Cough-variant asthma

My eight-year-old daughter has been diagnosed with asthma, but I am bit confused about the diagnosis as I have never heard her wheeze. It sound to me as if she is choking from mucous in the throat. The doctor has listened to her after she has had attacks of breathing difficulties before, and he has failed to hear the whistling that is associated with asthma. In light of an absence of wheezing, is it possible that she is in fact suffering from something else? She has been on azmacort for two months and proventil with the aerochamber for 6 months, as well as now being prescribed prednisone.

I am extremely concerned that there may be more wrong, or something else that we are failing to address and may thus be hurting my daughter by not looking deeper for an answer.

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

In my previous answer on asthma to which you referred, I made an analogy between the air passages of the lungs and the inner tube of a paper roll. In it, I tried to illustrate that there are three key components of asthma that cause the symptoms, constriction of the airways, swelling of the airway walls, and mucous production of the airways. But while we typically think of asthma symptoms being the wheezing of an asthma attack, there is really a spectrum of manifestations of this disease.

First let's consider the extremes. When the airways are normal, obviously there is no constriction, inflammation, or mucous. When an asthma attack is occurring, the airways get smaller causing a lot wheezing that often can be heard by people standing next to the child having the attack. The swelling causes a lot of irritation, so the child's cough is frequent and severe, and the mucous production makes it even more difficult to breathe because it can tend to block some of the airways.

But over the years, we have learned that there is quite clearly some middle ground between these two extremes. Asthma is a lot more than constricted airways that cause wheezing. And in fact, we now know that it is actually the inflammation or swelling in the airways that may be present even when there isn't a whole lot of wheezing that can be heard. This causes the child to cough a lot (usually more severely at night). This type of asthma has the name of Cough Variant Asthma. This name implies that it is indeed asthma that is causing the cough, but the asthma is not so severe as to cause any wheezing.

Recognizing this variation of asthma was an important step in helping children because for years this persistent cough was often chalked up to just having "bad sinuses," "allergy problems," or "multiple colds." And so, treating these children similarly to those who have more severe forms of asthma has done a lot in giving them better rest at night because they aren't waking up from the cough, better performance in school because they are getting better rest, and better accomplishment at strenuous activity because the cough they often get from exercise can be better controlled.

You are clearly an outstanding advocate for your child because it is always a healthy attitude to make sure the doctor is confident in the diagnosis. Could your daughter have something else going on? Of course she could, but that is a decision you and you doctor need to discuss and investigate together. In the meantime, there is a simple way to evaluate whether her cough is primarily due to asthma. When she has a "coughing fit", if it gets better with the proventil inhaler (used with the aerochamber), that is pretty good evidence that she has cough-variant asthma. Could the mucous be causing her cough? Absolutely, but remember, mucous production is one of the three hallmarks of asthma, so this may even strengthen the argument that this is the cause. The Azmacort decreases inflammation and makes it less likely that an asthma attack (or coughing episode in your child's case) will occur. In addition, it tends to make these attacks less severe. But it does not totally eliminate the attacks. So, the fact that she is on Azmacort but still occasionally having coughing episodes is not necessarily unusual for asthma. It sounds as if you have had good discussions with your doctor already concerning your daughter's coughing. I encourage you to keep it up because getting to the root of her problem and eliminating it will only come with good follow-up with the doctor.

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