A general practitioner who must work with an asthma patient, must be able to communicate and work together with other medical professionals to diagnose and treat the patient. For patients who don’t have a clinical obvious etiology, a bronchial provocation test should be used, as is the case with this patient. According to Rand, et. al. (2015) in cases where it is thought that asthma is the diagnosis, a bronchoscopy should be undertaken, something that may be accurate in this case given the history the patient has of the cough getting progressively worse in various settings. High resolution computed tomography can be used to then review more targeted investigations for the problem area. The optimal management for this case should be a combination of treatment trails as well as diagnostic testing. The trials should be based on the most likely aggravant or aggravants. The treatment effects should then be formally quantified.
Rand, et. al. (2015) states that there are different recommended managements for various aggravants. Most of the troublesome cases of chronic cough are reflective upon the presence of an aggravant, something which is likely the case with this patient as well. If the aggravant is asthma or bronchitis, then the cough will function as the only manifestation of the syndrome and unfortunately there are not currently any tests for airway function which will exclude corticosteroid responsive coughs. The cough in this case is unlikely related to airway inflammation if, after two weeks of an oral steroid trial, there is no response. If this is the aggravant, then the recommendation for drugs is an ACE inhibitor.
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According to Gershon, et. al, (2012, p. 1190) bronchial provocation testing can be performed on this patient and should it come back negative, it will exclude asthma but it will not rule out the possibility for a steroid responsive cough. Accurate measurement of the cough can lend itself to a better diagnosis, which can be done by way of ambulatory cough recording (Dhar & Ghoshal, 2013, p. 3). An assessment of the airway inflammation can be done with sputum eosinophilia.
Should the asthmatic tests fail to rectify the problem, an upper airway pathology may be an alternative path, the recommendation for which is topical corticosteroids. The recommendation for an upper airway investigation is to examine the ear, nose, and throat. If necessary, the patient can be referred to a specialist cough clinic which will have access to fiber optic laryngoscopy. Doing this would help the patient to manage the symptoms of the chronic cough while also finding the root etiology therein.
- Dhar, R., & Ghoshal, A. G. (2013). Asthma diagnosis and treatment–1003. Severe asthma: a
comparison of clinical severity and lung function. The World Allergy Organization journal, 6(Suppl 1), P3. - Gershon, A. S., Victor, J. C., Guan, J., Aaron, S. D., & To, T. (2012). Pulmonary function testing
in the diagnosis of asthma: a population study.CHEST Journal, 141(5), 1190-1196. - Rand, C., Shetterly, S., Tacinas, C., Vollmer, W. M., Wagner, N., Wamboldt, F. S., … & Magid, D. J. (2015). Pragmatic Trial of Health Care Technologies to Improve Adherence to Pediatric Asthma Treatment A Randomized Clinical Trial.
