A 20-year-old man with a history of asthma comes to the office due to a marked increase in cough, wheezing, and sputum production. The asthma is usually very well controlled on mometasone-formoterol 1 puff twice daily, but over the past week, the patient has used his inhaler several times daily for chest tightness, cough, and wheezing. These symptoms started 5 days ago, when he "felt lousy" and had muscle aches; cough; nasal congestion; thick, yellowish nasal discharge; sore throat; and fever. The fever and sore throat improved, but the cough and nasal congestion have persisted. The patient has no headache. He can barely sleep due to frequent coughing.
The patient is afebrile. Pulse is 82/min and respirations are 14/min. Pulse oximetry shows 97% on room air. Physical examination shows a healthy-appearing man who is not in acute respiratory distress. There is no sinus tenderness, but some postnasal drip is seen in the oropharynx. Lung examination shows good air entry and diffuse wheezing. The remainder of the physical examination is normal.
Which of the following is the most appropriate treatment for this patient?

Question

A 20-year-old man with a history of asthma comes to the office due to a marked increase in cough, wheezing, and sputum production.  The asthma is usually very well controlled on mometasone-formoterol 1 puff twice daily, but over the past week, the patient has used his inhaler several times daily for chest tightness, cough, and wheezing.  These symptoms started 5 days ago, when he "felt lousy" and had muscle aches; cough; nasal congestion; thick, yellowish nasal discharge; sore throat; and fever.  The fever and sore throat improved, but the cough and nasal congestion have persisted.  The patient has no headache.  He can barely sleep due to frequent coughing.
The patient is afebrile.  Pulse is 82/min and respirations are 14/min.  Pulse oximetry shows 97% on room air.  Physical examination shows a healthy-appearing man who is not in acute respiratory distress.  There is no sinus tenderness, but some postnasal drip is seen in the oropharynx.  Lung examination shows good air entry and diffuse wheezing.  The remainder of the physical examination is normal.
Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

This patient has an acute asthma exacerbation most likely due to a viral upper respiratory infection. Several published treatment guidelines recommend the use of systemic corticosteroids for the following: All moderate to severe acute asthma exacerbations (urgent care or emergency room settings)Mild exacerbations (outpatient setting) that have been unresponsive to standard inhaler therapy All moderate to severe acute asthma exacerbations (urgent care or emergency room settings) Mild exacerbations (outpatient setting) that have been unresponsive to standard inhaler therapy Meta-analyses demonstrate that patients treated with a short course of systemic corticosteroids had fewer future exacerbations requiring hospitalization and decreased use of reliever medications. In addition, patients given systemic corticosteroids within an hour of presentation were significantly less likely to be admitted to the hospital. The optimal dosage and duration of corticosteroid therapy have not been determined; however, general recommendations are prednisone 40-60 mg daily for 5-7 days. (Choice A) Tiotropium, a long-acting muscarinic antagonist, is a controller bronchodilator that can be added as part of the step-up strategy for persistent asthma that remains uncontrolled despite a high-dose inhaled corticosteroid (ICS) and a beta agonist. Ipratropium, a short-acting muscarinic antagonist, can be used as an adjunctive reliever bronchodilator during acute exacerbations. step-up strategy (Choice B) Antibiotics are not routinely indicated for asthma exacerbations. Levofloxacin would be appropriate treatment for community-acquired pneumonia or bacterial rhinosinusitis; however, this patient has no pulmonary findings to suggest pneumonia and no clinical evidence to suggest bacterial rhinosinusitis (eg, duration of symptoms ≥10 days, symptomatic worsening following improvement). (Choice C) Leukotriene receptor antagonists (eg, montelukast) are used primarily as adjunctive controller therapy for persistent asthma. When used on-demand for acute exacerbations, they may offer a small incremental benefit but do not fully suppress the rampant airway inflammation. Therefore, they are initiated with systemic corticosteroids and intensification of ICS-beta agonist therapy. (Choice E) Intranasal corticosteroid therapy (eg, budesonide) may reduce the nasal inflammation and upper airway cough syndrome associated with acute viral rhinosinusitis, but it has minimal impact on the bronchial inflammation and airway obstruction that occur with acute asthma exacerbation. Educational objective: A short course of systemic corticosteroids is indicated for patients with mild acute asthma exacerbations unresponsive to bronchodilator therapy. It reduces the need for hospitalization and improves long-term control. Prednisone 40-60 mg daily for 5-7 days is the recommended treatment regimen. __________

A 20-Year-Old Man with a History of Asthma Comes to the Office