How should I evaluate and manage a 33-year-old woman with asthma who has had fever for two days, chest congestion, back pain, and symptoms that are mild during the day but worsen at night and in the morning?

Evaluation and Management of Acute Asthma Exacerbation with Nocturnal Worsening

This patient requires immediate objective assessment with peak expiratory flow (PEF) measurement and vital signs to determine severity, followed by nebulized bronchodilator therapy and systemic corticosteroids if PEF is <50% predicted or vital signs indicate acute severe asthma. 1

Immediate Clinical Assessment

The nocturnal and early morning worsening pattern is highly significant—74% of asthma patients experience nocturnal symptoms at least weekly, and up to 80% of fatal asthma attacks occur overnight or in early morning hours. 2 This circadian pattern reflects peak airway inflammation at 04:00 AM and represents a critical marker of disease severity and mortality risk. 2

Objective Severity Markers to Obtain Now

Measure and document the following before any treatment:

• Peak expiratory flow (PEF) - compare to predicted values for a 33-year-old woman (approximately 450-500 L/min based on height) 1
• Respiratory rate - concerning if >25 breaths/min 1
• Heart rate - concerning if >110 beats/min 1
• Ability to speak in complete sentences - inability indicates severe obstruction 1
• Pulse oximetry - values >90% are reassuring but may miss CO₂ retention 3

Critical pitfall: Physicians' subjective assessments of airway obstruction are often inaccurate—objective measurement is mandatory. 3 Never rely on clinical impression alone, as patients may not appear distressed even with severe obstruction. 1

Severity Classification and Treatment Algorithm

If PEF >50% predicted AND vital signs normal (pulse <110, respirations <25, speaks normally):

Treat at home with:

• Nebulized salbutamol 5 mg or terbutaline 10 mg immediately 1
• Prednisolone 30-60 mg orally 1
• Reassess PEF 15-30 minutes after nebulizer 1
• If PEF improves to >75% predicted, step up usual inhaled corticosteroid therapy 1
• Follow-up within 48 hours mandatory 1

If PEF <50% predicted OR pulse >110 OR respirations >25 OR cannot complete sentences:

This is acute severe asthma—seriously consider hospital admission if more than one feature present: 1

• Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen 40-60% if available 1
• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1
• Reassess 15-30 minutes after treatment 1
• Arrange hospital admission if any severe features persist 1

Lower your threshold for admission because: The attack timing (symptoms worse at night/morning) and recent nocturnal symptoms are specific criteria that mandate more aggressive management. 1

If PEF <33% predicted OR life-threatening features present:

Immediate hospital transfer required—this is a medical emergency: 1

Life-threatening features include:

• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, or coma 1

Essential Diagnostic Considerations

Rule Out Respiratory Infection

The 2-day fever with chest congestion raises concern for a viral upper respiratory infection—approximately 50% of acute severe asthma episodes are triggered by upper respiratory infections. 3 However, antibiotics should only be given if bacterial infection is confirmed—they are not helpful for viral triggers or asthma alone. 1

Evaluate for Comorbid Conditions

The back pain warrants consideration of:

• Gastroesophageal reflux disease (GERD) - particularly relevant given nighttime symptom worsening; treatment may improve asthma control, especially with frequent nighttime symptoms 1, 4
• Musculoskeletal pain from coughing (less concerning)

Address the Nocturnal Pattern

The circadian worsening is not just a symptom—it reflects fundamental disease pathophysiology: 2

• Airway inflammation peaks at 04:00 AM with significantly reduced lung function compared to daytime 2
• Lung function diurnal variability can increase up to fourfold during unstable asthma 2
• Critical error: Measuring lung function only during daytime clinic visits misses the 04:00 AM nadir when obstruction peaks 2

Follow-Up Management

After acute treatment:

• Peak flow monitoring at home - particularly important to capture nocturnal dips 1, 2
• Written self-management action plan 1
• Step up maintenance therapy with inhaled corticosteroids (standard of care for persistent asthma) 5
• Consider adding long-acting beta-agonist if inadequate response to inhaled corticosteroids alone 5
• Influenza vaccination recommended - patients with asthma are at risk for complications 1

Key Pitfalls to Avoid

• Never discharge without objective reassessment 15-30 minutes post-treatment 1
• Do not underestimate severity based on daytime presentation—nocturnal symptoms indicate higher mortality risk 2
• Delay can be fatal—regard each emergency consultation as acute severe asthma until proven otherwise 1
• Underuse of corticosteroids is a major preventable factor in asthma deaths 1
• Sedation is absolutely contraindicated in acute asthma 1