How to manage and prevent asthma attacks in a 14-year-old boy with a 5-month history of asthma presenting with a dry cough?

Management of Dry Cough in a 14-Year-Old Known Asthmatic

For a 14-year-old asthmatic boy with a 5-month history of dry cough, inhaled corticosteroids (ICS) should be used as first-line treatment, with a stepwise approach to therapy if symptoms persist. 1

Initial Assessment

• Confirm that asthma is the cause of the dry cough:

  • Check for symptoms/signs of asthma and/or reversible airway obstruction
  • Perform spirometry (if available) to assess lung function and reversibility
  • Consider chest radiograph to rule out other causes 2

• Evaluate potential triggers:

  • Environmental tobacco smoke and other pollutants
  • Allergens or occupational sensitizers
  • Viral infections
  • Exercise
  • Environmental irritants 1

Treatment Algorithm

Step 1: First-Line Treatment

• Start with low-dose inhaled corticosteroids (ICS) as controller medication
• Provide short-acting beta-agonist (SABA) like albuterol for rescue therapy 1
• Albuterol should not be used more frequently than recommended (typically every 4-6 hours as needed) 3

Step 2: If Response is Incomplete After 4-8 Weeks

• Increase the inhaled corticosteroid dose 1
• Consider adding montelukast (leukotriene receptor antagonist) 1
• Montelukast should be taken once daily in the evening 4

Step 3: If Symptoms Persist

• Add long-acting beta-agonists (LABAs) in combination with ICS 1
• Reassess in 2-4 weeks 2

Step 4: For Severe, Persistent Cough Despite Optimal Therapy

• Consider a short course of oral corticosteroids (prednisone 40mg/day for 5-10 days) 1
• Consider referral to a pediatric pulmonologist if symptoms persist after 4 weeks of appropriate therapy 2

Prevention of Asthma Attacks

1. Identify and avoid triggers:

   • Remove exposure to tobacco smoke and other pollutants
   • Minimize exposure to allergens if sensitized
   • Avoid known irritants 1

2. Medication adherence:

   • Take controller medications daily as prescribed
   • Do not stop taking medications even when feeling well 4
   • Use proper inhaler technique

3. Written action plan:

   • Document when to increase therapy for worsening symptoms
   • Specify when to seek medical help 1

Important Considerations

• Complete resolution of cough may require up to 8 weeks of treatment 1
• Do not use SABA alone for long-term management of asthma 1
• Monitor for overreliance on rescue inhalers, which indicates poor control 1
• If cough persists despite optimal therapy, consider additional testing to confirm diagnosis 1

Common Pitfalls to Avoid

• Undertreatment: Inadequate step-up in therapy when control is poor leads to worse outcomes 1
• Overreliance on SABAs: Frequent use indicates poor control and need for controller medication 1
• Delayed response expectations: Improvement may take several weeks 1
• Ignoring comorbidities: Upper airway cough syndrome, gastroesophageal reflux disease, and non-asthmatic eosinophilic bronchitis can contribute to persistent cough 1
• Poor adherence: This is a common reason for poor response to therapy 5

By following this stepwise approach to management and prevention, the majority of asthmatic children with chronic dry cough can achieve good symptom control and prevent future exacerbations.