What is the plan of care for a patient with acute cough and no signs or symptoms of infection?

Management of Acute Cough Without Signs of Infection

For patients with acute cough and no signs or symptoms of infection, routine antibiotics should not be used, and treatment should focus on symptomatic relief with simple measures like honey and lemon, or over-the-counter antitussives such as dextromethorphan if needed. 1

Initial Assessment

Rule Out Serious Conditions First

• Assess vital signs and perform lung examination to ensure they are normal before proceeding with conservative management 1
• Directly ask about danger signs including:
  • Hemoptysis (requires immediate specialist referral for bronchoscopy) 1
  • Significant breathlessness or dyspnea 1
  • Fever ≥38°C, which would suggest infection 1
  • Purulent sputum production 1
  • Voice changes (may indicate vocal cord palsy) 1
  • History of foreign body inhalation (requires bronchoscopy) 1

When Pneumonia Can Be Excluded

• If vital signs are normal and lung examination is normal, pneumonia is unlikely and antibiotics are not indicated 1
• Consider measuring C-reactive protein (CRP) if there is any clinical uncertainty: CRP <10 mg/L or 10-50 mg/L without dyspnea and daily fever makes pneumonia unlikely 1
• Chest radiography is not needed when vital signs and examination are normal 1

Treatment Approach for Non-Infectious Acute Cough

First-Line Symptomatic Management

• The simplest and most cost-effective approach is a "home remedy" such as honey and lemon 1
• Acute viral cough is almost invariably benign and self-limiting, so prescribed treatment can be considered unnecessary 1
• Simple voluntary suppression of cough may be sufficient to reduce cough frequency through central modulation of the cough reflex 1

Over-the-Counter Antitussive Options (If Symptomatic Relief Needed)

Dextromethorphan is the preferred antitussive agent:

• Effective at suppressing acute cough based on meta-analysis evidence 1
• Recommended dose is 60 mg for maximum cough reflex suppression (commonly available doses are subtherapeutic) 1
• Non-sedating opiate with better side effect profile than codeine 1
• FDA-approved as a cough suppressant 2
• Caution: Do not use if taking MAOIs or within 2 weeks of stopping MAOIs 2
• Stop use if cough lasts more than 7 days or returns with fever, rash, or headache 2

Menthol inhalation:

• Suppresses cough reflex acutely but effect is short-lived 1
• Can be prescribed as menthol crystals or proprietary capsules 1

First-generation sedating antihistamines:

• Suppress cough but cause drowsiness 1
• May be suitable specifically for nocturnal cough that disturbs sleep 1

Agents NOT Recommended

• Codeine and pholcodine have no greater efficacy than dextromethorphan but have a much greater adverse side effect profile and are not recommended 1
• Antibiotics have no role when there are no signs of bacterial infection 1

Consider Alternative Diagnoses

If Cough is Due to Common Cold

• First-generation antihistamine plus decongestant has been shown to decrease severity of cough and hasten resolution of cough and postnasal drip 1
• Naproxen (NSAID) may favorably affect cough in double-blind controlled studies 1

Assess for Non-Infectious Triggers

• Identify and eliminate potential acute irritant or allergic exposures from the environment 1
• Consider acute asthma exacerbation if there is increasing breathlessness (treat appropriately) 1
• Rule out anaphylaxis if acute cough presents with breathlessness 1

Follow-Up and Duration Considerations

• If cough persists beyond 3 weeks, it becomes subacute cough and requires reassessment for postinfectious causes or other etiologies 1, 3
• If cough persists beyond 8 weeks, reclassify as chronic cough and pursue comprehensive evaluation for upper airway cough syndrome, asthma, gastroesophageal reflux disease, or other chronic causes 1, 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics for acute cough without evidence of bacterial infection (normal vital signs, normal lung exam, no fever, no purulent sputum) 1
• Do not overlook the possibility of pertussis if cough lasts ≥2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping 1, 3
• Avoid using codeine-based preparations when dextromethorphan is equally effective with fewer side effects 1
• Do not use aspirin in children <16 years due to Reye's syndrome risk 4