What is the treatment for a patient with cough and congestion for two weeks?

Treatment of Cough and Congestion at Two Weeks

For a patient with cough and congestion lasting two weeks, first rule out pertussis (especially if paroxysmal cough, post-tussive vomiting, or whooping sound is present), then treat symptomatically with inhaled ipratropium as first-line therapy, avoiding antibiotics unless bacterial infection is confirmed. 1, 2

Immediate Diagnostic Considerations

Rule Out Pertussis First

• Any cough lasting ≥2 weeks with paroxysmal episodes, post-tussive vomiting, or inspiratory whooping sound should be presumed to be pertussis until proven otherwise. 1, 2
• If pertussis is suspected, obtain a nasopharyngeal aspirate or Dacron swab for culture confirmation, but do not delay treatment while awaiting results. 1, 2
• Start azithromycin 500 mg once daily for 3-5 days immediately if pertussis is suspected, as early treatment within the first few weeks diminishes coughing paroxysms and prevents disease spread. 1, 2
• Isolate the patient for 5 days from the start of antibiotic treatment to prevent transmission. 1, 2

Assess for Other Specific Causes

• Stop any ACE inhibitor medications, as they commonly cause cough that typically resolves within days to 2 weeks of discontinuation. 2
• Evaluate smoking status, as smoking cessation is first-line treatment and most smoking-related coughs resolve within 4 weeks. 2
• Look for signs of bacterial sinusitis, though diagnosis should not be made during the first week of symptoms as viral and bacterial presentations are indistinguishable early on. 1

First-Line Symptomatic Treatment

For Upper Airway Symptoms (Congestion)

• Start a first-generation antihistamine/decongestant combination as first-line therapy for upper airway cough syndrome with congestion. 1, 3
• Add intranasal corticosteroids (such as fluticasone or mometasone) for at least 2-4 weeks if nasal congestion is prominent. 1, 3
• Avoid nasal decongestant sprays for more than 3-5 days due to risk of rebound congestion. 3

For Cough Suppression

• Inhaled ipratropium bromide is the recommended first-line agent for cough suppression in postinfectious cough, as it may attenuate the cough with fair evidence of benefit. 1, 2, 4
• If ipratropium fails and cough adversely affects quality of life, consider adding inhaled corticosteroids (such as budesonide or fluticasone). 1, 3
• Central-acting antitussives like dextromethorphan (60 mg, not subtherapeutic over-the-counter doses) or codeine should be reserved for when other measures fail. 1, 2, 4
• For severe paroxysms of cough, consider prednisone 30-40 mg daily for a short, finite period after ruling out other common causes like asthma or GERD. 1, 2, 3

What NOT to Do

Avoid Inappropriate Antibiotic Use

• Antibiotics have no role in treating postinfectious cough not due to bacterial sinusitis or pertussis, as the cause is viral, not bacterial. 1, 4
• Meta-analyses show antibiotics decrease cough duration by only 0.5 days over a 7-day period, with no impact on illness duration, activity limitation, or work loss. 1
• Routine antibiotic treatment contributes to resistance and causes adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection. 1, 4, 5

Avoid Ineffective Therapies

• Do not prescribe expectorants, mucolytics, or antihistamines alone for acute lower respiratory tract infection, as consistent evidence for beneficial effects is lacking. 4
• Guaifenesin may help loosen phlegm but has limited evidence for efficacy in postinfectious cough. 6, 7

Timeline for Reassessment

Expected Course

• The cough associated with acute viral bronchitis typically lasts 2-3 weeks, and patients should be counseled about this natural course. 5
• At 2 weeks, this is still considered acute cough with a different management approach than subacute (3-8 weeks) or chronic (>8 weeks) cough. 2, 4, 8

When to Escalate

• If cough persists beyond 3 weeks, consider postinfectious cough and trial ipratropium if not already started. 2, 3
• If cough persists beyond 8 weeks, reclassify as chronic cough and perform full workup including evaluation for asthma, GERD, and upper airway cough syndrome. 1, 2, 8
• Immediate further investigation is warranted if hemoptysis, constitutional symptoms, respiratory distress, hypoxemia, or risk factors for malignancy (age >40, smoking history) are present. 2

Critical Pitfalls to Avoid

• Delaying pertussis treatment while waiting for laboratory confirmation decreases treatment effectiveness, as antibiotics are most beneficial when started within the first 2 weeks. 1, 2
• Misclassifying a 2-week cough as chronic leads to inappropriate extensive workup and treatment. 2, 4
• Using subtherapeutic doses of over-the-counter dextromethorphan (typically 10-20 mg) instead of therapeutic doses (60 mg) provides insufficient cough suppression. 2, 4
• Forgetting isolation precautions if pertussis is diagnosed can lead to community transmission. 1, 2
• Prescribing antibiotics indiscriminately for viral postinfectious cough provides no benefit and contributes to antibiotic resistance. 1, 4