Asthma inhaler not helping cough
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Asthma Inhaler Not Helping Cough: Insights from Recent Research
Poor Inhalation Technique and Its Impact on Asthma Control
One of the primary reasons an asthma inhaler may not be effective in alleviating cough is incorrect inhalation technique. Research indicates that improper use of inhaler devices is prevalent among asthma patients, with error rates ranging from 0% to 53% depending on the type of inhaler used1. Incorrect inhalation technique can lead to poor symptom control and a higher likelihood of persistent cough1. Therefore, it is crucial for healthcare providers to ensure that patients are properly instructed on the correct use of their inhalers and to regularly reassess their technique.
Efficacy of High-Dose Inhaled Corticosteroids
For patients with chronic cough, high-dose inhaled corticosteroids (ICS) like beclomethasone have shown significant efficacy. In a study comparing high-dose beclomethasone to a placebo, 82% of patients in the active group experienced complete resolution of their cough, compared to only 15% in the placebo group2. This suggests that for some patients, increasing the dose of ICS may be necessary to achieve symptom relief.
Role of Bronchodilators in Reducing Cough
Bronchodilators such as salbutamol and ipratropium have been found to reduce cough responses in asthmatic patients. These medications work by altering neuroreceptor sensitivity and improving bronchial calibre, which can diminish the cough reflex3. Additionally, pretreatment with bronchodilators can help mitigate cough and wheezing induced by inhaled corticosteroids, making the therapy more tolerable for patients4.
Diagnosing Cough-Variant Asthma
Cough-variant asthma is a condition where cough is the predominant symptom. Positive results from methacholine inhalation challenges (MIC) followed by a favorable response to asthma therapy can confirm this diagnosis. A study found that cough severity significantly improved after one week of inhaled beta-agonist therapy in patients with cough-variant asthma5. This highlights the importance of appropriate diagnostic tests and targeted treatment in managing persistent cough in asthma patients.
Switching Inhaler Medications for Better Symptom Control
For patients whose cough persists despite using medium-dose ICS/long-acting beta-agonist (LABA) therapy, switching to a combination of indacaterol, glycopyrronium, and mometasone (IND/GLY/MF) may offer better symptom control. The REACH study aims to evaluate the efficacy of this combination in improving cough-specific quality of life and reducing cough severity6. This approach may be beneficial for patients who do not respond adequately to standard ICS/LABA therapy.
Formulation Considerations in Reducing Post-Inhalation Cough
The formulation of inhaled medications can also influence the incidence of post-inhalation cough. Factors such as the drug's solubility and the composition of the epithelial lining fluid play a role in cough sensitivity. Using insoluble neutral forms of drugs and appropriate excipients can help minimize cough induced by inhaled therapies7.
Conclusion
Persistent cough in asthma patients despite inhaler use can be attributed to several factors, including incorrect inhalation technique, the need for higher doses of ICS, and the potential benefits of bronchodilators and alternative inhaler combinations. Ensuring proper inhaler technique, considering high-dose ICS, and exploring different medication formulations can significantly improve symptom control and quality of life for asthma patients. Regular follow-ups and reassessments by healthcare providers are essential in managing these cases effectively.
Sources and full results
Most relevant research papers on this topic
Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial
Correct inhalation of prescribed medication improves health status and lung function in asthma and COPD patients.
RCT
Rigorous Journal
Highly CitedHigh-dose inhaled beclomethasone treatment in patients with chronic cough: a randomized placebo-controlled study.
High-dose inhaled beclomethasone effectively reduced chronic cough symptoms in a subgroup of patients without correlation to atopy or airway hyperresponsiveness.
RCTEffect of bronchodilators on the cough response to inhaled citric acid in normal and asthmatic subjects.
Bronchodilators can reduce asthmatic patients' cough response to inhaled citric acid, potentially due to altered neuroreceptor sensitivity and rapid changes in bronchial calibre.
RCTHighly CitedCough and wheezing from beclomethasone aerosol.
Pretreatment with a bronchodilator can effectively reduce cough and wheezing from beclomethasone aerosol therapy, enabling some patients to tolerate it, while others may require oral steroid therapy.
RCTInterpretation of positive results of a methacholine inhalation challenge and 1 week of inhaled bronchodilator use in diagnosing and treating cough-variant asthma.
Positive methacholine inhalation challenge results are only diagnostic of asthma when followed by a favorable response to asthma therapy, and only cough-variant asthma significantly improves after 1 week of inhaled beta-agonist use.
RCTHighly CitedReal-life effectiveness of indacaterol/glycopyrronium/mometasone for symptomatic relief of cough after switching from inhaled corticosteroid/long-acting β2-agonist therapy in patients with asthma: REACH study design
Indacaterol/glycopyrronium/mometasone (IND/GLY/MF) may provide better symptom relief and quality of life for asthmatic patients with persistent cough refractory to medium-dose ICS/LABA treatment.
RCTRigorous JournalPost-inhalation cough with therapeutic aerosols: Formulation considerations.
Post-inhalation cough with therapeutic aerosols can be limited by using insoluble neutral forms of drugs and excipients, reducing changes in epithelial lining fluid composition.
Cough after inhalation of corticosteroids delivered from spacer devices in children with asthma
Cough after inhalation of corticosteroids delivered from spacer devices is a common local side-effect in children with asthma, affecting compliance and requiring professional attention.
Observational StudyInhaled corticosteroids for non-specific chronic cough in children.
Inhaled corticosteroids show no significant improvement in reducing non-specific chronic cough in children over two years of age, with a small improvement seen with very high-dose corticosteroids.
Meta-AnalysisAllergen challenge increases capsaicin-evoked cough responses in patients with allergic asthma.
Allergen-induced bronchoconstriction and airway eosinophilia increase cough reflex sensitivity to capsaicin, leading to increased 24-hour spontaneous coughing in patients with allergic asthma.
RCTRigorous Journal