What is the appropriate management for a patient with right lung pain, a history of asthma, orthopnea (shortness of breath when laying down), and a persistent cough lasting over 2 weeks?

Immediate Management of Right Lung Pain with Asthma History and Persistent Cough

This patient requires an urgent chest X-ray to exclude pneumonia, pneumothorax, pulmonary embolism, or other serious pathology before proceeding with any empiric treatment algorithm. The combination of unilateral lung pain, orthopnea, and persistent cough in an asthma patient represents a red flag that demands imaging before assuming this is simply uncontrolled asthma. 1

Critical Initial Assessment

Obtain a chest radiograph immediately to exclude:

• Pneumonia (fever, focal consolidation, productive sputum)
• Pneumothorax (sudden onset sharp pain, decreased breath sounds)
• Pulmonary embolism (pleuritic chest pain, orthopnea, tachycardia)
• Congestive heart failure (orthopnea is a classic symptom)
• Masses or structural abnormalities
• Interstitial lung disease 1

The presence of orthopnea (shortness of breath when lying down) is particularly concerning as this is not a typical feature of uncomplicated asthma or cough variant asthma, and strongly suggests either cardiac pathology or significant pulmonary disease requiring immediate evaluation. 2

If Chest X-Ray is Normal: Systematic Treatment Algorithm

Step 1: Evaluate and Optimize Asthma Control (First Priority)

Given the known asthma history, initiate or intensify inhaled corticosteroid (ICS) therapy immediately as the foundation of treatment. 2

Start with:

• Inhaled corticosteroid at moderate-to-high dose
• Short-acting beta-agonist (SABA) for rescue use
• Response to bronchodilators typically occurs within 1 week, but complete cough resolution may take up to 8 weeks 1

Clinical indicators suggesting asthma as the cause:

• Cough worsening at night
• Cough triggered by cold air exposure or exercise
• Wheezing or chest tightness 2, 3

If spirometry is available and shows normal or near-normal values (FEV1 >70% predicted), perform bronchoprovocation challenge testing (methacholine challenge) to confirm airway hyperresponsiveness, as this is more sensitive than bronchodilator reversibility testing for cough variant asthma. 2 However, a negative bronchoprovocation test excludes asthma but does not rule out steroid-responsive cough (such as eosinophilic bronchitis). 2

Step 2: If Asthma Treatment Fails After 2 Weeks - Add Upper Airway Cough Syndrome (UACS) Treatment

Begin empiric therapy with a first-generation antihistamine-decongestant combination (such as brompheniramine/pseudoephedrine) for 1-2 weeks. 2, 1

Look for clinical pointers:

• Nasal discharge or congestion
• Throat clearing sensation
• Postnasal drip 1

Typical response time is noticeable improvement within days to 1-2 weeks, with complete resolution taking several weeks to months. 2

Step 3: If Both Asthma and UACS Treatments Fail - Initiate GERD Therapy

Start high-dose proton pump inhibitor (PPI) therapy twice daily along with:

• Dietary modifications (avoid caffeine, alcohol, chocolate, fatty foods)
• Lifestyle changes (elevate head of bed, avoid eating 3 hours before bedtime)
• Consider adding nocturnal H2-antagonist for full acid suppression 2, 1

Critical caveat: GERD-related cough requires patience—response may take 2 weeks to several months, with some patients requiring 8-12 weeks before improvement. 1 The evidence shows PPIs improve cough in only 36-57% of patients when given for 8 weeks, despite older literature suggesting 75-100% response rates. 2

Step 4: For Refractory Cough Despite Above Treatments

If cough persists despite adequate trials of ICS, UACS treatment, and GERD therapy:

Consider adding leukotriene receptor antagonist (LTRA) such as zafirlukast or montelukast, which has demonstrated efficacy even in patients whose cough was refractory to inhaled steroids and bronchodilators. 2

For severe refractory cases:

• Short course of oral prednisone 30 mg daily for 2 weeks 2
• If no response, cough is unlikely due to eosinophilic airway inflammation and alternative diagnosis should be considered 2

Advanced Diagnostic Testing (Only After Adequate Therapeutic Trials)

Proceed to advanced testing only after 8+ weeks of persistent cough despite systematic treatment trials: 1

• High-resolution CT chest (evaluate for bronchiectasis, interstitial lung disease, occult masses)
• 24-hour esophageal pH monitoring (if empiric GERD therapy failed)
• Bronchoscopy (evaluate for endobronchial lesions, eosinophilic bronchitis, sarcoidosis) 2, 1

Critical Pitfalls to Avoid

Do not assume this is simply uncontrolled asthma without imaging. The unilateral lung pain and orthopnea are atypical for uncomplicated asthma and demand exclusion of serious pathology first. 1

Do not treat with antibiotics reflexively. Persistent cough in asthma patients is typically due to inadequate anti-inflammatory control, not bacterial infection. 4

Do not prescribe benzodiazepines for anxiety without first optimizing asthma controller therapy, as beta-agonist side effects may be contributing to anxiety symptoms. 5

Recognize that chronic cough is frequently multifactorial—it is not uncommon to find two or even all three common causes (UACS, asthma, GERD) present simultaneously, and cough will not resolve until all contributing factors are effectively treated. 2

Do not miss the 3-week and 8-week thresholds that change diagnostic approach: cough 3-8 weeks suggests post-infectious cough (treat with inhaled ipratropium); cough >8 weeks is chronic cough requiring systematic evaluation. 1, 4