One-liner#

Evaluate acute cough (<3 weeks) to identify the minority needing antibiotics or urgent workup while managing the majority with supportive care, avoiding unnecessary antibiotics for viral URIs and acute bronchitis.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Respiratory distress: SpO₂ <92%, RR >24, accessory muscle use, inability to speak in full sentences
• Hemoptysis (more than blood-streaked sputum)
• Suspected PE: acute dyspnea + pleuritic chest pain + risk factors (immobility, malignancy, recent surgery)
• High fever with rigors and toxic appearance
• Immunocompromised with fever and respiratory symptoms
• Stridor or signs of upper airway obstruction
• Severe chest pain concerning for cardiac etiology

Key history#

Cough characteristics:

• Duration: <3 weeks = acute; 3–8 weeks = subacute (often post-infectious); >8 weeks = chronic
• Productive vs dry: purulent sputum does NOT reliably distinguish viral from bacterial
• Timing: nocturnal (asthma, GERD, HF), positional (GERD, post-nasal drip)
• Paroxysmal with whooping/post-tussive emesis: consider pertussis

Associated symptoms:

• Nasal congestion, rhinorrhea, sore throat: viral URI
• Fever: present in both viral and bacterial; high fever + rigors more concerning
• Dyspnea: suggests lower respiratory involvement (pneumonia, asthma, HF)
• Wheezing: asthma, bronchitis, COPD exacerbation
• Chest pain: pleuritic (pneumonia, PE), musculoskeletal (cough-induced)
• Hemoptysis: bronchitis (blood-streaked), pneumonia, PE, malignancy

Exposure and risk factors:

• Sick contacts: viral URI, influenza, COVID-19
• Smoking: chronic bronchitis, increased pneumonia risk, lung cancer
• Occupational/environmental: irritants, allergens
• Travel: TB exposure, endemic fungi (histoplasmosis, coccidioidomycosis)
• Immunocompromised: broader differential including opportunistic infections
• Recent hospitalization/healthcare exposure: resistant organisms

Pertussis risk factors:

• Unvaccinated or waning immunity (>10 years since Tdap)
• Paroxysmal cough with whooping, post-tussive emesis, or cough >2 weeks
• Exposure to confirmed case

Medication review:

• ACE inhibitors: dry cough in 5–20% of patients; can occur weeks to months after starting; resolves 1–4 weeks after stopping
• Beta-blockers: may trigger bronchospasm in asthmatics

TB risk factors (consider if any present):

• Born in or travel to high-prevalence country
• Homeless, incarcerated, or congregate living
• HIV or immunocompromised
• Close contact with active TB case
• Healthcare worker
• Cough >3 weeks + fever, night sweats, weight loss

Focused exam#

• Vitals: temperature, SpO₂, respiratory rate (RR >24 concerning)
• General: respiratory distress, ability to speak in full sentences
• HEENT: pharyngeal erythema, tonsillar exudates, post-nasal drip, sinus tenderness
• Neck: lymphadenopathy
• Lungs: wheezes (asthma, bronchitis), crackles (pneumonia, HF), rhonchi (secretions), decreased breath sounds (effusion, consolidation), egophony
• Cardiac: S3 (HF), murmurs
• Extremities: edema (HF), calf tenderness/swelling (DVT → PE)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Most patients with acute cough need NO testing—viral URI and acute bronchitis are clinical diagnoses.

Chest X-ray indications:

• Abnormal vital signs: SpO₂ <95%, HR >100, RR >24, temp >100.4°F (38°C)
• Focal lung findings on exam (crackles, egophony, dullness)
• Dyspnea out of proportion to exam
• Elderly or immunocompromised with respiratory symptoms
• Symptoms >3 weeks without improvement
• Hemoptysis (beyond blood-streaked sputum)
• Smoker with new or changed cough

When NOT to order CXR:

• Typical viral URI symptoms without dyspnea or abnormal vitals
• Acute bronchitis in otherwise healthy patient with normal exam
• Clear post-nasal drip etiology

Other testing:

Initial management#

Viral URI / Acute bronchitis:

• Supportive care: rest, hydration, honey for cough (adults)
• Symptomatic treatment (see medication table)
• NO antibiotics—does not shorten duration; contributes to resistance
• Set expectations: cough may last 2–3 weeks even with viral illness

When antibiotics ARE indicated:

• Confirmed or suspected bacterial pneumonia
• Pertussis (for transmission reduction, not symptom improvement)
• Bacterial sinusitis meeting criteria (symptoms >10 days OR severe onset OR worsening after initial improvement)
• Strep pharyngitis (positive rapid strep or culture)

Symptomatic treatment options:

Management by diagnosis#

Viral URI (Common Cold)#

Education:

• Caused by viruses (rhinovirus most common); antibiotics do not help
• Symptoms peak at days 2–3, then gradually improve over 7–10 days
• Cough may persist 2–3 weeks after other symptoms resolve

Treatment:

• Supportive care: rest, hydration
• Symptomatic relief: see medication table above
• Saline nasal irrigation
• Honey for cough (1–2 tablespoons at bedtime)

Follow-up: Return if symptoms worsen, fever develops, or not improving after 10 days.

