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Abstract: A 38-year-old female patient had been repeatedly diagnosed with bronchitis and had taken various cough and anti-inflammatory drugs for more than 6 months, but her cough never improved. After coming to our hospital for examination, she was diagnosed with cough variant asthma, also known as cough asthma, and was therefore treated according to the asthma standard. After medication, the patient’s treatment effect was obvious, with significant relief of cough, significant improvement of lung function, and significant improvement of the accompanying rhinitis symptoms.
Basic information】Female, 38 years old
Disease Type】Cough variant asthma
【Treatment Hospital】The First Hospital of Guangzhou Medical University
Date of consultation】February 2022
Treatment plan】Medication (budesonide suspension for inhalation, levosalbutamol hydrochloride nebulized inhalation solution, ipratropium bromide inhalation aerosol, beclomethasone formoterol inhalation aerosol, montelukast sodium tablets, mometasone furoate nasal spray, azathioprine hydrochloride nasal spray)
Treatment period】5 months of outpatient treatment, regular review
Treatment effect】Cough was significantly relieved, lung function was significantly improved, and the accompanying rhinitis symptoms were significantly improved.
I. Initial consultation
Ms. Zhang is a 38-year-old white-collar worker who reported that she developed a paroxysmal cough with no obvious cause more than 6 months ago, mainly a dry cough, which is easily triggered by exposure to cold air and oil fumes. She has a cough that affects her sleep and often wakes up at 5-6 am. He had been to several clinics and hospitals and was repeatedly diagnosed with “bronchitis”, but the effect of treatment was not satisfactory and the cough recurred. Later, he went to a hospital and underwent a pulmonary ventilation test and a bronchodilator test, which showed normal pulmonary ventilation and a negative bronchodilator test, and was treated with compound methocarbamol capsules, montelukast sodium tablets, and theophylline extended-release tablets, and his cough improved slightly, but his symptoms continued to recur.
After the patient’s detailed description, we performed relevant specialist examinations. Through the results of routine blood tests and induced coughing sputum examination, we found that the patient had elevated eosinophils. The exhaled nitric oxide measurement showed that the patient’s exhaled nitric oxide level was 31 ppb. Allergen examination revealed a significant increase in total IgE, and the patient had allergies to many things. The patient’s chest CT and sinus CT were later performed, and no significant abnormalities were found. The patient was considered to have cough variant asthma.
Figure 1: Blood count
Figure 2: Induced sputum cytology classification
II. Treatment history
Combined with the current situation of the patient, a combination of leukotriene receptor antagonists, montelukast sodium tablets, and long-acting bronchodilators, levosalbutamol hydrochloride nebulized inhalation solution and ipratropium bromide aerosol, as well as glucocorticoid inhalation, including budesonide suspension for inhalation, were considered for treatment to reduce the patient’s cough symptoms.
After deciding on the medication regimen, we communicated with the patient, informing him that he belonged to cough variant asthma, a special type of asthma that required long-term or even lifelong regular treatment with inhaled hormones. However, when the patient heard that hormonal drugs were used, he showed more resistance and thought that hormonal drugs had more side effects. We patiently explained to the patient that inhaled hormone drugs can act directly on the respiratory tract, and that they are fast-acting and have little effect on the body. The patient understood and was willing to cooperate with the treatment, so we gave the patient budesonide suspension, levosalbutamol hydrochloride nebulized inhalation solution and ipratropium bromide aerosol by nebulized administration, and after the symptoms were relieved, the patient was allowed to be discharged from the hospital and instructed to use beclomethasone formoterol inhalation aerosol regularly and take montelukast sodium tablets orally after discharge, and for his allergic rhinitis. The patient was instructed to use mometasone furoate nasal spray and azulfidine hydrochloride nasal spray for nasal spray treatment, and to use saline to wash his nose, and to conduct regular review.
III. Treatment effect
After the standardized anti-asthma treatment, the patient’s cough, sputum and shortness of breath were significantly relieved, and no dry rales were detected on examination. We repeatedly advised the patient to use beclomethasone formoterol inhalation aerosol regularly, as well as to take montelukast sodium tablets regularly, and to continue nasal spray treatment with mometasone furoate nasal spray and azulfidine hydrochloride nasal spray for his allergic rhinitis, and to use saline to wash his nose. 8 weeks later, the patient was reviewed locally and sent me the test results to check, so that I could to adjust his medication remotely and to evaluate the treatment cycle, which was expected to take about 5 months. After 3 months of treatment, the patient’s lung function has gradually normalized and no cough symptoms have appeared, and he now just carries beclomethasone formoterol inhalation aerosol with him in case it is necessary. In summary, the patient’s cough was significantly relieved, lung function improved significantly, and the accompanying rhinitis symptoms improved significantly, and the treatment effect was good, and the patient expressed satisfaction with the treatment.
IV. Notes
Happily, after a series of active treatments, the patient’s lung function gradually returned to normal and no cough symptoms appeared, and the treatment effect was more remarkable. However, since the essence of cough variant asthma is still asthma and still belongs to a chronic disease, patients still need to pay attention to the following conditions in their daily life.
1. as patients need longer-term medication, they should usually follow the medical advice to use the medication regularly and rinse their mouth immediately after inhaling the medication to avoid throat discomfort.
2. even for asthma with well-controlled symptoms, there is a possibility of acute attacks, so patients should carry emergency asthma medication with them on a daily basis.
3. Patients should avoid contact with allergens, such as pollen, dust, willow, etc., and if this cannot be avoided, they should be well protected by wearing a mask when they go out.
4. Patients should follow the doctor’s prescription for regular review in order to assess the recovery situation.
V. Personal insight
The typical symptom of cough variant asthma is irritant cough, which is often easily confused with bronchitis, and patients are often misdiagnosed as bronchitis, but they still do not improve after a long time of treatment. In this case, the patient was misdiagnosed and did not improve after a long period of treatment, but the real cause was identified and the treatment was timely, so that no serious consequences were caused.
In fact, patients with cough-variant asthma usually have a severe, persistent dry cough, especially at night or in the early hours of the morning, with frequent and intense attacks, and many patients have a tickling throat. The cough is often triggered and aggravated by colds, exercise, cold air inhalation, and can also be triggered by exposure to pollen, dust, or certain foods. In addition, the patient or first- or second-degree relatives often have a history of allergic diseases, such as allergic rhinitis and eczema, which can be indicative for the diagnosis of the disease. In daily life, if you have symptoms or a family history of the disease, you should consult a doctor to identify the allergen and pay attention to protection to avoid affecting your health.