How to manage a patient with chronic productive cough and asthma?

Management of Chronic Productive Cough in a Patient with Asthma

For this patient with chronic productive cough and a history of asthma, the most appropriate management is to restart inhaled corticosteroid (ICS) therapy along with a short-acting beta-agonist (SABA) as needed, and reassess in 2-4 weeks.

Initial Assessment and Diagnosis

This patient presents with:

• Productive cough lasting over one month
• History of asthma (currently not on treatment)
• Cough disturbing sleep
• Chest pain associated with coughing
• Cold, poorly insulated home environment
• No fever, shortness of breath, or increased work of breathing

Key Considerations

1. Duration of cough: >4 weeks classifies this as chronic cough 1
2. History of asthma: Previously used salbutamol and ICS but not recently
3. Normal vital signs: No fever, normal temperature, normal blood pressure
4. Normal respiratory exam: Good air entry, vesicular breath sounds, no wheeze or crackles

Management Algorithm

Step 1: Address Underlying Asthma

• Restart asthma medications:
  • Inhaled corticosteroid (previously used "orange" inhaler)
  • Salbutamol (blue inhaler) as needed for symptom relief
  • Recommended dose: 2 inhalations of salbutamol every 4-6 hours as needed 2

Step 2: Evaluate for Other Common Causes of Chronic Cough

• Upper Airway Cough Syndrome (UACS):

  • Patient reports occasional itchy eyes but denies rhinorrhea
  • Consider adding first-generation antihistamine/decongestant if nasal symptoms develop 3

• Gastroesophageal Reflux Disease (GERD):

  • If cough persists after addressing asthma, consider empiric treatment 3

Step 3: Environmental Modifications

• Address cold home environment:
  • Explore options for improving home insulation or heating
  • Cold air can trigger asthma symptoms and worsen cough

Step 4: Follow-up and Reassessment

• Schedule follow-up in 2-4 weeks 1
• If cough persists despite treatment, consider:
  • Sputum testing for eosinophils to evaluate for non-asthmatic eosinophilic bronchitis (NAEB) 3
  • Chest radiograph if not improving 1

Evidence-Based Rationale

1. Asthma as primary cause:

   • Asthma is one of the most common causes of chronic cough (25% of cases) 4
   • The patient has a history of asthma but is not currently using medications
   • Cough variant asthma may present with cough as the predominant symptom 4

2. Treatment approach:

   • ACCP guidelines recommend a systematic approach targeting common causes of chronic cough 3
   • For patients with asthma history, inhaled corticosteroids are the first-line treatment 1, 5
   • Studies show that inhaled corticosteroids are effective for long-term control of cough variant asthma 5

3. Avoiding overtreatment:

   • Guidelines recommend against empiric treatment for common adult causes unless features consistent with these conditions are present 1
   • Set time limits for therapeutic trials (2-4 weeks) to confirm or refute diagnoses 1

Important Clinical Pearls

• Do not assume this is a simple continuation of the son's recent illness requiring antibiotics
• Avoid oral corticosteroids as first-line therapy unless symptoms are severe or unresponsive to inhaled therapy
• Monitor for improvement in both daytime and nighttime cough symptoms
• Cough in asthma is associated with poorer asthma control, increased exacerbations, and worse quality of life 6
• Cold environment may be contributing to symptoms and should be addressed as part of comprehensive management

If no improvement occurs after 2-4 weeks of optimal asthma therapy, further investigation including spirometry and consideration of other diagnoses would be warranted.