Acute Bronchitis#

Education:

• Inflammation of bronchial tubes, usually following viral URI
• Cough is the predominant symptom; may produce sputum (color does NOT indicate bacterial infection)
• Typically resolves in 2–3 weeks; cough may linger longer
• Antibiotics do NOT help—multiple studies show no benefit

Treatment:

• Supportive care: rest, hydration, honey
• Cough suppressants if cough is disruptive (dextromethorphan, benzonatate)
• If wheezing present: consider albuterol inhaler

Follow-up: Return if dyspnea worsens, high fever develops, or cough not improving after 3 weeks.

Influenza#

Education:

• Viral infection; abrupt onset of fever, myalgias, cough, fatigue
• Most recover in 1–2 weeks; antivirals shorten duration by ~1 day if started early
• High-risk groups benefit most from antivirals

Treatment:

Antivirals—start within 48 hours of symptom onset:

Who should receive antivirals:

• Hospitalized patients
• Severe or progressive illness
• High-risk: age ≥65, chronic medical conditions (lung, heart, kidney, liver, diabetes), immunocompromised, pregnancy, BMI ≥40, nursing home residents
• Consider for household contacts of high-risk individuals

Supportive care:

• Acetaminophen or ibuprofen for fever/myalgias
• Rest, hydration
• Cough suppressants PRN

Follow-up: Return if dyspnea worsens, symptoms not improving after 7 days, or new concerning symptoms.

COVID-19#

Education:

• Viral infection; symptoms range from mild cold-like illness to severe pneumonia
• Isolation per current CDC guidelines
• High-risk patients may benefit from antivirals

Treatment:

Antivirals for high-risk patients (start within 5 days of symptom onset):

High-risk criteria for antivirals:

• Age ≥65
• Obesity (BMI ≥30)
• Diabetes, CKD, cardiovascular disease, chronic lung disease
• Immunocompromised
• Unvaccinated or incompletely vaccinated

Supportive care:

• Rest, hydration
• Acetaminophen for fever
• Pulse oximetry monitoring at home if available

Follow-up: Return if dyspnea worsens, SpO₂ <94%, or symptoms not improving after 7 days.

Community-Acquired Pneumonia (CAP)#

Education:

• Bacterial infection of the lungs; requires antibiotics
• Most outpatients recover fully with oral antibiotics
• Cough and fatigue may persist for several weeks after treatment

Treatment:

Outpatient CAP (no comorbidities, no recent antibiotics):

Outpatient CAP (comorbidities: chronic heart, lung, liver, renal disease; diabetes; alcoholism; malignancy; asplenia; immunocompromising conditions; or antibiotic use in past 3 months):

Follow-up: Reassess in 48–72 hours if not improving. CXR follow-up at 6–8 weeks for smokers or age >50 to ensure resolution (rule out underlying malignancy).

ACE Inhibitor Cough#

Education:

• Occurs in 5–20% of patients on ACE inhibitors
• Can develop weeks to months after starting medication
• Dry, tickling cough; often worse at night
• Resolves 1–4 weeks after stopping ACE inhibitor (occasionally longer)

Treatment:

• Switch to ARB (cross-reactivity <1%)
• If ACE inhibitor strongly indicated (e.g., HF with reduced EF, post-MI), discuss with cardiology before switching

Follow-up: Reassess cough 2–4 weeks after switching to ARB. If cough persists, evaluate for other causes.

Subacute/Post-Infectious Cough#

Education:

• Cough persisting 3–8 weeks after acute respiratory infection
• Due to bronchial hyperreactivity and/or post-nasal drip following infection
• Gradually improves over weeks; no antibiotics needed

Treatment:

• Reassurance and time (most resolve by 8 weeks)
• If bronchospasm suspected: albuterol inhaler PRN
• If post-nasal drip prominent: nasal steroid + antihistamine
• If severe/disruptive: consider short course of inhaled corticosteroid

Follow-up: If cough persists >8 weeks, transition to chronic cough workup (upper airway cough syndrome, asthma, GERD).

Pertussis#

Education:

• Highly contagious bacterial infection; “100-day cough”
• Three phases: catarrhal (1–2 weeks, cold-like), paroxysmal (1–6 weeks, severe coughing fits), convalescent (weeks to months, gradual improvement)
• Antibiotics reduce transmission but do not significantly shorten symptoms if started in paroxysmal phase
• Reportable disease—notify public health

Treatment:

Post-exposure prophylaxis:

• Same regimens as treatment
• Indicated for close contacts, especially high-risk (infants, pregnant women, immunocompromised)

Follow-up: Cough may persist for weeks to months; reassure patient. Notify public health. Ensure close contacts receive prophylaxis.

