When is a virtual visit appropriate for a patient presenting with cough?

Virtual Visits for Cough: Appropriateness Guidelines

Virtual visits are appropriate for patients with acute cough (less than 3 weeks duration) who have no red flag symptoms, while patients with chronic cough (more than 8 weeks) or concerning symptoms should be evaluated in person.

Assessment of Cough Duration and Classification

• Cough should be classified based on duration: acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) 1
• The initial assessment should determine if the cough represents a potentially life-threatening condition requiring immediate in-person evaluation 1
• Virtual visits are most suitable for acute cough without red flags, as these are typically due to self-limiting upper respiratory infections 1

Red Flags Requiring In-Person Evaluation

• Hemoptysis (blood in sputum) 1
• Smoker >45 years of age with a new cough or change in cough pattern 1
• Prominent dyspnea (shortness of breath), especially at rest or at night 1
• Hoarseness accompanying the cough 1
• Systemic symptoms such as fever, weight loss, or peripheral edema 1
• Trouble swallowing, vomiting, or recurrent pneumonia 1
• Abnormal findings on previous chest imaging 1

Virtual Visit Appropriateness by Cough Type

Appropriate for Virtual Visit:

• Acute cough (<3 weeks) without red flags 1
• Follow-up visits for previously diagnosed and stable cough conditions 1
• Routine follow-up within 4-6 weeks after initial evaluation as recommended by guidelines 1

Not Appropriate for Virtual Visit:

• Any cough with red flag symptoms 1
• Chronic cough (>8 weeks) requiring physical examination and potentially imaging 1
• Subacute cough (3-8 weeks) that hasn't responded to initial treatment 1
• Suspected COVID-19 cases requiring specific infection control protocols 1

Virtual Visit Assessment Components

• Detailed history of cough timing, intensity, and quality 1
• Assessment of cough severity using validated tools like the Punum ladder scale 1
• Screening for environmental and occupational exposures 1
• Medication review, particularly for ACE inhibitors which can cause persistent cough 1, 2
• Evaluation for common causes based on duration (upper respiratory infection for acute cough; post-infectious cough, asthma, or upper airway cough syndrome for subacute cough) 2, 3

Follow-Up Recommendations

• All patients with cough should be followed up within 4-6 weeks of initial assessment 1
• If cough persists beyond 8 weeks despite treatment, reclassify as chronic cough and arrange in-person evaluation 1, 2
• Patients initially managed virtually who develop new red flags should be promptly seen in person 1

Common Pitfalls to Avoid

• Failing to recognize red flags that require in-person evaluation 1
• Not using validated cough severity tools to objectively assess symptoms 1, 2
• Overlooking the possibility of pertussis in adults with prolonged cough 2
• Inappropriate use of antibiotics for viral or post-infectious cough 2
• Relying solely on patient history without appropriate physical examination for chronic cough 4, 5

Special Considerations

• Patients with suspected COVID-19 require specific infection control protocols that may not be compatible with routine in-person visits 1
• Chest imaging (radiography or CT) is essential for evaluating chronic cough but cannot be performed virtually 1
• The diagnostic value of history alone is limited for determining the cause of chronic cough, making physical examination crucial 4