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 (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), leucocytosis (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 leucocytosis (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 (7.5 mmol/L) 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:

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