Continuing cough and excess mucus after 8 months

Dear Dr Tinkleman
I wrote to you on 9th October last year and you gave some comforting advice on a persistent cough that had then lasted for 10 weks.
Since then, I have been treated for mild persistent asthma by a respiratory consultant, who added an HRCT scan to the clear x ray and laryngoscopy . The HRCT was also clear. Bronchial challenge with mannitol was very positive, IgE levels are high, as are levels of exhaled nitric oxide (70 ppb) The diagnosis was, as you suggested - asthma. I suffered from asthma as a child and have a long history of allergic type response, hives, rhinitis and hayfever. The view is that the asthma has returned, possibly as a result of a viral infection.
I have been treated since November with Seretide 250/25 (Advair), salbutamol as needed and Montelukast 10mg, in addition to fluticasone nasal spray and anti- -histamine  for rhinitis. However, I still have constant mucus in my throat, that is being constantly cleared, and bouts of coughing, producing gluey phlegm several times a day.
Although I have not had a day without symptoms, they were controlled until three weeks ago, since when  they have apparently become uncontrolled and I feel that I am almost back to square one, coughing more and producing more phlegm. I still sleep well at night and problems are almost all in the day.
In addition, I have seen two or three very tiny, fresh, frank blood spots, on a couple of occasions when I have done a  strenuous PEF test. These appeared on the PEF meter mouthpiece and have not been repeated. I think these are  likely to be from small blood vessels in my irritated throat. There has never been any hint of blood in my sputum. However, it has increased my concern about the apparently intractable nature of this condition and whether I should be worried about anything more sinister.
I have asked to be referred to an immunologist but I would be most grateful for any further advice or re-assurance you may be able to give.

Many thanks

[David Tinkelman, M.D.]

The description that you have provided suggests that your asthma is persistent, progressive, severe and sub-optimally responsive to conventional therapy and that must be very discouraging.  It also suggests that you have been receiving good medical care.  I suspect, as do you, that the “tiny blood spots” are related to the stress of hard coughing on chronically inflamed airways and probably not indicative of other, more serious disease.

I suggest that you and your doctors consider referral to one of two medical centers that are in the forefront of severe, refractory asthma management:  National Jewish Health in Denver, Colorado – Dr. Richard Martin and his associates or, The University of Pittsburgh Medical Center in Pittsburgh, PA., -- Dr. Sally Wenzel and her asthma team.  Each of these experts has intensively engaged in research and treated asthma of the severity of yours.  I realize that visiting one of these Centers is not a minor commitment; one that will involve additional expense but if I were faced with your current problem of uncontrolled asthma, one that must certainly have (and continue to have) a serious negative impact on the quality of your life, I would definitely seek to find a way to seek consultation at one of these centers.

Good luck