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Could that cough be asthma?
Patricia K. Musto, RN
t's 3:26 a.m. and you are jarred awake by the sound of your young son coughing. It seems like this has been a nightly event ever since he had that cold about six weeks ago. Poor kid, you think, as you struggle to shake off sleep. You will try to make him comfortable, or at least keep him company. That cough won't let him sleep! You resolve that this will be the last night that you and your son, John, watch the stars fade into morning. When your doctor's office opens, you'll call for an immediate appointment. Identifying the cause of a cough can be difficult. A persistent cough can be symptomatic of a vast number of disease states, including an infection, asthma, cystic fibrosis or gastroesophagealreflux (GERD), to name a few. A very common cause is postnasal drip syndrome or chronic nasal con-
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ASTHMA
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gestion. Persistent cough can also be the result of a nervous habit, or it can be an adverse effect of medication taken for another health problem. Cough receptors are concentrated in the larynx and upper airways; lower in the lungs, there are fewer. The cough reflex begins in these sensory receptors and then travels to the brain, which subsequently results in the cough. In order for a physician to begin to isolate the cause of a persistent cough, he or she generally takes a thorough, comprehensive history. The following are questions the physician may ask. * How long has the patient had the cough? • When during the day or night does the cough occur?.
• Is t h e c o u g h b e t t e r at c e r t a i n t i m e s of t h e year, and w o r s e at others? • W h a t f a c t o r s s e e m to m a k e t h e cough w o r s e : cold air, e x e r c i s e , u p p e r r e s p i r a t o r y infection, etc.? • Does the cough produce
phlegm?
• W h a t t r e a t m e n t s have b e e n a t t e m p t e d to control t h e c o u g h m cough medicine, antihistamines, a n t i b i o t i c s - - and w h a t has b e e n their success? • What medicine does the patient currently take? • D o e s t h e p a t i e n t have any o t h e r health problems, especially involving t h e lungs, h e a r t or sinuses?
or a short-acting chemical (called methacholine) that makes the airways constrict to definitely attribute the cough to asthma. These challenge procedures stimulate bronchospasm in susceptible individuals, in order to establish the diagnosis of asthma. This is done under the controlled conditions of the doctor's office. The bronchospasm is easily reversible and does not affect people who do not have hyperreactive airways. Although the classic symptoms of asthma are wheezing, shortness of breath and coughing, some people with asthma have no obvious symptoms other than a cough. This is referred to as "cough variant asthma." The treatment for this version of asthma, however, is the same as for asthma in general. The National Asthma Education and Prevention Program's Expert Panel Report 11, finalized in May 1997, recommends a therapeutic trial of either anti-inflammatory or bronchodilator medication. Once the diagnosis of cough variant asthma is certain, treatment should continue for long-term management of the
Although the classic s y m p t o m s of a s t h m a are w h e e z i n g , shortness of breath and coughing, s o m e people w i t h a s t h m a have no obvious s y m p t o m s o t h e r than a cough.
• Is t h e r e a f a m i l y h i s t o r y of allergy or a s t h m a ?
Once the questions in the history have been answered, the doctor performs a careful physical examination, which can further isolate or rule out possible causes of the cough. The exam discloses whether the patient has an acute infection, is in any apparent distress, or has other signs of respiratory symptoms, such as wheezing. It is not unusual, however, for the results of the physical exam to be normal. Diagnostic tests yield information that can further narrow the list of potential underlying causes. Normal chest and sinus X-rays can diminate infection, and a negative sweat chloride test rules out cystic fibrosis. Useful in diagnosingasthma is a spirometry test, a non-invasive office procedure which measures a patient's ability to exhale forcefully by blowing into a tube. Spirometry results indicate how open a patient's airways are and, thus, how easily that patient can move air in and out of his or her lungs. Even if asthma is present, this test may not be markedly abnormal when cough is the only presenting symptom. Sometimes it takes challenging the patient's airways with exercise to
subscribe
call
1.800.527.3284
ASTHMA
25
Cough, when it's a symptom of asthma, often worsens during the night, leading to difficulty waking up in the morning and exhaustion during the day.
