What is the recommended work‑up and management for a 67‑year‑old male with chronic asthma presenting for review of his laboratory results?

Recommended Work-Up and Management for a 67-Year-Old Male with Chronic Asthma

For a 67-year-old male with known chronic asthma presenting for laboratory review, the essential work-up includes spirometry with bronchodilator reversibility testing to objectively confirm the diagnosis and assess current control, measurement of peak expiratory flow (PEF) to establish a personal best value, and evaluation for common comorbidities including COPD, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and cardiovascular disease. 1

Diagnostic Confirmation and Assessment

Spirometry and Objective Testing

• Spirometry is mandatory because medical history and physical examination alone are unreliable for excluding alternative diagnoses or assessing lung status in adults with presumed asthma. 1
• Perform spirometry with bronchodilator reversibility testing to demonstrate both airflow obstruction and its reversibility—the two hallmarks of asthma. 1, 2
• If spirometry is normal or near-normal but clinical suspicion for asthma remains high, consider bronchoprovocation testing with methacholine to detect airway hyperresponsiveness. 1
• A negative methacholine challenge is more useful to rule out asthma than a positive test is to confirm it, since airway hyperresponsiveness can occur in other conditions. 1

Peak Flow Monitoring

• Establish the patient's personal best PEF value through home monitoring over 2–3 weeks during a period of good control. 1
• Peak flow meters are designed for monitoring disease control, not for diagnosis. 1

Critical Differential Diagnoses in Older Adults

In a 67-year-old male, you must actively exclude:

• COPD (chronic bronchitis or emphysema): Obtain diffusing capacity (DLCO) measurement if there is smoking history, incomplete reversibility on spirometry, or progressive dyspnea. 1
• Congestive heart failure: Assess for orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and elevated jugular venous pressure; consider BNP/NT-proBNP and echocardiography. 1
• Pulmonary embolism: Evaluate if there is acute-onset dyspnea, pleuritic chest pain, or risk factors for thromboembolism. 1
• Mechanical airway obstruction from benign or malignant tumors: Consider chest radiography or CT if there is hemoptysis, weight loss, or fixed obstruction on flow-volume loops. 1
• Vocal cord dysfunction (VCD): Suspect if symptoms are refractory to standard asthma therapy or if inspiratory flow-volume loops show variable flattening; confirm by laryngoscopy during an episode. 1
• Drug-induced cough: Review medications, particularly ACE inhibitors. 1

Laboratory and Imaging Studies

• Chest radiography is indicated to exclude pneumonia, heart failure, or structural lung disease if the diagnosis is uncertain or the patient is not responding to therapy. 1
• Routine laboratory tests (complete blood count, electrolytes) are not necessary for stable asthma but may be useful when considering alternative diagnoses or comorbidities. 1

Assessment of Asthma Control and Severity

Clinical History Elements

Document the following to classify severity and guide treatment:

• Symptom frequency: Daytime symptoms (days per week), nocturnal awakenings (nights per month), and limitation of daily activities. 1
• Rescue inhaler use: Use of short-acting β-agonists more than 2 days per week (excluding pre-exercise use) indicates inadequate control. 3
• Exacerbation history: Frequency, severity, and triggers (viral infections, allergens, exercise, cold air, irritants). 1
• Medication adherence: Poor adherence to inhaled corticosteroids is a common cause of apparent treatment failure. 4
• Occupational and environmental exposures: Identify potential allergens or irritants at home or work. 1, 4

Physical Examination Findings

• During stable periods, the physical examination may be entirely normal. 1
• Look for signs of atopy: eczema, allergic rhinitis, nasal polyps. 1
• Assess for comorbid conditions: signs of GERD, rhinosinusitis, obesity (suggesting OSA risk). 5

Evaluation for Common Comorbidities

GERD, OSA, and Allergic Rhinitis

• GERD can trigger or worsen asthma; inquire about heartburn, regurgitation, and nocturnal cough. 1, 5
• OSA is common in older adults and can complicate asthma control; screen with the STOP-BANG questionnaire and consider polysomnography if positive. 5
• Allergic rhinitis and chronic sinusitis frequently coexist with asthma and should be treated to optimize asthma control. 1, 5

