patients with severe exacerbations, treatment may extend to 7-21 days until lung function returns to baseline 3

Route Selection

Oral route is strongly preferred and equally effective as IV therapy when gastrointestinal absorption is intact 3, 2, 5. A randomized controlled trial demonstrated no difference in efficacy between oral prednisolone 100 mg daily versus IV hydrocortisone 100 mg every 6 hours 5.

Switch to IV only if: 1, 3

• Patient is vomiting
• Patient is severely ill or unable to swallow
• Gastrointestinal absorption is impaired

Critical Timing Considerations

Administer steroids within the first hour of presentation for all moderate-to-severe exacerbations 3, 2. The anti-inflammatory effects take 6-12 hours to become apparent, making early administration crucial for preventing deterioration 3, 2.

Monitoring Response

Measure and record the following 1, 3:

• Peak expiratory flow 15-30 minutes after starting treatment
• Continue monitoring every 4 hours initially
• Oxygen saturation (maintain >92%, or >95% in patients with heart disease) 2
• Respiratory rate, heart rate, ability to complete sentences

Duration and Tapering

No tapering is necessary for courses lasting 5-10 days, especially if the patient is concurrently taking inhaled corticosteroids 3, 4. Continue treatment until two days after control is established, not for an arbitrary fixed period 3.

Important Clinical Pitfalls to Avoid

• Do not delay steroid administration – this is a documented cause of preventable asthma deaths and unnecessary morbidity 1, 3
• Do not use unnecessarily high doses – doses above 60-80 mg/day have not shown additional benefit in severe exacerbations 3, 6
• Do not rely on clinical impression alone – always measure peak expiratory flow objectively 1, 3
• Do not use arbitrarily short courses (like 3 days) without assessing clinical response, as this may result in treatment failure 3
• Do not taper short courses (<7-10 days), as this is unnecessary and may lead to underdosing during the critical recovery period 3, 4

Concurrent Essential Therapy

Systemic steroids must be combined with 1, 2:

• High-dose inhaled β-agonists (salbutamol 5 mg or terbutaline 10 mg nebulized every 4 hours initially)
• Oxygen therapy to maintain SpO₂ >92%
• Ipratropium bromide 0.5 mg added to β-agonist in severe exacerbations

Special Considerations for Elderly Patients

While the dosing remains the same regardless of age 3, 4, elderly patients warrant:

• Lower threshold for hospital admission 1
• Monitoring for concurrent conditions (heart disease, diabetes) that may be affected by steroids
• Assessment of ability to use inhalers properly and social circumstances for safe discharge 1