What is the recommended treatment for a wet cough?

Treatment of Wet Cough

For children with chronic wet cough (>4 weeks duration) without specific warning signs, prescribe a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), with amoxicillin-clavulanate as the preferred agent. 1

Age-Specific Management Pathways

Children (≤14 years)

Initial Assessment:

• Determine cough duration: acute (<4 weeks) vs. chronic (>4 weeks), as this fundamentally changes management 1, 2
• Assess for "specific cough pointers" that indicate underlying disease requiring immediate investigation: coughing with feeding, digital clubbing, chest deformity, growth failure, or respiratory distress 1, 2
• Evaluate the character of sputum if the child can expectorate (color, consistency) 2

Treatment Algorithm for Chronic Wet Cough (>4 weeks):

1. Without specific cough pointers: Initiate 2 weeks of antibiotics targeted to common respiratory bacteria based on local antibiotic sensitivities 1

2. If cough resolves within 2 weeks: Diagnose as protracted bacterial bronchitis (PBB) 1, 2

3. If cough persists after 2 weeks: Prescribe an additional 2 weeks of appropriate antibiotics 1

4. If cough persists after 4 weeks total: Proceed to further investigations including flexible bronchoscopy with quantitative cultures and sensitivities, with or without chest CT 1, 2

5. With specific cough pointers present: Immediately undertake further investigations (flexible bronchoscopy and/or chest CT, assessment for aspiration, evaluation of immunologic competency) to assess for underlying disease 1

Acute Wet Cough (<4 weeks):

• Watchful waiting is appropriate without antibiotics unless signs of bacterial pneumonia are present 3
• Maintain adequate hydration through continued breastfeeding or formula/fluid intake 4
• Use saline nasal drops for nasal congestion contributing to post-nasal drip 4
• Minimize environmental irritants, particularly tobacco smoke exposure 4, 2

Adults

Symptomatic Management:

• For productive cough with thick mucus, guaifenesin 200-400 mg every 4 hours (up to 6 times daily) or extended-release formulations 1200 mg every 12 hours can help loosen phlegm and thin bronchial secretions 5, 6, 7
• Guaifenesin has demonstrated efficacy in reducing cough reflex sensitivity in patients with upper respiratory tract infections 8
• Simple home remedies such as honey and lemon may provide symptomatic relief 1

Critical Warning Signs Requiring Immediate Evaluation

Return immediately if any of the following develop:

• Respiratory distress (increased respiratory rate, retractions, grunting) 4, 2, 3
• High fever ≥39°C (102.2°F) 2, 3
• Oxygen saturation drops below 92% 4
• Paroxysmal cough with post-tussive vomiting or inspiratory "whoop" (suggesting pertussis) 4, 2, 3
• Inability to feed or signs of dehydration 4, 3
• Change in sputum to purulent (yellow/green) without improvement 2

Important Pitfalls to Avoid

In Children:

• Do NOT use over-the-counter cough and cold medications in children under 6 years due to lack of efficacy and risk of serious adverse events 4
• Do NOT prescribe codeine-containing medications due to potential for serious side effects including respiratory distress 4
• Do NOT prescribe antibiotics for acute wet cough (<4 weeks duration) unless there are signs of bacterial pneumonia or specific bacterial infection 3
• Do NOT dismiss chronic wet cough as "just a cold" - persistent wet cough for >4 weeks requires active management as it may prevent progression to bronchiectasis 2
• Do NOT delay antibiotic therapy in children with chronic wet cough without specific cough pointers once the 4-week threshold is reached 2

In Adults:

• Opiate antitussives (codeine, pholcodine) have no greater efficacy than other agents but carry a significant adverse side effect profile and are not recommended 1

Terminology Clarification

• Young children typically do not expectorate, so the term "wet cough" (defined by its loose, self-propagating sound) is used 1
• When children can expectorate, the term "productive cough" is preferred 1, 2
• If lower airway confirmation shows clinically important density of respiratory bacteria (≥10⁴ cfu/mL), use the term "microbiologically-based-PBB" (PBB-micro) to differentiate from clinically-based-PBB 1