What's the next step for a patient with a 3-week cough producing white phlegm, not responding to bronchodilator (inhaler) therapy, and showing mild attenuation of bronchovascular markings on chest X-ray (CXR), who has never taken antibiotics or corticosteroids (steroids)?

Management of 3-Week Cough with Mild CXR Findings

For this patient with a 3-week cough producing white phlegm and mild attenuation of bronchovascular markings on CXR who has failed bronchodilator therapy, you should NOT routinely prescribe antibiotics, and CT imaging is NOT indicated at this stage—instead, consider this a postinfectious cough and initiate a trial of inhaled ipratropium bromide. 1

Immediate Clinical Assessment

At 3 weeks, this cough is transitioning from acute to subacute (defined as 3-8 weeks duration), which places it in the postinfectious cough category rather than acute bronchitis. 1

Key diagnostic considerations at this stage:

• Rule out pertussis: If the cough includes paroxysms, post-tussive vomiting, or inspiratory whooping sounds, obtain nasopharyngeal culture for Bordetella pertussis immediately. 1 Early macrolide treatment (within first few weeks) diminishes coughing paroxysms and prevents disease spread. 1

• Exclude pneumonia clinically: The mild attenuation of bronchovascular markings on CXR does not suggest pneumonia. Pneumonia is unlikely if the patient lacks: heart rate >100 bpm, respiratory rate >24 breaths/min, fever >38°C, or focal consolidation findings on exam. 1

• Consider cough-variant asthma: Since the bronchodilator (Breyna inhaler) failed, cough-variant asthma becomes less likely, though not excluded. 1 True cough-variant asthma typically requires >2-3 weeks to diagnose and should show improvement with bronchodilator therapy. 1

CT Imaging Decision

CT is NOT indicated at this stage. 1

• Chest radiography is warranted for cough lasting ≥3 weeks in the absence of other known causes, which you've already completed. 1
• CT (specifically high-resolution CT) is reserved for suspected bronchiectasis when CXR is not characteristic, or when chronic cough persists beyond 8 weeks without diagnosis. 1, 2
• The mild attenuation of bronchovascular markings is a nonspecific finding that does not warrant immediate CT imaging. 1

Antibiotic Decision

Antibiotics are NOT indicated. 1

• Routine antibiotic treatment for uncomplicated acute bronchitis or postinfectious cough is not justified, regardless of cough duration. 1
• Fewer than 10% of acute bronchitis cases have bacterial etiology. 1
• For postinfectious cough not due to bacterial sinusitis or early pertussis infection, antibiotics have no role since the cause is not bacterial. 1
• White phlegm (as opposed to purulent sputum) does not indicate bacterial infection. 1

Recommended Treatment Algorithm

First-Line Therapy: Inhaled Ipratropium

Initiate inhaled ipratropium bromide as first-line treatment. 1

• This anticholinergic agent may attenuate postinfectious cough by reducing mucus hypersecretion and airway irritability. 1
• Evidence quality is fair with intermediate benefit (Grade B). 1

Second-Line Therapy: Inhaled Corticosteroids

If cough persists and adversely affects quality of life despite ipratropium, add inhaled corticosteroids. 1

• Postinfectious cough involves extensive airway inflammation and epithelial disruption. 1
• Inhaled corticosteroids address the underlying inflammatory pathology. 1
• This is expert opinion with intermediate benefit (Grade E/B). 1

Third-Line Therapy: Oral Corticosteroids

For severe, persistent cough after failing above measures, consider prednisone 30-40 mg daily for a short course. 1

• This should only be used when other common causes (upper airway cough syndrome, asthma, gastroesophageal reflux) have been ruled out. 1
• Evidence quality is low with intermediate benefit (Grade C). 1

Symptomatic Relief

Central-acting antitussives (codeine or dextromethorphan) can be offered when other measures fail. 1

• These provide short-term symptomatic relief but don't address underlying pathology. 1
• Evidence is fair with small/weak benefit (Grade C). 1

Critical Pitfalls to Avoid

Do not prescribe expectorants or mucokinetic agents—they show no consistent favorable effect on cough. 1

Do not continue bronchodilator therapy alone—the patient already failed this approach, and bronchodilators are not routinely recommended for acute bronchitis without wheezing. 1

Do not delay evaluation beyond 8 weeks—if cough persists past 8 weeks, it becomes chronic cough requiring comprehensive workup including consideration of upper airway cough syndrome, gastroesophageal reflux disease, non-asthmatic eosinophilic bronchitis, and potentially spirometry or methacholine challenge testing. 1, 3

When to Reassess

Re-evaluate at 2-3 weeks (5-6 weeks total cough duration). 1

• If cough persists beyond 8 weeks total, diagnoses other than postinfectious cough must be considered. 1
• At that point, consider spirometry, sputum induction for eosinophils, and evaluation for chronic causes. 1, 3