What is the initial management for a patient presenting with cough, congestion, sneezing, and a sensation of lungs burning in primary care?

Initial Management of Acute Cough with Congestion, Sneezing, and Burning Sensation

For a patient presenting with cough, congestion, sneezing, and a burning sensation in the lungs, first rule out pneumonia by checking vital signs and lung examination, then treat symptomatically with a first-generation antihistamine/decongestant combination plus naproxen for likely viral upper respiratory infection. 1, 2

Immediate Assessment: Rule Out Serious Illness

Your first priority is determining whether this represents a life-threatening condition versus a common viral illness 1:

Check for pneumonia indicators:

• Measure vital signs: tachypnea (elevated respiratory rate), tachycardia (heart rate >100), fever ≥38°C 1, 3
• Examine lungs for crackles, diminished breath sounds, or focal findings 1
• Assess for dyspnea or increased work of breathing 1, 3

If pneumonia is suspected (abnormal vital signs or lung findings), obtain a chest radiograph immediately 1, 2. Consider measuring C-reactive protein if available—CRP ≥30 mg/L increases pneumonia likelihood, while CRP <10 mg/L makes it unlikely 1.

If vital signs and lung exam are normal, pneumonia is unlikely and you're dealing with acute viral upper respiratory infection 1.

Key Historical Questions

• ACE inhibitor use? Stop immediately if present—this is a reversible cause of cough 1, 2, 4
• Smoking status? Counsel on cessation as this exacerbates cough 1, 2, 4
• Duration of symptoms? Acute cough (<3 weeks) suggests viral infection 1, 4
• Pertussis exposure or cough >2 weeks with paroxysms? Consider pertussis testing 1, 3

Treatment for Likely Viral Upper Respiratory Infection

Primary therapy (supported by double-blind placebo-controlled evidence):

• First-generation antihistamine/decongestant combination (e.g., chlorpheniramine + pseudoephedrine) decreases cough severity and hastens resolution 1, 2, 4
• Naproxen (nonsteroidal anti-inflammatory) favorably affects cough 1, 4

Symptomatic management:

• Oral decongestants for congestion relief 5
• Dextromethorphan-containing cough remedies may provide modest benefit 1
• Honey and lemon, menthol lozenges, or vapor for comfort 1

Critical Pitfall to Avoid

Do NOT prescribe antibiotics for this presentation if pneumonia is ruled out 1, 3. Acute bronchitis and viral upper respiratory infections do not benefit from antibiotics—they only reduce cough by approximately half a day while causing adverse effects including allergic reactions, nausea, and Clostridium difficile infection 3.

Patient Education

• Cough typically lasts 2-3 weeks with viral infections 3
• This is a "chest cold" or viral upper respiratory infection, not requiring antibiotics 3
• Practice respiratory hygiene: use handkerchief, wash hands frequently 1
• Stop smoking if applicable 1, 2

When to Reassess or Refer

Return immediately if:

• Coughing up blood 1
• Worsening breathlessness 1
• Prolonged fever with feeling unwell 1
• Symptoms persist beyond 3 weeks 1

If cough persists 3-8 weeks (subacute), consider postinfectious cough with persistent upper airway inflammation, transient bronchial hyperresponsiveness, or asthma exacerbation 1, 2. At that point, consider spirometry and empiric trial of inhaled bronchodilators/corticosteroids if asthma suspected 2, 4.