asthma symptoms. Some patients benefit from using inhaled bronchodilator (quick relief) medications as needed to control their cough. However, if "as needed" means the patient requires bronchodilator use on a daily basis, the symptoms are not well controlled, and he or she should begin anti-inflammatory medications. The non-steroidal antiinflammatory medication nedocromil is particularly well-suited to control cough resulting from asthma, due to its m e & a nism of action. It has a good safety profile with minimal side effects. Most of the inhaled corticosteroid anti-inflammatory medications are also considered to be both safe and effective. (Contact your health care provider to discuss these medications more specifically.) Your son's cough is intermittent, but occurs throughout the day and night. It is a non-productive cough that gets worse when he plays hard outside. He is otherwise health~ Your family history includes many members who have hay fever. Your doctor performs a spirometry test based on her suspicion of asthma. John's spirometry test results reveal "normal" values, but the doctor knows that normal only means the values are appropriate for a boy of John's age and height. They are not necessarily the best values that John can generate. After taking a bronchodilator medication and waiting 15 minutes, John's spirometry test is repeated. New results show that John's breathing has improved by greater than 15 percent, a significant amount. The doctor concludes that, since 1) most other possible causes of the 26
ASTHMA
to subscribe
call
1.800.527.3284
cough have been diminated, 2) John's only presenting complaint is the cough, and 3) John's breathing test demonstrated significant improvement after taking a bronchodilator medication (showing reversibility), then John's diagnosis is cough variant asthma. If there had been no reversibility, the doctor could have proceeded in one of two ways. She could have ordered provocation testing (methacholine) as described earlier, or she could have started to treat John on the basis of her suspicion that he has cough variant asthma. Your doctor prescribes for John an anti-inflammatory metered dose inhaler to be used with a spacer, and recommends that John do home peak flow measurements every day - - morning and night - - for the next four weeks until his return appointment. Peak flow measurements will help both you and John relate how he is feeling with how open his airways are. In time, with continued treatment, that number should become John's standard of wellbeing; if he can reach his "personal best" peak flow measurement, he will know his asthma is under control. The doctor writes out an asthma action plan, induding all of her instructions and the office telephone numbers. You leave the office with prescriptions, a written plan and peace of mind, knowing that you and John finally have the answer for his nighttime awakening. Tonight will be the best night's sleep you, John and the rest of your family have had in a long time! Patricia K. Musto, RN,, is a clinician nurse and clinical research coordinator with University Consultants in Allergy and Immunology, Rush Medical Center, Chicago, IL. She is also a nurse educator for the Asthma and Allergy Foundation of America, a member of the Chicago Asthma Consortium, and an Allied Health member of both the AAAAI and the ACAAI.
t's 3:26 a.m. and you are jarred awake by the sound of your young son coughing. It seems like this has been a nightly event ever since he had that cold about six weeks ago. Poor kid, you think, as you struggle to shake off sleep. You will try to make him comfortable, or at least keep him company. That cough won't let him sleep! You resolve that this will be the last night that you and your son, John, watch the stars fade into morning. When your doctor's office opens, you'll call for an immediate appointment. Identifying the cause of a cough can be difficult. A persistent cough can be symptomatic of a vast number of disease states, including an infection, asthma, cystic fibrosis or gastroesophagealreflux (GERD), to name a few. A very common cause is postnasal drip syndrome or chronic nasal con-
I
24
ASTHMA
to
subscribe
call
1.800.527.3284
gestion. Persistent cough can also be the result of a nervous habit, or it can be an adverse effect of medication taken for another health problem. Cough receptors are concentrated in the larynx and upper airways; lower in the lungs, there are fewer. The cough reflex begins in these sensory receptors and then travels to the brain, which subsequently results in the cough. In order for a physician to begin to isolate the cause of a persistent cough, he or she generally takes a thorough, comprehensive history. The following are questions the physician may ask. * How long has the patient had the cough? • When during the day or night does the cough occur?.
• Is t h e c o u g h b e t t e r at c e r t a i n t i m e s of t h e year, and w o r s e at others? • W h a t f a c t o r s s e e m to m a k e t h e cough w o r s e : cold air, e x e r c i s e , u p p e r r e s p i r a t o r y infection, etc.? • Does the cough produce
phlegm?
• W h a t t r e a t m e n t s have b e e n a t t e m p t e d to control t h e c o u g h m cough medicine, antihistamines, a n t i b i o t i c s - - and w h a t has b e e n their success? • What medicine does the patient currently take? • D o e s t h e p a t i e n t have any o t h e r health problems, especially involving t h e lungs, h e a r t or sinuses?
