A 63-year-old man with asthma presents with a two‑week history of productive cough, congestion, fever, and wheezing unresponsive to his usual inhaled therapies; exam shows rhonchi and wheezes, chest X‑ray pending. What is the appropriate treatment?

Treatment for Acute Asthma Exacerbation with Suspected Bacterial Superinfection

This patient requires immediate high-dose bronchodilator therapy, systemic corticosteroids, and empiric antibiotics given the two-week duration of productive cough with fever unresponsive to home treatments. 1, 2

Immediate Treatment Protocol

Bronchodilator Therapy

• Administer nebulized albuterol 5 mg (or terbutaline 10 mg) immediately using oxygen-driven nebulization if available, or deliver via metered-dose inhaler with spacer (20-40 puffs) 1
• Repeat bronchodilator treatments every 15-30 minutes based on response, with frequency up to every 15 minutes if initial improvement is inadequate 1
• Add ipratropium 0.5 mg to the nebulized beta-agonist given the severity and prolonged duration of symptoms 1

Systemic Corticosteroids

• Give prednisolone 40-60 mg orally OR hydrocortisone 200 mg IV immediately 1, 2
• Continue oral prednisone 40-60 mg daily for 5-10 days with no taper needed for short courses 3, 4
• Systemic steroids are essential as clinical benefits require 6-12 hours to manifest 2

Antibiotic Therapy

• Initiate empiric antibiotics immediately given the productive cough, fever, and two-week duration suggesting bacterial superinfection (likely bronchitis or pneumonia) 1
• The British Thoracic Society guidelines specify antibiotics should be given "only if bacterial infection is present"—this patient's fever and productive cough for two weeks meets this threshold 1
• Await chest X-ray results to guide antibiotic selection and duration, but do not delay treatment 1

Monitoring and Reassessment

Objective Measurements

• Measure peak expiratory flow 15-30 minutes after initial bronchodilator treatment and continue monitoring every 15-30 minutes initially 1
• Obtain pulse oximetry before oxygen administration; values >90% are reassuring but may miss CO₂ retention 2
• Continue supplemental oxygen to maintain adequate saturation 1

Clinical Assessment

• Severe airflow obstruction indicators include: accessory muscle use, pulsus paradoxus, inability to recline, pulse >120 bpm, and decreased breath sounds 2
• If peak flow remains <33% of predicted or best value 15-30 minutes after nebulization, immediate hospital referral is required 1

Critical Pitfalls to Avoid

• Do not withhold antibiotics in this scenario—the two-week productive cough with fever indicates bacterial infection requiring treatment, not just asthma exacerbation 1
• Never administer sedation as it is contraindicated in acute severe asthma 1
• Avoid chest physiotherapy as it provides no benefit 1
• Do not rely solely on clinical assessment of airway obstruction severity, as physician subjective assessments are often inaccurate 2

Transition to Maintenance Therapy

After Acute Stabilization

• Once stabilized, transition to high-dose inhaled corticosteroids plus long-acting beta-agonist combination therapy (fluticasone/salmeterol or budesonide/formoterol) 1, 3
• This patient's failure to respond to home treatments indicates inadequate baseline control requiring step-up to at least Step 4 therapy (medium-to-high dose ICS/LABA) 1

Follow-up Requirements

• Reassess in 24-48 hours to ensure clinical improvement 1
• Complete the antibiotic course based on chest X-ray findings and clinical response 1
• Continue oral corticosteroids for full 5-10 day course, then transition back to optimized inhaled therapy 3, 4
• Address potential triggers: upper respiratory infection (most common cause of acute severe asthma), medication non-adherence, allergen exposure, or insufficient baseline controller therapy 2