A 26-year-old teacher has consulted her general practitioner (GP) for her persistent cough.

History
A 26-year-old teacher has consulted her general practitioner (GP) for her persistent cough.
She wants to have a second course of antibiotics because an initial course of amoxicillin
made no difference. The cough has troubled her for 3 months since she moved to a new
school. The cough is now disturbing her sleep and making her tired during the day. She
teaches games, and the cough is troublesome when going out to the playground and on
jogging. In her medical history, she had her appendix removed 3 years ago. She had her
tonsils removed as a child and were said to have recurrent episodes of bronchitis between
the ages of 3 and 6 years. She has never smoked and takes no medication other than an
oral contraceptive. Her parents are alive and well and she has two brothers, one of whom has hay fever.
Examination
The respiratory rate is 18/min. Her chest is clear and there are no abnormalities in the nose,
pharynx, cardiovascular, respiratory, or nervous systems.

Questions
• What is your interpretation of these findings?
• What do you think is the likely diagnosis and what would be appropriate treatment

Questions answer:

interpretation of finding:

·         peak flow pattern shows a degree of diurnal variation. But it does not show complete information about asthma.

·         mean daily variation in peak flow from the recordings is 36 L/min.

·         mean evening peak flow is 453 L/min.

·         mean diurnal variation of 8 per cent.

·         small diurnal variation is considered normal.

·         diurnal variation of >15 per cent is consider abnormal mean asthma.

·         ‘bronchitis’ in childhood was probably asthma.

·         family history of an atopic condition (hay fever in a brother).

·         cough by exercise and going out in the cold also suggest bronchial hyperresponsiveness typical of asthma.

·          When the chest X-ray of patients is clear then cough is likely to be produced by one of three main causes in non-smokers. Around half of such cases have asthma or will go on to develop asthma over the next few years.

·         Half of the rest have rhinitis or sinusitis with a postnasal drip.

·         In around 20 per cent the cough is related to gastro-esophageal reflux. A small number of cases will be caused by otherwise-unsuspected problems such as foreign bodies, bronchial ‘adenoma’, sarcoidosis or fibrosing alveolitis. Cough is a common side effect in patients treated with angiotensin-converting enzyme (ACE) inhibitors.

Diagnosis and Treatment:

Diagnosis:

 Patients is asthma confirmed by exercise test, which was associated with a 25 per cent drop in FEV after completion of 6 min of vigorous exercise.

    Medication to treat asthma:    

Medications used to treat asthma are divided into two general classes:

Quick-relief medications used to treat acute symptoms and long-term control medications used to prevent further exacerbation. Antibiotics are generally not needed for sudden worsening of symptoms.

FAST–ACTING : 

salbutamol metered dose inhaler commonly used to treat asthma attacks.

  Short-acting beta2 receptor agonist (SABA), such as salbutamol (albuterol USAN) are the first line treatment for asthma symptoms.

Anticholinergic medications, such as ipratropium bromide, provide additional benefit when used in combination with SABA in those with moderate or severe symptoms.

Anticholinergic bronchodilators can also be used if a person cannot tolerate a SABA. 

LONG–TERM CONTROL:

1. Corticosteroids are generally considered the most effective treatment available for long-term control.
2. Inhaled forms such as beclomethasone are usually used except in the case of severe persistent disease, in which oral corticosteroids maybe needed.
3. Long-acting beta-adrenergic agonists (LABA) such as salmeterol and formoterol can improve asthma control, at least in adults, when given in combination with inhaled corticosteroids.
4.anti-leukotriene agents such as montelukast and zafirlukast) maybe used in addition to inhaled corticosteroids, typically also in conjunction with a LABA
5.mast cell stabilizers such as cromolyn sodium) are another non-preferred alternative to corticosteroids.                                                                                                             6. For children with asthma which is well-controlled on combination therapy of inhaled corticosteroids (ICS) and long-acting beta₂-agonists (LABA), the benefits and harms of stopping LABA and stepping down to ICS-only therapy are uncertain.