A 46-year-old man comes to the office due to a 3-day history of cough, wheezing, and shortness of breath. Symptoms started a week ago with nasal congestion, sore throat, and body aches. The cough is productive of thin, whitish sputum. The patient has no fever, chills, chest pain, or abdominal pain. He has asthma managed with budesonide-formoterol as needed. Since yesterday, he has used the inhaler multiple times without significant symptom relief. His other medical condition is hypertension. He does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 138/74 mm Hg, pulse is 86/min, and respirations are 20/min. Pulse oximetry is 96% on room air. The patient speaks in full sentences. He appears mildly uncomfortable but does not use accessory respiratory muscles. Jugular venous pressure is normal. There is no nasal sinus tenderness. The pharyngeal mucosa is without exudates. Bilateral expiratory wheezing with prolonged expiration is noted. Inspiratory breath sounds are normal. Heart sounds are normal. Peak expiratory flow is 30% lower than his prior baseline. Which of the following is the most appropriate next step in management of this patient?

Question

A 46-year-old man comes to the office due to a 3-day history of cough, wheezing, and shortness of breath.  Symptoms started a week ago with nasal congestion, sore throat, and body aches.  The cough is productive of thin, whitish sputum.  The patient has no fever, chills, chest pain, or abdominal pain.  He has asthma managed with budesonide-formoterol as needed.  Since yesterday, he has used the inhaler multiple times without significant symptom relief.  His other medical condition is hypertension.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 138/74 mm Hg, pulse is 86/min, and respirations are 20/min.  Pulse oximetry is 96% on room air.  The patient speaks in full sentences.  He appears mildly uncomfortable but does not use accessory respiratory muscles.  Jugular venous pressure is normal.  There is no nasal sinus tenderness. The pharyngeal mucosa is without exudates.  Bilateral expiratory wheezing with prolonged expiration is noted.  Inspiratory breath sounds are normal.  Heart sounds are normal.  Peak expiratory flow is 30% lower than his prior baseline.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with 3 days of cough, wheezing, and shortness of breath has an acute asthma exacerbation, defined as an increase in asthma symptoms (eg, cough, dyspnea, wheezing) combined with a >20% reduction in peak expiratory flow rate. The most common trigger is viral upper respiratory infection, which is suggested by this patient's recent nasal congestion, sore throat, and myalgia. Several published treatment guidelines recommend the use of systemic corticosteroids for: Mild exacerbations in the outpatient setting that have been unresponsive to standard inhaler therapy (eg, no improvement despite increasing inhaled corticosteroid-formoterol as needed use, as in this patient). All moderate to severe acute asthma exacerbations in the urgent care or emergency department. Emergency medical care is necessary for patients with severe symptoms (eg, hypoxemia, difficulty speaking, use of accessory muscles, reduction in peak expiratory flow >50% from baseline); however, those with mild symptoms, such as this patient, can be treated on an outpatient basis (Choice E). Patients treated promptly with a short course of systemic corticosteroids have fewer future exacerbations requiring hospitalization and have improved long-term asthma control. The optimal dosage and duration of corticosteroid therapy are not strictly defined; however, general recommendations are prednisone 40-60 mg daily for 5-10 days. (Choice A) Inhaled, long-acting muscarinic antagonists (LAMAs) (eg, tiotropium) are chronic controller agents recommended for asthma step-up therapy in patients with inadequate response to a scheduled inhaled corticosteroid and beta agonist. They are not used to treat acute exacerbations. LAMA monotherapy is preferred as initial treatment for most patients with chronic obstructive pulmonary disease (COPD). asthma step-up therapy (Choice B) Chest x-rays are not routinely obtained during an asthma exacerbation unless there is evidence of a superimposed cardiopulmonary condition such as pneumonia (eg, fever, purulent sputum, crackles, egophony). Nasal congestion, mildly productive cough, and myalgia are consistent with a viral upper respiratory infection; in this situation, chest x-ray would likely be unrevealing. (Choice C) Macrolide antibiotics (eg, azithromycin) are beneficial for certain patients with acute exacerbations of COPD, partially because they dampen neutrophil-mediated airway inflammation. In multiple clinical trials, macrolides had no benefit for acute asthma exacerbations, which are driven by eosinophil-mediated airway inflammation. Educational objective: A short course of systemic corticosteroids is indicated for outpatient treatment of 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 a widely adopted regimen. References: Treatment for acute asthma in the emergency department: practical aspects. (http://www.ncbi.nlm.nih.gov/pubmed/20391960) Management of acute asthma exacerbations. (http://www.ncbi.nlm.nih.gov/pubmed/21766754)

A 46-Year-Old Man Comes to the Office Due to a 3-Day