How to manage a patient with wheezes and tachycardia, possibly with a history of asthma or COPD?

Management of Wheezes and Tachycardia

In a patient presenting with wheezes and tachycardia, immediately assess severity using objective criteria: if heart rate >110 beats/min with respiratory rate >25 breaths/min and inability to complete sentences, this indicates severe acute asthma or COPD exacerbation requiring immediate high-dose inhaled bronchodilators (salbutamol 5 mg or terbutaline 10 mg nebulized), systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg), and oxygen therapy. 1

Understanding the Tachycardia in Context

The tachycardia in this scenario is not a separate problem to "control" but rather a physiologic response to respiratory distress and hypoxemia. 1 The British Thoracic Society explicitly lists heart rate >110 beats/min as one of the defining features of severe asthma, alongside wheezing and breathlessness. 1 The tachycardia will resolve as you treat the underlying respiratory condition—attempting to directly suppress the heart rate without addressing the respiratory pathology would be dangerous and inappropriate. 1

Immediate Assessment Algorithm

Severity Stratification

Severe features present if ANY of the following: 1

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow <50% predicted or best

Life-threatening features present if ANY of the following: 1

• Peak expiratory flow <33% predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma

Critical Pitfall

If the patient has bradycardia instead of tachycardia, this paradoxically indicates a life-threatening situation with impending respiratory arrest—the heart rate has slowed due to severe hypoxia and exhaustion. 1 This requires immediate advanced life support preparation.

Immediate Treatment Protocol

First-Line Bronchodilator Therapy

Administer immediately: 1

• Salbutamol 5 mg OR terbutaline 10 mg via nebulizer with oxygen (if available)
• Alternative: Multiple actuations of metered-dose inhaler into large spacer device (20-40 puffs total)

Important caveat: While beta-agonists are essential, they can paradoxically worsen tachycardia temporarily. 2 The FDA label for albuterol warns that beta-adrenergic agonists may have clinically significant cardiac effects in individual patients. 2 However, withholding bronchodilators due to tachycardia concerns would be inappropriate—the respiratory distress itself is driving the tachycardia, and bronchodilators are life-saving. 1

Systemic Corticosteroids

Give immediately, do not delay: 1

• Prednisolone 30-60 mg orally OR
• Hydrocortisone 200 mg intravenously OR
• Both simultaneously in severe cases

The European Respiratory Society recommends oral prednisolone 30-40 mg daily for moderate exacerbations to improve lung function and shorten recovery time. 3

Oxygen Therapy

For acute severe asthma: 1

• Nebulizers should run with oxygen flow rate of 6-8 L/min
• If cylinders cannot produce this flow, use electrical compressors with simultaneous nasal oxygen at 4 L/min

Additional Therapy for Life-Threatening Features

If life-threatening features are present, add: 1

• Ipratropium bromide 0.5 mg nebulized with the beta-agonist
• IV aminophylline 250 mg over 20 minutes OR salbutamol/terbutaline 250 µg IV over 10 minutes

Critical warning: Do not give bolus aminophylline to patients already taking oral theophyllines. 1

Distinguishing Asthma from COPD

This distinction matters for long-term management but should not delay immediate bronchodilator and steroid therapy. 3, 4

Asthma Features: 5, 6

• Symptoms variable, intermittent, worse at night
• Triggered by specific exposures (allergens, exercise, cold air)
• Spirometry shows >12% and >200 mL improvement in FEV1 post-bronchodilator
• Can occur at any age

COPD Features: 1, 3, 6

• Progressive symptoms, persistent daily
• Smoking history (most patients are long-term smokers over age 40)
• Morning cough, recurrent respiratory infections
• Spirometry shows FEV1/FVC <70% with minimal reversibility
• Purulent sputum suggests infectious exacerbation

Asthma-COPD Overlap: 6, 7

• Displays features of both diseases
• Spirometry shows reversibility (consistent with asthma) but persistent baseline airflow limitation (characteristic of COPD)
• Treatment should follow asthma guidelines primarily, with inhaled corticosteroids and bronchodilators always required

Antibiotic Considerations for COPD Exacerbations

The American Thoracic Society recommends antibiotics immediately if TWO or more of: 3

• Increased breathlessness
• Increased sputum volume
• Development of purulent sputum

For COPD patients, purulent sputum with increased volume and breathlessness meets criteria for infectious exacerbation requiring antibiotics. 3

Hospital Admission Criteria

Immediate referral to hospital if: 1

• Any life-threatening features present
• Features of severe attack persist after initial treatment
• Peak expiratory flow 15-30 minutes after nebulization remains <33% predicted or best value

Lower threshold for admission if: 1

• Seen in afternoon or evening rather than earlier in day
• Recent hospital admission or previous severe attacks

Why the Tachycardia Resolves with Treatment

As bronchodilators open airways and oxygen delivery improves, the physiologic stress response diminishes. 1 The sympathetic nervous system activation decreases, hypoxemia resolves, and work of breathing reduces—all of which naturally lower the heart rate. 1 Attempting to pharmacologically suppress tachycardia with beta-blockers or calcium channel blockers would be contraindicated and potentially fatal, as these would worsen bronchospasm and respiratory function. 1

Monitoring Response

Reassess at 15-30 minutes: 1

• Repeat peak expiratory flow measurement
• Assess ability to speak in sentences
• Check respiratory rate and heart rate
• If improving, continue bronchodilators every 4-6 hours
• If not improving or deteriorating, add ipratropium and consider hospital transfer

The tachycardia should gradually improve as respiratory parameters normalize—persistent tachycardia despite improving respiratory status may indicate complications such as pneumothorax, pulmonary embolus, or cardiac issues requiring further investigation. 1