What is the diagnosis and treatment for a patient presenting with reactive airway disease, wheezing, and acute cough, with potential differential diagnoses including chronic bronchitis, postnasal drip, Angiotensin-Converting Enzyme (ACE) inhibitor-induced cough, Gastroesophageal Reflux Disease (GERD), and seasonal allergies, currently being treated with Pulmicort (budesonide) and albuterol inhaler, and previously taking lisinopril (an ACE inhibitor)?

From the Guidelines

The patient should use Pulmicort 1 puff twice daily as a controller medication and albuterol inhaler as needed for symptoms, and discontinue lisinopril due to borderline low blood pressure, which may also be contributing to the cough, as recommended by the American College of Chest Physicians (ACCP) guidelines 1. For treatment of the acute cough, the patient should also use Flonase and Cetirizine for possible seasonal allergies, and perform nasal saline rinses to help with postnasal drip. The patient's daughter should monitor blood pressure and schedule an appointment if readings exceed 130/80. Avoiding triggers like smoke and pollen is recommended. The patient should return to the clinic today for proper inhaler technique instruction and should seek medical attention for any new or worsening symptoms. This comprehensive approach addresses both the reactive airway disease and the differential diagnoses for the cough, including chronic bronchitis, postnasal drip, ACE inhibitor-induced cough, GERD, and reactive airway disease. Controlling inflammation with Pulmicort and treating allergies with Flonase and Cetirizine will help reduce airway reactivity, while stopping lisinopril eliminates a potential cause of chronic cough. The ACCP guidelines recommend a systematic approach to diagnosing and managing cough, including identifying and treating common causes such as UACS, asthma, and GERD 1. In patients with chronic cough, therapy should be given in sequential and additive steps because more than one cause of cough may be present 1. The guidelines also recommend that patients with a chronic cough who smoke should be counseled and assisted with smoking cessation 1. In a patient with cough who is receiving an ACE inhibitor, therapy with the drug should be stopped and the drug should be replaced 1. The patient's treatment plan should be regularly reviewed and adjusted as needed to ensure optimal management of their reactive airway disease and cough. Key points to consider in the management of the patient's cough include:

• Identifying and treating common causes of cough such as UACS, asthma, and GERD
• Using a systematic approach to diagnosing and managing cough
• Stopping ACE inhibitors in patients with cough
• Counseling and assisting patients with smoking cessation
• Regularly reviewing and adjusting the patient's treatment plan as needed.

From the FDA Drug Label

The therapeutic effects of conventional doses of orally inhaled budesonide are largely explained by its direct local action on the respiratory tract Improvement in the control of asthma symptoms following inhalation of budesonide inhalation suspension can occur within 2 to 8 days of beginning treatment, although maximum benefit may not be achieved for 4 to 6 weeks The patient's symptoms of reactive airway disease with wheezing are being treated with Pulmicort (budesonide) as a controller medication, which is expected to improve symptoms within 2 to 8 days of starting treatment, with maximum benefit achieved in 4 to 6 weeks.

• The patient has been advised to use albuterol inhaler as needed for acute symptoms.
• The patient should use the medication twice a day at regular intervals for optimal effectiveness 2.

From the Research

Treatment of Reactive Airway Disease

• The patient is being treated with Pulmicort, a controller medication, to manage reactive airway disease symptoms 3.
• The use of albuterol inhaler as needed is also recommended to help control symptoms.
• Avoiding potential triggers such as smoke and pollen, and using nasal saline rinses are also advised to help manage symptoms.

Comparison of Inhaler Therapies

• Studies have compared the effectiveness of different inhaler therapies, including budesonide/formoterol and fluticasone/salmeterol 3, 4, 5, 6.
• Results suggest that budesonide/formoterol may be a useful treatment option for patients with asthma, with significant improvements in ACT scores and FeNO levels 3.
• However, other studies have found that fluticasone-based triple therapies may be associated with a lower risk of COPD exacerbations and mortality compared to budesonide-based triple therapies 4.
• Another study found that budesonide-based triple therapy was generally as effective as fluticasone-based triple therapy in reducing exacerbations, but was associated with a lower incidence of severe pneumonia and possibly also of all-cause death 5.

Management of Acute Cough

• The patient's acute cough is being managed with Flonase and Cetirizine for possible seasonal allergies exacerbated by pollen.
• Nasal saline rinses are also recommended to help with postnasal drip.
• The patient has been advised to stop taking lisinopril due to borderline low blood pressures, and to monitor blood pressures closely 3.