What is the best approach to manage chronic cough, sternum pain, and wheezing in a patient with allergies?

Management of Chronic Cough, Sternum Pain, and Wheezing in Allergic Patients

The best approach to manage chronic cough, sternum pain, and wheezing in a patient with allergies is to initiate treatment with inhaled corticosteroids as first-line therapy, followed by a stepwise approach that includes adding bronchodilators and addressing upper airway causes if symptoms persist.

Initial Assessment and Diagnosis

When evaluating a patient with chronic cough, sternum pain, and wheezing with allergies, consider these key conditions:

1. Asthma/Cough Variant Asthma (CVA):

   • Characterized by cough, wheezing, and chest discomfort
   • May present with normal physical examination and spirometry
   • Sternum pain may represent chest tightness, a common asthma symptom

2. Upper Airway Cough Syndrome (UACS):

   • Common comorbidity in allergic patients
   • Often coexists with asthma

3. Non-Asthmatic Eosinophilic Bronchitis (NAEB):

   • Presents with cough without airflow obstruction or hyperresponsiveness
   • Responds to corticosteroids

Diagnostic Approach

1. Methacholine Challenge Testing:

   • If physical examination and spirometry are normal but asthma is suspected
   • High negative predictive value (essentially excludes asthma if negative) 1

2. Airway Inflammation Assessment:

   • Consider non-invasive measures like sputum eosinophil counts or FeNO
   • Helps identify eosinophilic inflammation that may respond to corticosteroids 1

Treatment Algorithm

Step 1: First-Line Treatment

• Inhaled Corticosteroids (ICS):
  • Start with standard dose ICS for suspected asthma or NAEB 1
  • Complete resolution may require up to 8 weeks of treatment 1
  • For patients with sternum pain and wheezing, ICS addresses the underlying inflammation

Step 2: If Incomplete Response After 4-8 Weeks

• Increase ICS Dose 1, 2
• Add Long-Acting Beta-Agonist (LABA) if symptoms persist 1
• Consider Leukotriene Inhibitor as add-on therapy 1

Step 3: Address Upper Airway Component

• First-Generation Antihistamine/Decongestant (A/D):
  • For patients with concurrent UACS symptoms 1
  • Expect some improvement within 1-2 weeks
  • Complete resolution may take several weeks to months

Step 4: For Persistent Symptoms

• Add Nasal Corticosteroids if nasal symptoms persist 1
• Consider Sinus Imaging if symptoms continue despite treatment 1

Special Considerations

Sternum Pain Management

• Sternum pain in this context is likely related to:

  1. Chest wall muscle strain from coughing
  2. Asthma-related chest tightness
  3. Costochondritis exacerbated by coughing

• The pain typically improves with effective control of the underlying condition

Monitoring and Follow-up

• Assess response after 4-8 weeks of initial therapy
• Use validated tools like the Asthma Control Test (ACT) to monitor symptoms 2
• Consider stepping down therapy once good control is achieved for 3 months

Common Pitfalls to Avoid

1. Inhaler-Induced Cough:

   • ICS may sometimes exacerbate cough due to components in the aerosol 1
   • Consider changing to a different ICS formulation if this occurs

2. Overlooking Multiple Causes:

   • Chronic cough is often multifactorial 1
   • May need to address both asthma and UACS simultaneously

3. Inadequate Treatment Duration:

   • Complete resolution of cough may take up to 8 weeks with ICS 1
   • Avoid premature discontinuation of therapy

4. Missing Non-Asthmatic Eosinophilic Bronchitis:

   • Consider NAEB in patients with normal spirometry and negative methacholine challenge 1
   • Still requires anti-inflammatory treatment with ICS

By following this systematic approach, most patients with chronic cough, sternum pain, and wheezing related to allergies will experience significant symptom improvement. The cornerstone of therapy remains controlling the underlying airway inflammation with appropriate anti-inflammatory medications.