Cardiovascular Disease

• In a 67-year-old male, dyspnea may be cardiac rather than pulmonary; assess cardiovascular risk factors and consider ECG and echocardiography if clinically indicated. 1

Chronic Management Strategy

Controller Medication Selection

• Inhaled corticosteroids (ICS) are the cornerstone of chronic asthma therapy and should be prescribed for all patients with persistent asthma (symptoms >2 days/week or nocturnal symptoms >2 nights/month). 3
• Start with low-dose ICS for mild persistent asthma; escalate to medium or high doses if control is inadequate. 3
• For patients ≥12 years with inadequate control on ICS alone, add a long-acting β-agonist (LABA) rather than increasing the ICS dose or adding a leukotriene receptor antagonist. 3
• Leukotriene receptor antagonists (e.g., montelukast) are an alternative for patients who cannot or will not use ICS, though they are less effective. 3

Rescue Medication

• Short-acting β-agonists (albuterol/salbutamol) are the most effective therapy for acute symptom relief and should be prescribed to all patients. 3
• Increasing use of rescue inhalers (>2 days/week or >2 nights/month) signals inadequate control and the need to step up controller therapy. 3

Monitoring and Follow-Up

• Schedule regular follow-up every 3–6 months to assess control, adjust medications, review inhaler technique, and reinforce adherence. 3
• Provide a written asthma action plan that specifies daily medications, how to recognize worsening symptoms, and when to seek urgent care. 1, 3
• Teach proper inhaler technique at every visit; incorrect technique is a common cause of treatment failure. 1

Management of Acute Exacerbations

Severity Assessment

Classify exacerbations by objective criteria:

• Mild: PEF >50% predicted, able to speak in full sentences, respiratory rate <25/min, pulse <110/min. 3
• Severe: PEF <50% predicted, difficulty completing sentences, respiratory rate ≥25/min, pulse ≥110/min. 1, 3
• Life-threatening: PEF <33% predicted, silent chest, cyanosis, confusion, exhaustion, or respiratory arrest. 1

Immediate Treatment

• Administer high-dose inhaled β-agonist immediately: salbutamol 5 mg via oxygen-driven nebulizer or 4–8 puffs via metered-dose inhaler with spacer, repeated every 20 minutes for three doses. 1, 6
• Give systemic corticosteroids early: oral prednisolone 30–60 mg immediately (or IV hydrocortisone 200 mg if the patient is vomiting or severely ill). 1, 6
• Systemic corticosteroids require 6–12 hours to exert anti-inflammatory effects, making early administration critical. 6
• Add ipratropium bromide 0.5 mg to nebulized β-agonist treatments in severe exacerbations. 1, 6
• Provide supplemental oxygen to maintain SpO₂ >92%. 1

Reassessment and Disposition

• Measure PEF 15–30 minutes after initial treatment to assess response. 1, 6
• Hospitalize if: PEF remains <50% predicted after initial treatment, the patient cannot complete sentences, SpO₂ <92% on oxygen, or any life-threatening features are present. 1, 3
• For outpatient management, continue oral prednisolone 30–60 mg daily for 5–10 days without tapering (no taper is needed for courses <7–10 days, especially if the patient is on ICS). 6
• Arrange primary care follow-up within 1 week and respiratory specialist review within 4 weeks. 1, 3

Critical Pitfalls to Avoid

• Do not rely on clinical impression alone; always obtain objective measurements (spirometry, PEF) to confirm the diagnosis and assess severity. 1
• Do not assume the diagnosis is correct: up to 33% of adults with physician-diagnosed asthma may not have current asthma when objectively reassessed. 7
• Do not underdose systemic corticosteroids during exacerbations; underuse is a documented factor in preventable asthma deaths. 1, 6
• Do not prescribe antibiotics unless there is clear evidence of bacterial infection (purulent sputum, fever, consolidation on chest X-ray). 1, 3
• Never use sedatives in acute asthma; they are contraindicated and can precipitate respiratory failure. 1, 3
• Do not discharge after an exacerbation until the patient has been stable on discharge medications for ≥24 hours, PEF is >75% predicted, and inhaler technique has been verified. 1