Management of Persistent Asthma with Chest Tightness Despite Current Treatment

Assessment and Immediate Management

The American Thoracic Society recommends that a patient with bronchial asthma on combination therapy with fluticasone/salmeterol and as-needed albuterol who has chest tightness and limited response to prednisone, should have their treatment escalated with the addition of a short-acting muscarinic antagonist and consideration of hospitalization if symptoms persist 1, 2
The British Thoracic Society indicates that the limited response to prednisone 50mg in a patient with asthma suggests a potentially severe exacerbation that requires escalation of therapy 2, 3

The National Asthma Education and Prevention Program suggests that short-acting muscarinic antagonists, such as ipratropium, provide additional bronchodilation through a different mechanism than beta-agonists and can be added to the current bronchodilator regimen 1, 2
The Global Initiative for Asthma recommends increasing the frequency of short-acting beta-agonist to every 15-20 minutes for the first hour in patients with severe exacerbations 2, 4

The American College of Chest Physicians recommends hospitalization for patients with persistent chest tightness or other symptoms of acute severe asthma, peak expiratory flow (PEF) <50% of predicted or best value, oxygen saturation <92% on room air, or inability to complete sentences in one breath 2, 4
The European Respiratory Society suggests that if symptoms improve significantly with initial management, patients can be managed as outpatients with continued prednisolone, increased dose of fluticasone/salmeterol, and addition of a leukotriene modifier, along with provision of a peak flow meter and written asthma action plan 1, 5

The British Thoracic Society recommends ensuring the patient sees their primary care provider within 1 week, arranging specialist respiratory review within 1 month, monitoring symptoms and peak flow readings twice daily, and evaluating the need for stepping up long-term controller therapy based on the frequency and severity of symptoms 1, 5