How do I treat a 21-year-old male with a 1-month history of productive cough, prominent airways, bronchial wall thickening, and borderline hyperinflation on chest X-ray (CXR), suggestive of airway disease, possibly bronchitis or asthma?

Treatment of Productive Cough with Airway Disease in a Young Adult

For a 21-year-old male with a 1-month productive cough and CXR findings suggestive of airway disease (bronchitis or asthma), inhaled corticosteroids should be initiated as first-line therapy, with consideration of adding a long-acting beta-agonist if symptoms persist. 1

Initial Assessment and Diagnosis

The patient presents with:

• 1-month history of productive cough
• CXR showing prominent airways bilaterally (L>R)
• Bronchial wall thickening in superior right hilum
• Borderline hyperinflation suggesting possible reactive airway disease/asthma

This clinical picture is most consistent with either:

1. Cough-variant asthma
2. Non-asthmatic eosinophilic bronchitis (NAEB)
3. Acute bronchitis with possible underlying reactive airway disease

Treatment Algorithm

Step 1: First-Line Therapy

• Initiate inhaled corticosteroids (ICS) 1, 2
  • Medium-dose ICS (e.g., fluticasone 250 mcg twice daily)
  • This addresses the underlying airway inflammation regardless of whether the diagnosis is asthma or NAEB

Step 2: If Incomplete Response After 2-4 Weeks

• Add long-acting beta-agonist (LABA) 1, 3
  • Consider combination ICS/LABA inhaler (e.g., fluticasone/salmeterol)
  • This provides both anti-inflammatory and bronchodilator effects
  • Combination treatment with ICS and LABA provides greater asthma control than increasing ICS dose alone 3

Step 3: For Persistent Symptoms

• Consider stepping up ICS dose and adding leukotriene inhibitor 1
• Re-evaluate for alternative causes of cough 1
  • Assess for upper airway cough syndrome, GERD
  • Consider bronchial challenge testing to confirm asthma diagnosis

Evidence-Based Rationale

The CHEST guidelines strongly recommend ICS as first-line treatment for both asthma and NAEB (Grade 1B for asthma, Grade 2B for NAEB) 1. The evidence supporting this approach is particularly strong for asthma.

For asthma-related cough, the addition of a LABA to ICS therapy provides superior control compared to increasing ICS dose or adding leukotriene modifiers 3. This combination addresses both inflammatory and bronchoconstrictive components of airway disease 3, 4.

Studies show that salmeterol combined with ICS produces additional reductions in pro-inflammatory cells and cytokines compared to ICS alone, which may explain the improved control of symptoms 4.

Important Considerations

• Avoid antibiotics unless there are clear signs of bacterial infection, as most cases of acute bronchitis are viral and self-limiting 5
• Assess for triggers that may exacerbate symptoms, including occupational exposures 2, 6
• Monitor response to therapy - improvement with corticosteroids supports an eosinophilic inflammatory process 2, 7
• Consider spirometry and/or bronchial challenge testing to definitively diagnose asthma if symptoms persist

Pitfalls to Avoid

• Don't assume bacterial infection without clear evidence - overuse of antibiotics is common in bronchitis management 5
• Don't delay anti-inflammatory treatment - both asthma and NAEB respond well to ICS therapy 1
• Don't miss other causes of chronic cough if symptoms persist despite appropriate therapy 1
• Don't overlook the need for follow-up to assess treatment response and adjust therapy accordingly

This approach prioritizes treating the underlying inflammation while providing symptomatic relief, with the goal of preventing progression to persistent airflow obstruction and improving quality of life.