Treatment of Acute Cough with Yellow Mucous, Chest Congestion, and Headache
For acute cough with yellow sputum and systemic symptoms like headache, this is most likely viral acute bronchitis or upper respiratory tract infection that does not require antibiotics, and treatment should focus on symptomatic relief with simple remedies, antihistamine-decongestant combinations, or antitussive agents. 1, 2
Initial Assessment and Red Flags
Before initiating symptomatic treatment, rule out conditions requiring specific intervention:
- Exclude pneumonia if there is tachypnea, tachycardia, dyspnea, or abnormal lung findings on examination—these warrant chest radiography 3, 2
- Consider bacterial sinusitis only if symptoms persist beyond 7 days, as viral and bacterial presentations are indistinguishable in the first week 1
- Assess for pertussis if cough persists beyond 2 weeks with paroxysmal features, post-tussive vomiting, or whooping 1
Primary Treatment Approach
First-Line Symptomatic Management
Start with simple, cost-effective remedies:
- Home remedies such as honey and lemon are as effective as over-the-counter preparations and are the simplest first approach 1
- First-generation antihistamine/decongestant combinations (brompheniramine with sustained-release pseudoephedrine) effectively reduce cough, post-nasal drip, and throat clearing associated with upper respiratory infections 1
- Naproxen can decrease cough in the common cold setting 1
Antitussive Options When Simple Measures Fail
If symptomatic relief is inadequate, consider these agents in order of preference:
- Dextromethorphan at 60 mg (higher than typical over-the-counter doses) provides maximum cough reflex suppression with prolonged effect, though caution is needed with combination products containing paracetamol 1
- Benzonatate offers an alternative to opioid antitussives without the adverse effect profile of codeine, particularly when opioids are contraindicated 4
- Menthol inhalation (menthol crystals or proprietary capsules) provides acute but short-lived cough suppression 1
- Sedative antihistamines (first-generation) suppress cough but cause drowsiness, making them suitable specifically for nocturnal cough 1
- Codeine or pholcodine have no greater efficacy than dextromethorphan but carry significant adverse effects and are not recommended as first-line agents 1
Expectorant Consideration
- Guaifenesin helps loosen phlegm and thin bronchial secretions to make coughs more productive, which may be beneficial for productive cough with yellow mucous 5
What NOT to Do
Avoid these interventions that lack evidence or cause harm:
- Do not prescribe antibiotics for acute viral bronchitis—they provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, and Clostridium difficile infection 1, 2
- Do not use newer-generation nonsedating antihistamines as they are ineffective for reducing cough in the common cold 1
- Do not diagnose bacterial sinusitis during the first week of symptoms, as viral and bacterial presentations are indistinguishable 1
Expected Course and Follow-Up
- Acute viral cough typically lasts 2-3 weeks, and patients should be educated about this natural course 2
- If cough persists beyond 3 weeks but less than 8 weeks, consider post-infectious cough 1
- If cough persists beyond 8 weeks, evaluate for chronic causes including upper airway cough syndrome, asthma, or gastroesophageal reflux disease 6
Clinical Pitfalls to Avoid
- Overuse of antibiotics: The most common error is prescribing antibiotics for viral acute bronchitis—emphasize to patients this is a "chest cold" to reduce expectations for antibiotics 2
- Premature diagnosis of bacterial sinusitis: Wait at least 7 days before considering bacterial infection 1
- Ignoring red flags: Always assess for pneumonia features (tachypnea, abnormal lung findings) that require chest radiography 3, 2
- Underdosing dextromethorphan: Standard over-the-counter doses are subtherapeutic; 60 mg provides optimal cough suppression 1