A patient on maintenance inhaled budesonide twice daily develops wheezing due to viral pharyngitis; what is the appropriate treatment?

Treatment of Pharyngitis-Induced Wheezing in a Patient on Maintenance Budesonide

Administer nebulized salbutamol 5 mg (or terbutaline 10 mg) immediately as first-line bronchodilator therapy for acute wheezing, regardless of maintenance inhaled corticosteroid use. 1

Immediate Bronchodilator Management

Your patient requires acute bronchodilator therapy, not adjustment of maintenance budesonide:

• Give nebulized salbutamol 5 mg or terbutaline 10 mg as the initial treatment for any audible wheezing episode 1
• Use oxygen as the driving gas at 6–8 L/min unless the patient has documented CO₂ retention 1
• If a nebulizer is unavailable, deliver salbutamol via MDI with spacer (100 µg per actuation, up to 20 actuations) 1
• Repeat the beta-agonist every 20 minutes for up to three doses in the first hour if improvement occurs 1

Critical point: Maintenance budesonide is not designed to relieve acute symptoms and extra doses should not be used for that purpose 2. Acute wheezing requires short-acting beta₂-agonists like albuterol 2.

Escalation Strategy if Initial Response is Inadequate

• Add ipratropium bromide 500 µg to the nebulized salbutamol when the initial beta-agonist response is insufficient 1
• Continue the combination every 4–6 hours until symptoms resolve 1
• If the patient remains poorly responsive after 2–3 combination treatments, initiate systemic corticosteroids (prednisolone 2 mg/kg/day for 3 days, maximum 40 mg/day, or hydrocortisone 100 mg IV every 6 hours) 1

Severity Assessment While Treating

Evaluate for features requiring hospital admission:

• Severe indicators: respiratory rate >25/min, inability to complete sentences, peak expiratory flow ≤50% predicted 3, 1
• Life-threatening features: silent chest, cyanosis, bradycardia, hypotension, altered mental status 1
• If any severe or life-threatening features are present, consider hospital admission while continuing bronchodilator therapy 3

Role of Maintenance Budesonide During Viral Illness

Continue the twice-daily maintenance budesonide throughout the viral illness 2. The evidence shows:

• Budesonide has direct antiviral and anti-inflammatory activity against human rhinovirus via autophagy activation, reducing viral load and IL-1β cytokine levels 4
• Intermittent high-dose budesonide (800–1600 µg twice daily for 7 days) started at the onset of viral respiratory infection can reduce wheeze severity in children with viral-induced asthma 5
• However, routine prophylactic budesonide after viral bronchiolitis does not prevent subsequent wheezing episodes 6

Do not increase the maintenance budesonide dose unless the patient has documented asthma with recurrent viral-triggered exacerbations, in which case consider 1 mg twice daily for 7 days at the first sign of respiratory infection symptoms 7.

Common Pitfalls to Avoid

• Do not delay bronchodilator therapy while attempting to differentiate viral pharyngitis from other causes; acute bronchospasm requires immediate treatment 1
• Do not use extra doses of budesonide to treat acute wheezing; patients should be instructed that budesonide is not meant to relieve acute symptoms 2
• Do not discontinue maintenance budesonide during the viral illness, as symptoms may worsen after discontinuation 2
• Do not continue repeated nebulizations indefinitely without escalation; if no improvement after 2–3 treatments, add ipratropium and consider systemic corticosteroids 1

When to Seek Further Medical Attention

Instruct the patient to notify their healthcare provider immediately if they experience:

• Decreasing effectiveness of short-acting beta₂-agonists 2
• Need for more inhalations than usual of rescue medication 2
• Significant decrease in lung function 2
• Persistent symptoms despite appropriate bronchodilator use 1