Symptomatic Management of Lower Respiratory Tract Infections
Cough suppressants, expectorants, mucolytics, antihistamines, inhaled corticosteroids, and bronchodilators should not be prescribed for symptomatic management of acute lower respiratory tract infections (LRTIs) in primary care. 1
Definition and Classification of LRTIs
- LRTIs are acute illnesses (present for 21 days or less), usually with cough as the main symptom, with at least one other lower respiratory tract symptom (sputum production, dyspnoea, wheeze or chest discomfort/pain) 1
- Common types include acute bronchitis, pneumonia, and exacerbations of chronic lung diseases 1
Evidence Against Symptomatic Treatments
- High-quality evidence shows that common symptomatic treatments provide minimal benefit while potentially causing adverse effects 1
- This recommendation is given the highest evidence rating (A1) in clinical guidelines, indicating strong evidence against their routine use 1
Limited Exceptions for Cough Management
- In cases of dry and bothersome cough, dextromethorphan and codeine may be considered for symptom relief 1
- These should be used selectively and not as routine management for all LRTI patients 1
Focus on Appropriate Antibiotic Use
- Antibiotics should be reserved for specific indications:
- Suspected or confirmed pneumonia 1
- COPD exacerbations with all three cardinal symptoms: increased dyspnoea, sputum volume, and sputum purulence 1
- Severe COPD exacerbations 1
- High-risk patients (age >65 with comorbidities like cardiac failure, insulin-dependent diabetes, or serious neurological disorders) 1
Monitoring Response
- Patients should be advised to return if symptoms persist beyond 3 weeks 1
- Clinical effects of antibiotic treatment should be expected within 3 days 1
- Seriously ill patients should be seen again within 2 days of the initial visit 1
Indications for Hospital Referral
- Severely ill patients with suspected pneumonia (tachypnoea, tachycardia, hypotension, confusion) 1
- Patients with pneumonia who fail to respond to antibiotic treatment 1
- Elderly patients with pneumonia and elevated risk of complications 1
- Patients suspected of pulmonary embolism 1
- Patients suspected of malignant disease of the lung 1
Common Pitfalls to Avoid
- Prescribing symptomatic treatments that lack evidence of benefit 1
- Failing to distinguish between viral and bacterial etiologies 2
- Not considering patient risk factors that might warrant more aggressive therapy 2
- Relying solely on clinical examination to rule out pneumonia, as physical signs may be normal or non-specific 3
Special Considerations
- In patients with suspected pneumonia, a chest X-ray should be performed to confirm the diagnosis 1, 3
- C-reactive protein (CRP) testing can help determine the likelihood of pneumonia: levels <20 mg/L make pneumonia highly unlikely, while levels >100 mg/L make pneumonia likely 1
- For patients with prolonged symptoms despite treatment, consider alternative diagnoses or complications 3, 2