How should I treat a patient with newly‑onset reactive airway disease presenting with acute wheezing, cough, and shortness of breath after a viral upper‑respiratory infection?

Treatment of New-Onset Reactive Airway Disease After Viral Upper Respiratory Infection

For a patient with new-onset reactive airway disease presenting with acute wheezing, cough, and shortness of breath after a viral URI, initiate inhaled bronchodilators (albuterol) and inhaled corticosteroids immediately, with complete resolution potentially requiring up to 8 weeks of treatment. 1

Initial Assessment & Diagnosis

Confirm the diagnosis by documenting reversible airflow obstruction on spirometry or, if spirometry is normal, perform methacholine challenge testing to demonstrate bronchial hyperresponsiveness consistent with asthma. 1 However, recognize that bronchial hyperresponsiveness alone does not confirm asthma—definitive diagnosis requires documented resolution of symptoms with specific antiasthmatic therapy. 1

Key clinical features to identify:

• Viral URI symptoms (fever, fatigue, dry cough, nasal congestion) that preceded the reactive airway symptoms by days to weeks 1
• Wheezing, dyspnea, and cough that persist beyond the acute viral phase 1
• Physical examination may reveal shortness of breath, wheezing, or may be entirely normal 1
• Absence of purulent sputum, fever, or lung crackles that would suggest bacterial pneumonia 2

First-Line Pharmacologic Treatment

Initiate standard antiasthmatic therapy immediately:

• Inhaled short-acting beta-agonist (albuterol): 2 puffs every 4-6 hours as needed for acute symptom relief 1
• Inhaled corticosteroids: Fluticasone 220 mcg or budesonide 360 mcg twice daily 1, 2
  • Partial improvement typically occurs within 1 week 1
  • Complete resolution may require up to 8 weeks of continuous treatment 1

Critical pitfall to avoid: Some inhaled corticosteroid formulations (particularly beclomethasone dipropionate) may paradoxically induce cough due to aerosol dispersants; if this occurs, switch to triamcinolone acetonide or another formulation. 1

Escalation for Severe or Refractory Symptoms

For severe symptoms or inadequate response to inhaled therapy:

• Oral prednisone 40 mg daily (or equivalent) for 1 week, followed by transition to inhaled corticosteroids 1
• Before escalating, exclude:
  • Improper inhaler technique 1
  • Inhaled steroid-induced cough 1
  • Coexisting conditions (gastroesophageal reflux disease, upper airway cough syndrome) that make asthma difficult to control 1

Adjunctive Therapy for Post-Infectious Cough Component

If prominent cough persists despite bronchodilator therapy:

• Inhaled ipratropium bromide: 2-3 puffs (17-34 mcg per puff) four times daily 1, 2
  • This has the strongest evidence for attenuating post-infectious cough 2
  • Expected response within 1-2 weeks 2
  • Can be mixed in nebulizer with albuterol if used within one hour 3

What NOT to Do

Antibiotics are explicitly contraindicated unless there is documented bacterial sinusitis or early pertussis infection—they provide no benefit for viral-triggered reactive airway disease and contribute to antimicrobial resistance. 1, 2, 4

Do not use oral corticosteroids as first-line therapy when inhaled corticosteroids have not been tried, as this exposes patients to unnecessary systemic side effects. 1

Monitoring & Follow-Up

Reassess at 1-2 weeks to evaluate response to inhaled therapy. 1 If symptoms persist beyond 8 weeks, reclassify as chronic cough and systematically evaluate for:

• Upper airway cough syndrome (UACS) 1, 2
• Persistent asthma requiring long-term controller therapy 1
• Gastroesophageal reflux disease 1, 2

Perform spirometry at initial assessment, after symptoms stabilize to document attainment of normal airway function, and at least every 1-2 years to monitor for decline in pulmonary function. 1

Special Considerations

Distinguish from post-viral bronchial hyperreactivity syndrome: This condition mimics asthma but resolves spontaneously within 3 weeks to 3 months after viral infection. 5 If symptoms persist beyond 3 months or recur with subsequent viral infections, the diagnosis is more consistent with true asthma requiring long-term management. 5

Consider pertussis if cough is accompanied by paroxysms, post-tussive vomiting, or inspiratory whooping sound—early macrolide therapy is indicated when pertussis is confirmed. 1, 2

Recognize that viral respiratory infections cause extensive desquamation of airway epithelium, widespread inflammation, and transient bronchial hyperresponsiveness that can persist for weeks to months. 1 This explains why aggressive anti-inflammatory therapy is required even after the acute viral illness has resolved. 1