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Posted March 14, 2025INTRACTABLE ASTHMA IN 72 YEAR LADY
Case Report: Nocturnal Exacerbation of Intractable Asthma
Introduction
Intractable asthma in elderly patients poses significant management challenges due to comorbidities, polypharmacy, and heightened susceptibility to infections. This case highlights a 72-year-old woman with poorly controlled asthma exacerbated by bronchitis and sinusitis, complicated by a transient nocturnal respiratory event despite aggressive therapy.
Case Presentation
Demographics
Age/Gender: 72-year-old female
Medical History: Asthma, hypertension, lobectomy (past)
Medications: Losartan 50 mg/day for hypertension
Presentation
The patient presented with an asthma exacerbation unresponsive to:
Ventolin inhaler (2 puffs BID)
Pulmocort (budesonide 2 puffs BID)
Ipratropium + Ventolin nebulizer every 12 hours
Initial Workup
BP: 135/80 mmHg (on losartan)
Labs: Elevated urea (7.5 mmol/L), leukocytosis (12.3 × 10³/µL), neutrophilia, elevated rheumatoid factor
Imaging: Normal chest X-ray (prior to admission)
Diagnosis
Intractable asthma secondary to bronchitis and sinusitis
Treatment Initiated
Bronchodilators: Ventolin increased to 2 puffs QID; added Symbicort (budesonide/formoterol) 2 puffs BID
Antibiotics: Cefuroxime 500 mg BID (for bacterial bronchitis/sinusitis)
Anti-inflammatory: Prednisolone 40 mg BID
Adjuncts: Montelukast 10 mg daily
Nocturnal Event
On day 3, she developed sudden-onset dyspnea lasting 5 hours overnight, resolving spontaneously by morning.
Investigations
Echocardiogram (2 weeks prior): Normal ejection fraction, right atrial pressures, and valve function
Pulse Oximetry: 98% (no hypoxemia)
Repeat Labs: Persistent leukocytosis (12.3 × 10³/µL) and neutrophilia
Differential Diagnosis for Nocturnal Event
Asthma Exacerbation: Nocturnal worsening of airway inflammation/bronchospasm
Infection-Related: Mucus plugging from unresolved bronchitis/sinusitis
Dehydration/Secretions: Elevated urea indicating dehydration ? thickened airway secretions
Environmental Triggers: Allergen/irritant exposure (e.g., dust mites, cold air)
Management Adjustments
Increased oral fluid intake to reduce mucus viscosity
Sputum culture/sensitivity ordered; cefuroxime continued pending results
Added tiotropium (LAMA) for nocturnal bronchospasm
Serial peak expiratory flow (PEF) measurements
Outcome
Symptoms resolved after 5 hours; no recurrence with adjusted therapy
Follow-up sputum culture confirmed bacterial infection sensitive to cefuroxime
Discharged on tapered prednisolone, continued Symbicort, montelukast, and tiotropium
Discussion
This case underscores the complexity of managing intractable asthma in older adults. Key insights include:
Nocturnal asthma exacerbations are linked to circadian variations in airway inflammation
Infections (bronchitis/sinusitis) perpetuate mucus production and airway obstruction
Dehydration is a modifiable risk factor for mucus plugging
Multimodal therapy (anti-inflammatory, bronchodilators, hydration) is critical in refractory cases
Final Diagnosis
Nocturnal asthma exacerbation secondary to bronchitis, sinusitis, and dehydration-induced mucus plugging
Author
Dr. Abunyewa, M.D M.B ChB MSc MIS MACDA MACPM MACP, Preventive Health Institute
Date: 14th March 2025