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A child with recurrent cough and allergic rhinitis

A 7-year-old boy presented with recurrent cough for the past 3 weeks. He also complained of headache, sore throat, and nasal congestion for about 3 weeks. His mother reported that he also snored on some nights and had to breathe through the mouth while sleeping.

Over the past 3-4 days, the episodes of wet, productive cough had increased during the night. Additionally, he was having occasional attacks of sneezing over the past few days usually after coming back from school.

History

The child was a known case of asthma but was not responding to inhaled corticosteroids.

The parents reported that he had been having frequent episodes of nasal congestion and colds since the age of 4 years. He also had two episodes of hives over the past year which subsided on their own without any medication.

Family history revealed a positive history of pollen allergy in the mother and asthma in his elder brother. On further questioning, the parents revealed that they had brought a puppy home around 3 years ago and recalled that the patient’s symptoms had been appearing off and on since that time.

Examination and investigations

The patient appeared well and comfortable with no pallor or cyanosis. His temperature, RR, BP, and pulse were normal.

On physical examination, allergic shiners were evident, and the turbinates were enlarged and swollen. There was white postnasal discharge and cobblestone posterior pharynx mucosa. Nothing abnormal was found on auscultation. Nasal endoscopic examination did not reveal any abnormality. Eye and ear examination was normal.

Complete blood count (CBC) was normal and the patient did not get the swab test done. The patient was found to be allergic to animal dander and house dust mites on skin prick testing. The patient was diagnosed with allergic rhinitis.

Management

The child was a known case of asthma but was not responding to inhaled corticosteroids.

Case Scenario

In a patient not responding to treatment for asthma, the clinician must look for comorbidities. It is common for children with asthma to have allergic disease. Around 80% of asthmatics have allergic rhinitis as a comorbidity.

Jog P. Coughology – The art & science of navigating cough: In pediatric practice. Mumbai: Docmode Publishing; 2024.

Disclaimer: The scientific content of this publication has been developed by DocMode Health Technologies Ltd. for educational purposes through an educational grant of Glenmark Pharmaceuticals Ltd. This publication is distributed free of cost as a service to the medical profession for educational purposes only. Although greatest possible care has been taken in compiling, checking and developing the content to ensure that it is accurate and complete, the authors, the publisher, its servants or agents, or Glenmark Pharmaceuticals Ltd., shall not be responsible or in anyway liable for any injury or damage to any persons in view of any reliance placed on or action taken on basis of the information in this publication or any errors, omissions or inaccuracies and/or incompleteness of the information in this publication, whether arising from negligence or otherwise. Glenmark Pharmaceuticals Ltd. neither agrees nor disagrees with the views expressed in this publication and does not constitute or imply an endorsement, sponsorship or recommendation.

Patients with asthma-related chronic cough have a higher risk of increased airway inflammation, higher risk of comorbidities and worse clinical outcomes.

The association of chronic cough and characteristics of patients with asthma has not been much explored in the real-world setting.

Study

A group of researchers conducted a prospective cohort study in patients with asthma.

After 3 months of optimized asthma therapy according to standard guidelines, patients with asthma were groups as below:

Study findings

The increased disease burden, comorbidities, airway inflammation, exacerbations related to chronic cough in asthma calls for more attention to strategize better therapeutic regimens.

Lung function and asthma control

CC group had greater airflow obstruction (Table 1) , worse asthma-related quality of life, higher ACQ score, a poorer asthma control than the non-CC group
More patients in CC group used systemic steroids due to exacerbation (p=0.002) and required hospital admission (p<0.001) in the past year.

Inflammatory biomarkers

Airway inflammation was higher in the CC group.
The CC group had higher blood eosinophil and monocyte counts, higher sputum eosinophil percentage and sputum neutrophil percentage, compared with the non-CC group.

Comorbidities

More number of patients in the CC group experienced three or more than three comorbidities, such as uncontrolled rhinitis, anxiety or depression, chronic obstructive pulmonary disease (COPD), and bronchiectasis.

Daily life activities

Absenteeism, work productivity loss, and activity impairment was higher in the CC group than the non-CC group.

Table 1. Comparison of airflow obstruction as assessed by FEV1 (% predicted) and FEV1/FVC between CC and non-CC groups

CC group

PrebronchodilatorFEV1, mean ± SD, % predicted

Prebronchodilator FEV1/FVC, mean ± SD, %

Healthy Students(n=305)

71.00 ± 21.50

65.00 ± 13.10

Asthmatic Students(n=56)

<0.001

The increased disease burden, comorbidities, airway inflammation, exacerbations related to chronic cough in asthma calls for more attention to strategize better therapeutic regimens.

