What is the best course of treatment for a patient with persistent dry chest sensation, chest discomfort, and lung pain, who has been experiencing these symptoms since a certain date and has no cough or mucus production, and is currently on inhaled corticosteroid therapy?

Treatment Approach for Persistent Dry Chest Discomfort and Lung Pain Without Cough

Immediate Diagnostic Consideration

This clinical presentation—persistent chest discomfort and lung pain without cough or mucus production—does NOT fit typical COPD or acute bronchitis patterns, and requires ruling out cardiac, pulmonary embolism, pneumothorax, or pleuritic causes before attributing symptoms to airways disease. 1

The absence of cough is particularly notable, as cough is a cardinal symptom in most obstructive airways diseases. 1

If Airways Disease is Confirmed

Step 1: Verify Current ICS Therapy Effectiveness

Before escalating therapy, you must:

• Confirm proper inhaler technique - this is the most common cause of apparent treatment failure 2
• Assess medication adherence - non-adherence often masquerades as treatment resistance 1
• Review environmental exposures - ongoing irritant exposure undermines ICS efficacy 1

Step 2: Add Long-Acting Bronchodilator to ICS

If symptoms persist despite confirmed adequate ICS use, add a long-acting beta-agonist (LABA) to the existing low-to-medium dose ICS rather than increasing ICS dose alone. 1, 2

• This combination (ICS + LABA) provides superior symptom control compared to doubling ICS dose 1
• Specific regimen: Continue current ICS dose and add salmeterol 50 μg twice daily or equivalent LABA 2
• Never use LABA as monotherapy - this increases risk of severe exacerbations and asthma-related deaths 1, 2, 3

Step 3: Consider Adding Long-Acting Muscarinic Antagonist (LAMA)

If ICS + LABA combination fails to control symptoms after 2-6 weeks:

• Add tiotropium (LAMA) to create triple therapy (ICS + LABA + LAMA) for maximal bronchodilation 1, 4
• Tiotropium improves dyspnea, exercise capacity, and reduces hyperinflation in moderate to severe disease 4
• This stepwise approach (dual then triple therapy) is preferred over jumping directly to triple therapy 1

Step 4: Alternative Add-On Therapies

If triple therapy remains inadequate:

• Add leukotriene receptor antagonist (montelukast or zafirlukast) to the existing regimen 1, 3
• Leukotriene modifiers have shown efficacy in cough previously resistant to bronchodilators and ICS 3
• Consider roflumilast for severe obstruction with chronic bronchitis phenotype and frequent exacerbations 1

Step 5: Short-Term Oral Corticosteroids

Only if all above steps fail, consider a trial of oral prednisone 40 mg daily for 5-10 days to assess steroid responsiveness 1, 3

• This diagnostic/therapeutic trial helps distinguish steroid-responsive from steroid-resistant disease 1
• If effective, transition back to optimized inhaled therapy 3
• Monitor for hyperglycemia, weight gain, insomnia, and immunosuppression 5

Critical Pitfalls to Avoid

• Do not diagnose COPD or asthma based solely on chest discomfort without cough - this atypical presentation warrants cardiac and pulmonary workup first 1
• Do not use LABA monotherapy - always combine with ICS to prevent serious adverse events 1, 2, 3
• Do not prescribe long-term oral corticosteroids for stable disease - serious side effects outweigh benefits 5, 3
• Do not assume treatment failure without verifying inhaler technique - poor technique is extremely common 2

Monitoring and Reassessment

• Reassess response at 2-6 weeks after each therapeutic change 2
• Once stable control achieved for 2-4 months, attempt step-down to minimum effective therapy 2
• Refer to pulmonology if symptoms persist despite triple therapy (ICS + LABA + LAMA) 2

Special Consideration for This Case

The complete absence of cough and mucus production is highly unusual for typical obstructive airways disease. 1 Before attributing these symptoms to airways disease and escalating inhaled therapy, strongly consider:

• Cardiac ischemia or heart failure (especially given "chest discomfort" and "lung pain" descriptors) 1
• Pulmonary embolism
• Pleural disease
• Chest wall or musculoskeletal pain
• Gastroesophageal reflux disease (GERD) presenting as chest discomfort 1

If cardiac and other serious causes are excluded and airways disease confirmed, proceed with the stepwise algorithm above, starting with optimizing current ICS therapy before adding LABA. 1, 2