How to manage an 18-year-old asthmatic male (asthma) with a 4-month history of dry cough, currently using salbutamol (albuterol) puffs 2 times a week?

Management of 18-year-old Asthmatic with Persistent Dry Cough

The patient requires step-up therapy with the addition of a daily inhaled corticosteroid (ICS) as controller medication, while continuing salbutamol as needed for symptom relief. 1

Assessment of Current Asthma Control

This patient presents with:

• 4-month history of persistent dry cough
• Known asthmatic
• Currently using salbutamol puffs twice weekly

Based on these findings, the patient has:

• Persistent symptoms (chronic cough for 4 months)
• Regular need for rescue medication (salbutamol)
• Likely inadequate control on current regimen

Management Algorithm

Step 1: Initiate Controller Medication

• Start low-dose inhaled corticosteroid (ICS) as daily controller medication 1
• Continue salbutamol as needed for symptom relief
• Verify proper inhaler technique for both medications 2

Step 2: Follow-up Assessment (2-4 weeks)

• If symptoms improve:
  • Continue current therapy
  • Schedule follow-up in 3 months
• If symptoms persist:
  • Move to Step 3

Step 3: Escalation of Therapy (if needed)

• Increase ICS dose to medium-dose 1
• OR add long-acting beta-agonist (LABA) in combination with ICS
• Consider adding montelukast (leukotriene receptor antagonist) 1

Step 4: Further Management (if needed)

• If symptoms still persist after 4-8 weeks of optimized therapy:
  • Consider referral to pulmonologist
  • Consider additional diagnostic testing to confirm diagnosis or identify comorbidities 1

Specific Medication Recommendations

1. Controller Medication:

   • Low-dose ICS (e.g., beclomethasone, fluticasone, or budesonide) daily
   • Ensure proper inhaler technique and adherence

2. Rescue Medication:

   • Continue salbutamol as needed for symptom relief
   • Monitor frequency of use - increasing use may indicate worsening control

3. Additional Considerations:

   • Provide written asthma action plan
   • Identify and address potential triggers
   • Consider peak flow monitoring

Common Pitfalls to Avoid

• Undertreatment: Relying solely on as-needed salbutamol for persistent symptoms is inadequate 1
• Poor inhaler technique: Ensure patient demonstrates proper technique with all inhalers 2
• Inadequate follow-up: Regular monitoring is essential to assess response to therapy
• Ignoring comorbidities: Consider allergic rhinitis, GERD, or other conditions that may exacerbate cough 1
• Delayed escalation: If symptoms persist despite initial therapy, promptly adjust treatment

Education Points for Patient

• Explain difference between controller and rescue medications
• Emphasize importance of daily controller use even when asymptomatic
• Demonstrate proper inhaler technique
• Discuss potential triggers and avoidance strategies
• Review warning signs that require urgent medical attention

This approach follows current guidelines for asthma management, focusing on achieving symptom control and preventing exacerbations through appropriate step-up therapy.