In a patient with asthma on daily inhaled fluticasone and albuterol rescue, how should the asthma regimen be managed during an acute upper‑respiratory viral infection?

Management of Asthma During Acute Upper Respiratory Viral Infection

Continue the patient's daily inhaled fluticasone at the current dose and maintain albuterol as rescue therapy, while closely monitoring for increased symptoms that may require temporary escalation. 1

Core Management Principle

The fundamental approach is to maintain baseline controller therapy without routine dose adjustment during viral upper respiratory infections (URIs). 1 Viral URIs are the most common trigger of asthma exacerbations, particularly in children, but prophylactic increases in inhaled corticosteroid (ICS) doses have not demonstrated consistent benefit and carry potential risks. 1

Specific Medication Management

Inhaled Corticosteroid (Fluticasone)

• Continue the current daily fluticasone dose without routine doubling or quadrupling during the URI. 2 Controlled trials show that pre-emptive dose escalation in adherent patients does not effectively prevent exacerbations and may increase systemic side effects. 3

• Do not discontinue the ICS during the viral illness, as maintaining anti-inflammatory therapy is essential to prevent progression to severe exacerbation. 2

Rescue Albuterol

• Patients may need short-acting beta-agonist more frequently during URIs for symptom control. 1 This is expected and appropriate.

• Monitor albuterol use as a severity indicator: if the patient requires albuterol more than every 4 hours for 24 hours, this signals a severe exacerbation requiring immediate medical evaluation and likely systemic corticosteroids. 1

When to Escalate Treatment

Indications for Adding Oral Corticosteroids

Add oral prednisone 40–60 mg daily for 5–10 days (no taper needed) if any of the following develop: 4

• Inability to complete sentences in one breath 4
• Respiratory rate >25 breaths/min 4
• Heart rate >110 beats/min 4
• Peak expiratory flow (PEF) <50% of predicted or personal best 4
• Albuterol needed more frequently than every 4 hours 1

Emergency Department Referral Criteria

Immediate ED transfer is required for: 4

• PEF <33% of predicted 4
• Silent chest, cyanosis, or feeble respiratory effort 4
• Altered mental status (confusion, drowsiness) 4
• Inability to speak at all 4

Evidence on Pre-emptive High-Dose ICS

The PEAK trial demonstrated that pre-emptive high-dose fluticasone (750 mcg twice daily) started at URI onset reduced rescue oral corticosteroid use by approximately 50% (8% vs 18% of URIs required rescue steroids). 3 However, this approach was associated with significant growth suppression (height z-score difference -0.24, weight z-score difference -0.26). 3 Given these safety concerns, this strategy should not be adopted in routine clinical practice until long-term adverse effects are clarified. 3

Combination ICS/LABA During Viral Season

For patients on fluticasone/salmeterol combination therapy, continue the combination unchanged during URIs. 5 Retrospective data suggest that fluticasone/salmeterol provides superior protection against virus-associated exacerbations compared to ICS alone, with significantly fewer exacerbations when URIs occur (p=0.0057). 5 Summer dispensing of fluticasone/salmeterol was associated with reduced fall exacerbations (adjusted OR 0.53–0.59 across age groups). 6

Monitoring Protocol

• Measure PEF twice daily during the URI if the patient has a peak flow meter. 2
• Assess symptom frequency: nighttime awakenings, activity limitation, and rescue inhaler use. 2
• Schedule follow-up within 48 hours if symptoms worsen or albuterol use increases to more than 2–3 times daily. 2

Critical Pitfalls to Avoid

• Do not delay systemic corticosteroids while "trying bronchodilators first" if severe features develop—both must be given immediately. 4
• Never administer sedatives during an asthma exacerbation, as they are absolutely contraindicated. 4
• Do not rely on subjective assessment alone—objective PEF measurement is essential to avoid under-recognizing severity. 4
• Avoid intranasal fluticasone during URIs, as it does not prevent acute otitis media and may increase AOM incidence during rhinovirus infections (45.7% vs 14.7%, p=0.005). 7

Patient Education

• Provide a written asthma action plan with clear instructions on when to increase albuterol, when to start oral prednisone, and when to seek emergency care. 8
• Verify inhaler technique at every visit, as poor technique is a common cause of treatment failure. 8
• Emphasize adherence to daily controller therapy, as consistent use provides the best protection against virus-triggered exacerbations. 5, 6