or a short-acting chemical (called methacholine) that makes the airways constrict to definitely attribute the cough to asthma. These challenge procedures stimulate bronchospasm in susceptible individuals, in order to establish the diagnosis of asthma. This is done under the controlled conditions of the doctor's office. The bronchospasm is easily reversible and does not affect people who do not have hyperreactive airways. Although the classic symptoms of asthma are wheezing, shortness of breath and coughing, some people with asthma have no obvious symptoms other than a cough. This is referred to as "cough variant asthma." The treatment for this version of asthma, however, is the same as for asthma in general. The National Asthma Education and Prevention Program's Expert Panel Report 11, finalized in May 1997, recommends a therapeutic trial of either anti-inflammatory or bronchodilator medication. Once the diagnosis of cough variant asthma is certain, treatment should continue for long-term management of the
Although the classic s y m p t o m s of a s t h m a are w h e e z i n g , shortness of breath and coughing, s o m e people w i t h a s t h m a have no obvious s y m p t o m s o t h e r than a cough.
• Is t h e r e a f a m i l y h i s t o r y of allergy or a s t h m a ?
Once the questions in the history have been answered, the doctor performs a careful physical examination, which can further isolate or rule out possible causes of the cough. The exam discloses whether the patient has an acute infection, is in any apparent distress, or has other signs of respiratory symptoms, such as wheezing. It is not unusual, however, for the results of the physical exam to be normal. Diagnostic tests yield information that can further narrow the list of potential underlying causes. Normal chest and sinus X-rays can diminate infection, and a negative sweat chloride test rules out cystic fibrosis. Useful in diagnosingasthma is a spirometry test, a non-invasive office procedure which measures a patient's ability to exhale forcefully by blowing into a tube. Spirometry results indicate how open a patient's airways are and, thus, how easily that patient can move air in and out of his or her lungs. Even if asthma is present, this test may not be markedly abnormal when cough is the only presenting symptom. Sometimes it takes challenging the patient's airways with exercise to
subscribe
call
1.800.527.3284
ASTHMA
25
Cough, when it's a symptom of asthma, often worsens during the night, leading to difficulty waking up in the morning and exhaustion during the day.
asthma symptoms. Some patients benefit from using inhaled bronchodilator (quick relief) medications as needed to control their cough. However, if "as needed" means the patient requires bronchodilator use on a daily basis, the symptoms are not well controlled, and he or she should begin anti-inflammatory medications. The non-steroidal antiinflammatory medication nedocromil is particularly well-suited to control cough resulting from asthma, due to its m e & a nism of action. It has a good safety profile with minimal side effects. Most of the inhaled corticosteroid anti-inflammatory medications are also considered to be both safe and effective. (Contact your health care provider to discuss these medications more specifically.) Your son's cough is intermittent, but occurs throughout the day and night. It is a non-productive cough that gets worse when he plays hard outside. He is otherwise health~ Your family history includes many members who have hay fever. Your doctor performs a spirometry test based on her suspicion of asthma. John's spirometry test results reveal "normal" values, but the doctor knows that normal only means the values are appropriate for a boy of John's age and height. They are not necessarily the best values that John can generate. After taking a bronchodilator medication and waiting 15 minutes, John's spirometry test is repeated. New results show that John's breathing has improved by greater than 15 percent, a significant amount. The doctor concludes that, since 1) most other possible causes of the 26
ASTHMA
to subscribe
call
1.800.527.3284
cough have been diminated, 2) John's only presenting complaint is the cough, and 3) John's breathing test demonstrated significant improvement after taking a bronchodilator medication (showing reversibility), then John's diagnosis is cough variant asthma. If there had been no reversibility, the doctor could have proceeded in one of two ways. She could have ordered provocation testing (methacholine) as described earlier, or she could have started to treat John on the basis of her suspicion that he has cough variant asthma. Your doctor prescribes for John an anti-inflammatory metered dose inhaler to be used with a spacer, and recommends that John do home peak flow measurements every day - - morning and night - - for the next four weeks until his return appointment. Peak flow measurements will help both you and John relate how he is feeling with how open his airways are. In time, with continued treatment, that number should become John's standard of wellbeing; if he can reach his "personal best" peak flow measurement, he will know his asthma is under control. The doctor writes out an asthma action plan, induding all of her instructions and the office telephone numbers. You leave the office with prescriptions, a written plan and peace of mind, knowing that you and John finally have the answer for his nighttime awakening. Tonight will be the best night's sleep you, John and the rest of your family have had in a long time! Patricia K. Musto, RN,, is a clinician nurse and clinical research coordinator with University Consultants in Allergy and Immunology, Rush Medical Center, Chicago, IL. She is also a nurse educator for the Asthma and Allergy Foundation of America, a member of the Chicago Asthma Consortium, and an Allied Health member of both the AAAAI and the ACAAI.