What is the best course of treatment for a patient with asthma experiencing increased cough and sputum production?

Management of Asthma with Increased Cough and Sputum Production

For a patient with asthma experiencing increased cough and sputum production, inhaled corticosteroids (ICS) should be initiated or increased as first-line treatment, with the addition of a bronchodilator if symptoms persist.

Assessment of Severity

Before initiating treatment, it's important to assess the severity of the asthma exacerbation:

• Severe exacerbation signs 1:

  • Peak Expiratory Flow (PEF) <50% of predicted
  • Respiratory rate >25 breaths/min
  • Heart rate >110 beats/min
  • Inability to complete sentences in one breath

• Life-threatening signs 1:

  • PEF <33% predicted
  • Silent chest, cyanosis
  • Feeble respiratory effort
  • Altered consciousness

Treatment Algorithm

1. Mild to Moderate Symptoms:

• First step: Initiate or increase inhaled corticosteroids 2

  • For patients already on ICS, step up the dose
  • If this is a new presentation, start ICS at appropriate dose

• Second step: If response is incomplete after 1-2 weeks, add:

  • Leukotriene receptor antagonist 2
  • Consider short-acting beta-agonist (SABA) for symptom relief 2

2. Severe Symptoms:

• Immediate treatment 1:

  • Oxygen therapy (40-60% concentration)
  • Nebulized salbutamol 5 mg or terbutaline 10 mg
  • Systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV)

• If no improvement after 15-30 minutes 1:

  • Add ipratropium bromide 500 μg via nebulizer
  • Consider hospital admission if no response

Evidence-Based Rationale

The 2020 CHEST guidelines specifically state that "inhaled corticosteroids should be considered as first-line treatment" for asthma with cough as a prominent symptom 2. This approach targets the underlying airway inflammation that causes both the cough and sputum production.

While partial improvement may occur within 1 week of bronchodilator therapy, complete resolution of cough may require up to 8 weeks of treatment with inhaled corticosteroids 2. This highlights the importance of patience and persistence with the treatment regimen.

For patients with cough variant asthma (where cough is the predominant symptom), the therapeutic approach should be similar to typical asthma management 2. If the response to ICS is incomplete, the guidelines recommend "stepping-up the inhaled corticosteroid dose and considering a therapeutic trial of a leukotriene inhibitor" 2.

Important Considerations

• Assess for infection: Increased sputum production could indicate a respiratory infection that may require additional treatment

• Rule out other causes: Consider non-asthmatic eosinophilic bronchitis (NAEB) or gastroesophageal reflux disease (GERD) if response to asthma treatment is poor 2

• Potential pitfalls 1:

  • Underestimating severity (always use objective measures like PEF)
  • Delaying corticosteroid administration
  • Overreliance on SABAs without addressing underlying inflammation

• Monitoring response: Repeat assessment of symptoms, PEF, and sputum production is essential to determine if treatment adjustments are needed

Special Situations

• Cough variant asthma: May require longer treatment (up to 8 weeks) with ICS for complete resolution 2

• Steroid-resistant cases: Consider assessment of airway inflammation via induced sputum if available, as persistent eosinophilia may require more aggressive anti-inflammatory therapy 2

• Brittle asthma: May require a written treatment plan developed with a specialist 2

Remember that increased use of rescue medication (more than twice weekly) indicates poor asthma control and should prompt review of maintenance therapy 1.