Diagnosis and Management of Acute Upper Respiratory Symptoms
Primary Diagnosis
This patient most likely has either the common cold or acute bronchitis, which are clinically overlapping syndromes that are difficult—and often impossible—to distinguish from one another. 1
The combination of sore throat, nasal stuffiness, cough, and sputum production represents classic symptoms of an acute upper respiratory tract infection (URTI). 1 The hallmark symptoms of the common cold specifically include nasal stuffiness and discharge, sneezing, sore throat, and cough, with cough occurring in up to 83% of cases within the first 2 days of illness. 1 Acute bronchitis presents with cough (with or without sputum production) as the predominant symptom, often accompanied by other respiratory symptoms. 1
Critical Diagnostic Distinctions
Before finalizing the diagnosis, you must actively rule out pneumonia, acute asthma, and COPD exacerbation. 1
Pneumonia can be clinically excluded if the patient lacks ALL of the following: heart rate >100 bpm, respiratory rate >24 breaths/min, oral temperature >38°C, and focal consolidation findings (egophony or fremitus) on chest examination. 1, 2 If any of these are present, obtain a chest radiograph. 1
Acute asthma is frequently misdiagnosed as acute bronchitis in approximately one-third of patients presenting with acute cough. 1 Consider asthma if the patient has had at least two similar episodes in the past 5 years (65% of such patients have mild asthma). 1
Influenza should be considered if fever is present along with headache, myalgia, cough, and sore throat. 1
Management Algorithm
Step 1: Do NOT Prescribe Antibiotics
Routine antibiotic treatment is not justified and should not be offered for acute bronchitis or the common cold. 1 Fewer than 10% of acute bronchitis cases are bacterial, and most are viral in origin. 1 Antibiotics provide no benefit for viral URTIs and significantly increase adverse effects in adults (odds ratio 3.6). 3
Step 2: Symptomatic Treatment Options
Offer short-term symptomatic relief with the following agents: 1
Antitussive agents (dextromethorphan or codeine) can be offered for short-term cough suppression. 1
First-generation antihistamines (diphenhydramine) may help with nasal symptoms and cough. 1
Decongestants (phenylephrine) for nasal stuffiness. 1
Analgesics (acetaminophen, ibuprofen, or naproxen) for sore throat pain and any fever. 4, 5
Step 3: Avoid Ineffective Therapies
Do NOT prescribe the following: 1, 2
Expectorants or mucokinetic agents have no consistent favorable effect on cough. 2
Inhaled bronchodilators (β-agonists) should not be routinely used unless the patient has wheezing, and even then benefit is small. 1
Topical antibiotics lack evidence for benefit and contribute to antimicrobial resistance. 6
Step 4: Reassess if Symptoms Persist
If cough persists beyond 3 weeks, the diagnosis must be reconsidered. 1 At this point:
Consider pertussis if there are paroxysms, post-tussive vomiting, or inspiratory whooping sounds—obtain nasopharyngeal culture for Bordetella pertussis and treat with a macrolide antibiotic if confirmed. 1, 2
Consider subacute cough management with inhaled ipratropium bromide as first-line treatment, followed by inhaled corticosteroids if needed. 2
Obtain chest radiography for cough lasting ≥3 weeks without other known causes. 2
Common Pitfalls to Avoid
Do not prescribe antibiotics to meet patient expectations. Instead, explain that antibiotics will not help viral infections and may cause harm. 1 The widespread use of antibiotics for acute bronchitis is not justified and vigorous efforts to curtail their use should be encouraged. 1
Do not confuse acute bronchitis with asthma. If the patient has recurrent episodes, consider asthma as the underlying diagnosis. 1
Do not delay evaluation beyond 3 weeks. Acute bronchitis is self-limited and should resolve within 3 weeks; persistence requires investigation for other causes. 1