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MKSAP 19 "Quiz Me!" Question: Answer and Critique

Answer

C: Prednisone, 5-day course

Educational Objective

Treat an asthma exacerbation.

Critique

The most appropriate management for this patient with an asthma exacerbation is to start a 5-day course of prednisone (Option C). Asthma exacerbation is an acute worsening of symptoms or lung function from baseline that necessitates a step up in therapy. Prompt recognition and treatment of asthma exacerbations are needed to relieve symptoms and prevent hospitalizations. All patients with asthma should have a written asthma management plan that helps them recognize the symptoms of an exacerbation and begin self-treatment. If symptoms do not improve with self-treatment, evaluation is appropriate. Clinicians should screen for patient factors that contribute to an increased risk of death from asthma and should counsel patients appropriately. Important risk factors include a history of near-fatal asthma attack or intubation; an emergency department or hospital visit in the last 12 months; poor asthma medication adherence or not using inhaled glucocorticoid; current or recent treatment with an oral glucocorticoid; psychosocial stressors or psychiatric disease; food allergy; and overuse of a short-acting β2-agonist. On physical examination, signs of a severe asthma exacerbation that should prompt aggressive intervention and hospitalization include being unable to speak in full sentences; use of accessory muscles of respiration; respiration rate greater than 30/min, heart rate greater than 120/min; oxygen saturation less than 90% with the patient breathing ambient air; and agitation, confusion, or drowsiness. This patient does not have any signs of or risk factors for a severe asthma exacerbation; therefore, she can be safely managed as an outpatient. The best next step is to begin an oral glucocorticoid such as prednisone for a period of 5 to 7 days.

Asthma exacerbations do not require antibiotics (Option A) unless other signs suggestive of infection, such as fever, are present.

Patients such as this one with low risk for a severe asthma exacerbation can be treated with a 5- to 7-day course of prednisone. A 14-day course of prednisone (Option D) is unnecessarily long, and intravenous glucocorticoids, such as methylprednisone, followed by a course of prednisone (Option B) is also excessive and unnecessary.

The patient has already stepped up her maintenance therapy without resolution of her symptoms; therefore, changing her therapy from budesonide to budesonide-formoterol (Option E) is unlikely to be effective.

Key Points

All patients with asthma should have a written asthma management plan that helps them recognize the symptoms of an exacerbation and begin self-treatment.

Patients with an asthma exacerbation who continue to have symptoms after self-treatment should be treated with an oral glucocorticoid.

Bibliography

Fergeson JE, Patel SS, Lockey RF. Acute asthma, prognosis, and treatment. J Allergy Clin Immunol. 2017;139:438-447. PMID: 27554811 doi:10.1016/j.jaci.2016.06.054

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