Should patients with asthma and mild bronchitis who have no wheeze and good air entry be given inhaled corticosteroids, such as fluticasone (fluticasone), for treatment?

Should Patients with Asthma and Mild Bronchitis Receive Steroids Without Wheeze or Good Air Entry?

Yes, patients with asthma should receive inhaled corticosteroids even in the absence of wheeze and with good air entry, as asthma can present with minimal or no audible wheeze (cough variant asthma), and inhaled corticosteroids remain the first-line treatment for persistent asthma regardless of physical examination findings. 1

Clinical Reasoning for Treatment

Asthma Without Wheeze is Common and Requires Treatment

• Cough variant asthma (CVA) presents as chronic cough without wheeze or dyspnea, yet still requires inhaled corticosteroid therapy as first-line treatment. 1
• The absence of wheeze on examination does not exclude significant airway inflammation or the need for anti-inflammatory therapy. 1
• Physical examination findings in asthma are often non-diagnostic, and normal lung sounds do not rule out underlying eosinophilic inflammation requiring corticosteroid treatment. 1

Inhaled Corticosteroids as First-Line Therapy

• For adult and adolescent patients with chronic cough due to asthma as a unique symptom, inhaled corticosteroids should be considered as first-line treatment (Grade 1B). 1
• Low-dose inhaled corticosteroids (such as fluticasone 100-250 mcg/day equivalent) administered twice daily are the most effective single long-term controller medication for persistent asthma. 2
• Inhaled corticosteroids improve symptom scores, lower exacerbation rates, reduce symptom frequency, and decrease the need for rescue medications compared to other single long-term control medications. 1

Dosing Strategy

Initial Treatment Approach

• Start with low-dose inhaled corticosteroids (fluticasone 100-250 mcg/day or equivalent) administered twice daily. 2
• For fluticasone specifically, this translates to approximately 88-110 mcg twice daily via metered-dose inhaler. 2
• Use a spacer device to enhance lung deposition and reduce local side effects, and have the patient rinse their mouth after each use. 3

Step-Up Therapy if Inadequate Response

• If response is incomplete after 4-6 weeks, step up the inhaled corticosteroid dose and consider adding a leukotriene inhibitor after reconsidering alternative causes of cough. 1
• Beta-agonists can also be considered in combination with inhaled corticosteroids. 1
• For patients ≥12 years with inadequate control on low-dose inhaled corticosteroids, adding a long-acting beta-agonist (LABA) is the preferred adjunctive therapy rather than simply increasing the corticosteroid dose. 1, 2

Important Considerations for "Mild Bronchitis"

Distinguishing Asthma from Chronic Bronchitis

• The term "mild bronchitis" in a patient with known asthma likely represents an asthma exacerbation or poorly controlled asthma rather than a separate condition. 1
• In patients with chronic bronchitis without asthma (COPD spectrum), short-term inhaled corticosteroids (4 weeks) do not significantly improve lung function or inflammatory parameters. 4
• However, if the patient has established asthma, the presence of concurrent bronchitic symptoms does not negate the need for inhaled corticosteroid therapy. 1

Role of Biomarkers

• Non-invasive measurement of airway inflammation (such as sputum eosinophils or fractional exhaled nitric oxide) has clinical utility, and the presence of eosinophilic airway inflammation is likely to be associated with a more favorable response to corticosteroids (Grade 2B). 1
• If available, measuring eosinophilic inflammation can help predict corticosteroid responsiveness, though treatment should not be delayed awaiting these results in symptomatic patients. 1

Common Pitfalls to Avoid

• Do not withhold inhaled corticosteroids based solely on the absence of wheeze on physical examination. Asthma can present without audible wheeze, particularly in cough variant asthma. 1
• Do not use short-acting beta-agonists alone as long-term management. Using rescue inhalers more than 2 days per week for symptom relief indicates inadequate control and the need to initiate or intensify anti-inflammatory therapy. 1, 2
• Ensure proper inhaler technique before concluding treatment failure, as poor technique is a common cause of apparent lack of response. 2
• Never use long-acting beta-agonists as monotherapy without inhaled corticosteroids, as this increases the risk of asthma exacerbations. 1, 2

Monitoring and Reassessment

• Reassess asthma control every 2-6 weeks initially after starting treatment. 2, 3
• If no clear benefit is observed within 4-6 weeks, reconsider alternative diagnoses or step up therapy. 1, 2
• Monitor for local side effects including oral candidiasis, dysphonia, and cough, which can be minimized with proper spacer use and mouth rinsing. 3, 5