Urgent Care Management of Cough
The urgent care management of cough should follow a systematic approach based on cough duration, with initial assessment focusing on ruling out life-threatening conditions and then addressing the most common causes according to duration classification. 1
Initial Assessment
Red Flag Evaluation
- Immediately assess for life-threatening conditions:
Key History Elements
- Duration of cough (acute <3 weeks, subacute 3-8 weeks, chronic >8 weeks)
- Medication use (particularly ACE inhibitors)
- Smoking status
- Systemic symptoms (fever, weight loss)
- Sputum characteristics
- Associated symptoms (dyspnea, wheezing, chest pain) 1
Physical Examination
- Vital signs with oxygen saturation
- Upper airway examination for signs of rhinitis, pharyngitis, postnasal drip
- Lung examination for wheezing, crackles, decreased breath sounds
- Cardiac examination 1
Management Algorithm by Cough Duration
1. Acute Cough (<3 weeks)
A. If signs of serious illness present:
- Obtain chest imaging (X-ray)
- Consider laboratory tests (CBC, blood cultures if febrile)
- Treat underlying condition (antibiotics for pneumonia, etc.)
- Consider hospital admission for severe cases 1, 2
B. If non-life-threatening (common cold, acute bronchitis):
2. Subacute Cough (3-8 weeks)
A. Post-infectious cough:
- Consider inhaled ipratropium bromide as first-line therapy
- For persistent symptoms, consider short course of inhaled corticosteroids
- For severe cases, consider short course of oral prednisone (30-40mg daily) 2
- Rule out pertussis if paroxysmal cough with post-tussive vomiting or inspiratory whooping (obtain nasopharyngeal swab and start macrolide if suspected) 2
B. Non-infectious subacute cough:
- Manage as chronic cough (see below) 1
3. Chronic Cough (>8 weeks)
A. Initial empiric treatment:
- Discontinue ACE inhibitors if applicable (switch to another class) 1
- Smoking cessation counseling for smokers 1
- Begin with oral first-generation antihistamine/decongestant for Upper Airway Cough Syndrome (UACS) for 2-4 weeks 1, 2
B. If cough persists after UACS treatment:
- Evaluate for asthma (consider bronchodilator and inhaled corticosteroid trial for 4 weeks)
- If asthma treatment fails, consider non-asthmatic eosinophilic bronchitis (NAEB) and treat with inhaled corticosteroids 1, 2
C. If cough still persists:
- Evaluate for GERD (empiric trial of PPI with lifestyle modifications for 4-8 weeks)
- Consider referral to specialist if cough remains unexplained 1, 2
Special Considerations
Medication-Related Cough
- ACE inhibitor-induced cough requires discontinuation of the medication and replacement with alternative agent (typically ARB) 1
- Improvement usually occurs within 1-4 weeks after discontinuation 5
Refractory Cough
- For persistent unexplained cough, consider:
Antibiotic Use
- Reserve antibiotics for confirmed bacterial infections
- Not indicated for routine management of acute viral or post-viral cough 2, 4
Common Pitfalls to Avoid
Overuse of antibiotics for viral or post-viral cough - this provides no benefit and contributes to antibiotic resistance 2, 4
Failure to discontinue ACE inhibitors when they are the cause of chronic cough 1
Inadequate duration of empiric therapy - treatments for chronic cough causes often require 2-8 weeks before improvement is seen 1, 2
Missing serious underlying conditions by not obtaining appropriate imaging in patients with concerning symptoms 1, 2
Treating only one cause when multiple etiologies may be contributing to chronic cough 1