Cough-Variant Asthma - Are we missing the diagnosis?

in MED-HIVE9 months ago (edited)

For the past month or so, I have been increasingly seeing patients who are presenting with a "refractory" dry cough.

Before we proceed further, full disclaimer - I am still a junior doctor in internal medicine specialist training.

So back to the cough patients, almost all of them have already seen a few professors or senior consultants - there were notably a few who had even taken ENT consultation. But to no avail - the symptomatic management (aka Cough syrups, anti-histamines) gives relief for a couple of days and then the cough recurs.

I look at all the prescriptions from all these higher centers and I start to break a sweat. This is going to be tough, I think to myself. What was I going to do when much, much senior doctors couldn't!

On further history taking the patients almost exclusively reveal the cough occurs at night. Okay now we're getting somewhere. There is diurnal variation to their symptoms. Diurnal respiratory symptoms almost exclusive indicate Asthma - even if the patient complains of NO breathlessness. I am stubborn and tend to not accept any other explanation until we have excluded Asthma - I have gotten into debates with my professors on this as well.

The thing with cough variant asthma is, the cough is usually so troublesome that the patients do not mention minor breathlessness if any. But we'll see if we start close-ended questions 8 out of 10 patients will in fact complain of some degree of breathlessness - again, worst at night.

After I have reached this point, there's only one thing left to do - I put the stethoscope on the patients' chest and auscultate the lung. Guess what I found 100% of the time - yep, Ronchi! Textbook Asthma!

Interestingly though, the management is usually similar whether the patient has breathlessness or not - a short course of oral steroid plus inhalers as add-ons depending which step of Asthma the patient falls under. But to ensure adherence to treatment it is of utmost importance that we explain the condition to the patient. Because let me tell you, all the patients will be wondering - I came for a cough and the doctor is giving me Inhalers and no cough syrup? They will quickly drop your prescription in the bin on the way out and find a new doctor!

Another fallacy I noticed is the increasing tendency of doctors to prescribe Montelukast to literally ANY sort of cough! If the patient has a cough, they will have a montelukast in the prescription. We need to ask ourselves, it it really rational?

The only rational use of montelukast starts from the Step 3 of Asthma according to the NICE Guidelines of the United Kingdom.

If your patients' cough isn't responding to traditional anti-tussives (aka cough syrups), think a little outside the box! You'll be surprised!


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  2. Davidson Principles and Practice of Medicine, 23rd Edition


Thanks so much for your post.
For reference purposes can you add a link to some of the sources you spoke off.. such as the nice guidelines and any research article on montelukast and asthma.

Speaking of cough syrups, a few sordid events has been recorded too of how it took the life of some kids in Africa. Most people go to the drug store for the syrup for every kind of cough, but I see it as kill the alarm while the harm is ongoing.

NB. Do consider adding the references as a link at the bottom of your post Sir. To avoid plagiarism strikes.

Ah right, here you go - this is the nice guideline.

And most of the information is also available in the book "Davidson Principles and Practice of Medicine"

Most people go to the drug store for the syrup for every kind of cough

Yeah I agree, this is turning out to be a very bad practice, especially when the pharmacys start handing out antibiotics without doctor's prescription.

NB. Do consider adding the references as a link at the bottom of your post Sir. To avoid plagiarism strikes.

Noted. But I only very rarely cite directly from any sources when I am writing - that takes the fun out of the writing. My style of writing is usually very, very casual - stuff you'd never read in a medical book or a typical science article :D The information is universal of course, I mean no matter how casually I write the treatment of asthma will remain the same 😉

Hehe.. yeah.. but the admins kinda want to have some form of control of information where seemingly scientific post, even tho we love the casualty you bring in there. We can be assured our readers will enjoy the post and also for continuing education for the other professionals on here.

I am well familiar with Davidson text book too. A great text

It can be cited too, just for further reads.

I just found your statement of being a resident.. That's cool.

but the admins kinda want to have some form of control of information where seemingly scientific post

Yep, I respect that and have added the resources!

Thanks so much. I really love that. Do find time to join the prompt for visual and eye Care too..

It's time to follow along with our health weekly discussion around the theme of the month,which is VISION AND EYE HEALTH

Hola @simplifylife encantada de estar aquí. Gracias por aportar a nuestra comunidad, por expresar y plasmar a través de tu escrito esta experiencia, es valiosa para todos. Es muy acertada tu opinión, por mucho que nos formen los textos, es perentorio, exigente y obligatorio individualizar a cada paciente. Es necesario combinar la teoría (experiencia de otros demostrada científicamente) con la práctica (que es nuestra experiencia bien llevada). Cada paciente es un mundo en su existencia, una individualidad, cargada de una inmunidad que a veces actúa a su manera. Con esto quiero decir que la terapia que funciona para un paciente no es necesariamente la adecuada para otro. Me alegro como médico de tus análisis y reflexiones, refuerzan tu pensamiento y te hacen especial.
Te estás formando en una especialidad médica apasionante, como es la Medicina Interna, que te permite una visión global de la persona enferma, asociada a todas sus entidades nosológicas que otras especialidades no te proporcionan. Es una especialidad llena de beneficios para la investigación y de grandes aportaciones a nuestra medicina. Tus escritos así lo denotan. Felicitaciones.
Te invito respetuosamente a nuestra convocatoria semanal y mensual, nos gustaría conocer tus opiniones y experiencias al respecto.
Feliz semana para ti y los tuyos.

Hi @simplifylife nice to be here. Thank you for contributing to our community, for expressing and expressing through your writing this experience, it is valuable for everyone. It is very accurate your view, no matter how much we are trained in the texts, it is peremptory, demanding and mandatory to individualize each patient. It is necessary to combine the theory (experience of others scientifically proven) with the practicum (which is our experience well conducted). Each patient is a world in its existence, an individuality, loaded with an immunity that sometimes acts in its own way. By this I mean that the therapy that works for one patient is not necessarily the right one for another. I am glad as a physician for your analysis and thoughts, it strengthens your thinking and makes you special.
You are training in an exciting medical specialty, such as Internal Medicine, which allows you a global vision of the sick person, associated with all its nosological entities that other specialties do not provide. It is a specialty full of benefits for research and great contributions to our medicine. Your writing denotes it. Congratulations.
I respectfully invite you to our weekly and monthly call, we would like to know your opinions and experiences in this regard.
Happy week to you and yours.

Yes, you are absolutely correct. We are entering into an era of more tailored prescribing for individual patients. I think it is time we start to move away from template management plans for every patient with the same diagnosis. And it is already happening in countries like the United Kingdom.

Internal Medicine is indeed fun, broadens the concept and approach to a patient!

Thinking outside the box is needed in the medical field, and one should be ready to improvise instead of sticking always to what is there, you never know what experience improvising may bring in.

Indeed, we have been left quite surprised at times the outcomes of thinking outside the box has brought in the wards!

It is a great adventure and knowledgeable all in one☺☺

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