Reference: Deng SJ, Wang J, Liu L, Chronic cough in asthma is associated with increased airway inflammation, more comorbidities, and worse clinical outcomes. Allergy Asthma Proc. 2022;43(3):209–219.

Objective and subjective measurement of cough in asthma

Several tools with subjective and objective measures have been developed to measure the clinical impact of cough in asthma; however, the extent to which they have been studied in patients with cough is unclear.

Study

A group of researchers conducted a systematic literature review to explore the extent to which cough has been assessed within the asthma literature.

Study findings

Use of diagnostic criteria for asthma

There was a variation in different studies

Cough measurement tools

Cough monitoring, cough reflex sensitivity testing, validated PRO measures, and non-validated PRO measures.

Cough frequency endpoints

A range of cough frequency endpoints such as coughs, coughs per hour, cough seconds or cough events were reported

Measurement of cough reflex sensitivity

In 61 studies
A broad range of antitussives (capsaicin, saline, citric acid, histamine, tartaric acid, mannitol, sodium bicarbonate and sodium gluconate) were used.
Cough reflex sensitivity was higher in asthmatics than controls (8 studies).
Higher cough reflex sensitivity was associated with increase in cough severity, a worsening cough-related quality of life (QoL), and an increase in cough frequency.

Validated patient-reported outcome measures

19 studies used at least one quality of life questionnaire to assess the impact of cough. The Leicester Cough Questionnaire (LCQ) was most used.
Cough-related QoL was associated with asthma symptom scores and measures of asthma control and asthma-related QOL

Use of non-validated tools

Around 42 studies used measurement tools that had not been validated in cough assessment.
Likert scales/cough diaries, the European Community.
Respiratory Health Survey (ECRHS), and an interview were used

Although cough is a common symptom in asthmatics, it is underestimated as a clinical problem. Several validated objective and subjective measures of cough exist; however, they need to be researched thoroughly and further incorporated into the design of asthma studies and clinical trials.

Reference: Holmes J, Heaney LG, McGarvey LPA. et al. Objective and subjective measurement of cough in asthma: A systematic review of the literature. Lung. 2022;200(2):169–178.

Hydration status can affect coughing in asthmatics

Water is crucial in airway homeostasis. Normal hydration protects the airway epithelium and promotes proper mucociliary clearance. Dehydration stimulates the production of pro-inflammatory mediators that affect the airway calibre, particularly in asthma.

Little is known about the relationship between hydration and cough in asthma in real life.

Study

A group of researchers set out to conduct a real-life study to investigate the relationship between the hydration status and both the frequency and duration of coughs in asthmatic children and adolescents.

Students (n=400) were asked answer a 22-item questionnaire to check the presence of asthma, the incidence of cough, and the duration of cough episodes during the previous 12 months.
Urine samples were also collected to assess osmolality.
Valid data were obtained from 305 healthy and 56 asthmatic students.

Study findings

Mean urine osmolality

Higher in asthmatics than healthy students (1012±197.7 vs. 863.0±223.0 mOsm/kg, respectively; p<0.001)
Higher in symptomatic than asymptomatic asthmatics 1025.4±191.6 mOsm/kg vs. 909.4±190.7 mOsm/kg (p<0.01)

Incidence of coughing episodes

The incidence of coughing episodes was significantly higher in asthmatic than in healthy students (97.5% vs. 62.5%, respectively)
These results were more prominent in dehydrated asthmatics (p<0.001)

Duration of coughing and hydration

Coughing episodes showed a singificantly longer duration by their hydration status (p<0.001)

Routine inspection
Pulmonary function test
x²
P value

Healthy Students(n=305)

837.1 ± 220.2

120(39.3%)
86(28.2%)
99(32.4%)

Asthmatic Students(n=56)

1012.4 ± 197.7

8(14.3%)
16(28.6%)
32(57.1%)

0.01

0.001
0.08
0.001

There is a clear association between coughing and real-life hydration status in young asthmatics. It is important to implement adequate water consumption in asthmatics to minimize coughing.

Reference: Zanasi A, Dal Negro RW. Coughing can be modulated by the hydration status in adolescents with asthma. Children (Basel). 2022;9(4):577.

Repsi Bytes

A child with recurrent cough and allergic rhinitis

History

Examination and investigations

Management

Case Scenario

Patients with asthma-related chronic cough have a higher risk of increased airway inflammation, higher risk of comorbidities and worse clinical outcomes.

Study

Objective and subjective measurement of cough in asthma

Study

Study findings

Hydration status can affect coughing in asthmatics

Study

Study findings

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