What is the best course of action for a 45-year-old male with an asthma exacerbation, experiencing nasal congestion, chest tightness, and wheezing, despite using albuterol and Wixela (fluticasone/salmeterol)?

From the Guidelines

This patient is experiencing an acute asthma exacerbation triggered by seasonal changes, requiring immediate intervention with oral corticosteroids, continued use of his maintenance inhaler, and as-needed use of a short-acting beta2-agonist. I recommend starting oral prednisone 40mg daily for 5 days to reduce airway inflammation, as suggested by the guidelines for managing asthma exacerbations 1. The patient should continue his Wixela maintenance inhaler as prescribed, and use albuterol 2 puffs every 4-6 hours as needed for breakthrough symptoms, following the dosages recommended for asthma exacerbations 1. He should also add a nasal corticosteroid spray such as fluticasone 1-2 sprays in each nostril daily to address the nasal congestion that may be contributing to his asthma symptoms. The patient should follow up with his primary care provider within 1 week if symptoms don't improve, and keep his scheduled pulmonology appointment in May. If symptoms worsen despite treatment, he should seek immediate medical attention. This treatment approach addresses both the acute bronchospasm with albuterol and the underlying inflammation with corticosteroids. The nasal spray will help manage upper airway symptoms that can trigger lower airway reactivity through the unified airway concept. Seasonal transitions often exacerbate asthma due to changing allergen profiles and temperature/humidity fluctuations, making this a common time for symptom flares that require temporary intensification of therapy. Key considerations in managing this patient's asthma exacerbation include:

• Ensuring proper inhaler technique and adherence to prescribed medications
• Monitoring for signs of worsening symptoms or severe exacerbation
• Adjusting treatment as needed based on patient response and guidelines for asthma management 1

From the FDA Drug Label

Inhaled beta-2 selective agonists and systemically administered corticosteroids are the treatments of first choice for management of acute exacerbations of asthma The patient has already used albuterol nebulizers (an inhaled beta-2 selective agonist) this morning, but there is no mention of systemically administered corticosteroids. Given the patient's symptoms of tight chest and wheezing, and the fact that he has already used his inhaler more frequently, the next step would be to consider adding systemically administered corticosteroids to his treatment, as they are the treatments of first choice for management of acute exacerbations of asthma, along with inhaled beta-2 selective agonists. The use of intravenous theophylline is not recommended as the first line of treatment, as the results of controlled clinical trials on its efficacy in acute exacerbations of asthma have been conflicting, and it may increase the risk of adverse effects 2.

From the Research

Patient Presentation

• The patient is a 45-year-old male presenting with an asthma flareup, reporting nasal congestion and increased use of his inhaler over the past 2-3 weeks.
• He woke up with tightness in the chest and wheezing, and has done 3 albuterol nebulizers this morning, with the last treatment at 8:30 am.
• He has a new patient pulmonology appointment in May and has been using his maintenance inhaler (Wixela) as prescribed.

Management of Acute Asthma Exacerbations

• According to 3, acute severe asthma is characterized by severe pulmonary hyperinflation due to marked limitation of the expiratory flow, and the main objective of initial ventilator management is to ensure adequate gas exchange and prevent further hyperinflation and ventilator-associated lung injury.
• The study 4 suggests that patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids.
• The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations, as noted in 4.

Treatment Options

• The study 5 found that albuterol MDI with a spacer was more effective than a nebulizer in reducing follow-up visits to the clinic and was effective at reducing ED visits within 30 days.
• According to 6, albuterol MDI with a holding chamber can be given optimally at 60-min intervals with minimal adverse effects for the majority of patients, but patients who initially demonstrate a low or poor bronchodilator response to albuterol should be given subsequent treatments at 30-min intervals.
• The study 7 found that inhaled albuterol delivered via jet nebulizer, metered dose inhaler with spacer, or dry powder were all effective in treating acute severe asthma, with no significant differences in FEV1 improvement between the three delivery methods.

Next Steps

• The patient's symptoms and treatment response should be closely monitored, and adjustments to his treatment plan should be made as needed, based on the guidelines outlined in 3 and 4.
• Consideration should be given to adding a short-acting muscarinic antagonist and magnesium sulfate infusion to his treatment plan, as suggested in 4.
• The patient's upcoming pulmonology appointment in May should be kept, and his treatment plan should be reviewed and updated as necessary, taking into account the findings from 5, 6, and 7.