In an adult presenting with harsh breath sounds (coarse wheezes or stridor) and dyspnea, what is the immediate management?

Immediate Management of Harsh Breath Sounds and Dyspnea in Adults

Administer nebulized salbutamol 5 mg (or terbutaline 10 mg) with oxygen as the driving gas at 6-8 L/min immediately, as this is the first-line treatment for acute bronchospasm presenting with audible wheezing and dyspnea. 1

Initial Assessment While Treating

Distinguish stridor from wheezing immediately, as this determines whether the obstruction is upper airway (laryngeal/tracheal) versus lower airway (bronchial). 2, 3

• Stridor is a loud, musical sound of constant pitch heard with tracheal or laryngeal obstruction, typically loudest over the central airway with inspiratory predominance. 2, 3
• Wheezing represents high-pitched continuous sounds (≥400 Hz) from oscillating narrowed bronchial airways, typically expiratory. 4
• If upper airway obstruction is suspected (dysphonia, inspiratory stridor, monophonic wheeze loudest centrally), evaluate with flow-volume curves and laryngoscopy rather than bronchodilators. 2

Assess severity markers immediately to guide escalation:

• Severe asthma indicators: inability to complete sentences, respiratory rate ≥25/min, heart rate ≥110/min, accessory muscle use. 2, 5
• Life-threatening features: silent chest, cyanosis, bradycardia, hypotension, altered mental status (exhaustion, confusion, coma). 2, 1
• Peak expiratory flow ≤50% predicted indicates severe disease requiring escalation. 2, 1

Bronchodilator Administration Protocol

Use oxygen-driven nebulization at 6-8 L/min for all patients unless contraindicated. 1

• In patients with documented CO₂ retention and acidosis (typically COPD), use compressed air instead of oxygen to avoid worsening hypercapnia. 1, 6
• If nebulizer unavailable, deliver salbutamol via MDI with spacer: 100 µg per actuation, repeat up to 20 actuations. 1

Do not withhold beta-agonists due to elevated heart rate, as tachycardia is primarily driven by the respiratory distress itself, not the medication. 5

Escalation for Inadequate Response

Add ipratropium bromide 500 µg to the nebulized beta-agonist if initial response is insufficient within 15-30 minutes. 1, 5

• Continue combination therapy (salbutamol + ipratropium) every 20 minutes for up to three doses in the first hour if improvement occurs. 1
• Use a mouthpiece rather than mask with ipratropium in elderly patients to minimize glaucoma risk. 5

Initiate systemic corticosteroids immediately for severe presentations:

• Prednisolone 30-60 mg orally OR hydrocortisone 100-200 mg IV every 6 hours. 1, 5
• Continue for at least 3 days to reduce airway inflammation and prevent relapse. 1

If bronchodilator therapy remains ineffective after 2-3 treatments, consider:

• Aminophylline infusion: 5 mg/kg IV loading dose over 20 minutes (omit if already on theophylline), followed by 1 mg/kg/hour maintenance. 1
• Transfer to intensive care for continuous bronchodilator delivery or mechanical ventilation consideration. 1

Monitoring and Reassessment

Measure peak expiratory flow at 15-30 minutes after initial treatment, then before and after each subsequent treatment. 1, 5

• Continue treatments every 4-6 hours until PEF >75% predicted and diurnal variability <25%. 1
• Monitor oxygen saturation continuously in severe cases. 5

Consider arterial blood gas if hospital admission is required to assess for hypercapnia and acidosis. 1

Critical Differential Diagnoses to Exclude

Rule out upper airway obstruction (foreign body, epiglottitis, vocal cord dysfunction) if stridor predominates or if there is dysphonia with normal PaO₂. 2

Consider anaphylaxis if dyspnea is accompanied by pruritus, urticaria, or hypotension—this requires epinephrine, not just bronchodilators. 2

Evaluate for cardiac causes (congestive heart failure) if wheezing is accompanied by orthopnea, peripheral edema, or elevated jugular venous pressure, though bronchodilators should not be delayed. 2

Assess for pneumothorax or pneumomediastinum in patients with sudden-onset dyspnea and subcutaneous emphysema, particularly if ventilation is difficult. 2

Hospital Admission Criteria

Admit to hospital if:

• Life-threatening features present (silent chest, cyanosis, altered mental status, bradycardia). 1
• PEF remains <33% predicted after initial treatment. 1
• Inadequate response to initial bronchodilator therapy after 2-3 treatments. 1
• Patient requires continuous nebulization or shows deteriorating respiratory status. 1

Common Pitfalls to Avoid

Do not assume all wheezing is asthma—chronic bronchitis, COPD, foreign body aspiration, and cardiac disease can all present with harsh breath sounds. 3, 4

Do not delay bronchodilator therapy to obtain spirometry in patients with obvious severe respiratory distress—treat first, measure later. 2

Do not continue repeated nebulizations indefinitely without adding systemic corticosteroids and considering admission if no significant improvement occurs. 1

Do not use oxygen as nebulizer driving gas in known CO₂ retainers—this can worsen hypercapnia and precipitate respiratory failure. 1, 6