Asthma Exacerbation#

Education:

• Airway inflammation and bronchospasm triggered by infection, allergens, or irritants
• Viral URIs are the most common trigger for exacerbations
• Early treatment prevents progression to severe exacerbation

Treatment:

Mild exacerbation (speaking in sentences, SpO₂ >94%):

• Increase SABA use: albuterol 2–4 puffs Q4–6H PRN
• Consider short course of oral steroids if not responding

Moderate exacerbation (speaking in phrases, SpO₂ 90–94%):

Severe exacerbation (speaking in words, SpO₂ <90%, accessory muscle use):

• Send to ED
• While awaiting transport: continuous albuterol nebulizer, ipratropium, start steroids

Follow-up: Reassess in 1–2 days if moderate exacerbation. Review maintenance therapy; step up if needed. Ensure asthma action plan in place.

COPD Exacerbation#

Education:

• Acute worsening of respiratory symptoms beyond normal day-to-day variation
• Usually triggered by infection (viral or bacterial) or environmental factors
• Defined by increased dyspnea, sputum volume, and/or sputum purulence

Treatment:

Outpatient management (mild-moderate exacerbation):

Antibiotic indications in COPD exacerbation:

• All 3 cardinal symptoms (increased dyspnea + increased sputum volume + increased sputum purulence)
• 2 cardinal symptoms if one is increased purulence
• Severe exacerbation requiring mechanical ventilation

Follow-up: Reassess in 48–72 hours. If not improving, consider CXR, escalation of therapy, or hospitalization. Review maintenance therapy after recovery.

Follow-up#

Default intervals:

• Viral URI/acute bronchitis: Return only if worsening or not improving after 10 days
• Influenza/COVID: Reassess if not improving after 7 days or worsening
• Pneumonia: Phone or in-person reassessment at 48–72 hours; CXR at 6–8 weeks for smokers/age >50
• Asthma/COPD exacerbation: Reassess in 1–2 days; follow-up in 2–4 weeks to review maintenance therapy

Return precautions (all patients):

• Worsening shortness of breath or difficulty breathing
• Fever >101.3°F (38.5°C) that is new or worsening
• Coughing up blood (more than streaks)
• Chest pain that is severe or worsening
• Unable to keep fluids down
• Confusion or altered mental status
• Symptoms not improving after expected timeframe

Patient instructions#

• Most coughs are caused by viruses and will get better on their own in 1–3 weeks. Antibiotics do not help viral infections.
• Rest and drink plenty of fluids. Honey (1–2 tablespoons) at bedtime can help soothe cough.
• Over-the-counter cough medicines may provide some relief but will not cure the cough.
• Wash your hands frequently and cover your cough to avoid spreading infection.
• If you smoke, this is a good time to consider quitting—smoking prolongs cough and increases risk of complications.
• Take any prescribed medications exactly as directed, even if you start feeling better.
• Call the office or seek care if you develop worsening shortness of breath, high fever, coughing up blood, or chest pain.

Smartphrase snippets#

.COUGHACUTEVIRAL Acute cough consistent with viral upper respiratory infection. No red flags (normal oxygen, no respiratory distress, no focal lung findings). Plan: supportive care with rest, hydration, honey for cough, OTC symptomatic treatment PRN. Antibiotics not indicated. Discussed expected course (1–3 weeks) and return precautions.

.COUGHACUTEBRONCHITIS Acute bronchitis. Cough predominant symptom following viral URI. No evidence of pneumonia (normal vitals, no focal lung findings, no hypoxia). Plan: supportive care; antibiotics not indicated per guidelines. Discussed that cough may persist 2–3 weeks. Return if worsening dyspnea, high fever, or not improving after 3 weeks.

.COUGHACUTEPNEUMONIA Community-acquired pneumonia confirmed on CXR. Outpatient treatment appropriate (no hypoxia, no severe illness, able to take PO). Started [amoxicillin 1g TID / doxycycline 100mg BID / levofloxacin 750mg daily] x 5 days. Discussed return precautions and need for reassessment if not improving in 48–72 hours. CXR follow-up scheduled for [date] to confirm resolution.

Related pages#

• Cough (Chronic) — evaluation of cough lasting >8 weeks
• Dyspnea (Acute) — acute shortness of breath differential
• Wheeze — wheezing-focused evaluation
• Heart Failure (problem) — chronic HF management when cough is due to pulmonary congestion
• Asthma (problem) — chronic asthma management
• COPD (problem) — chronic COPD management