What is the initial approach in primary care for a patient presenting with coughing and shortness of breath without current home medications?

Initial Primary Care Approach to Cough and Shortness of Breath

Obtain a chest radiograph and perform spirometry immediately, as these are mandatory baseline investigations for any patient presenting with cough and shortness of breath. 1, 2

Immediate Assessment

Red Flags Requiring Urgent Evaluation

• Assess for life-threatening conditions including pneumonia, pulmonary embolism, or systemic illness requiring immediate intervention 2, 3
• Evaluate respiratory distress indicators: markedly elevated respiratory rate, intercostal retractions, cyanosis, altered mental status, grunting, or severe breathlessness 2, 3
• Identify high-risk features: hemoptysis, prominent systemic illness, suspicion of inhaled foreign body, or concern for lung cancer 1, 2

Essential History Elements

• Medication review: Specifically ask about ACE inhibitors, which must be discontinued immediately if present as they are a common reversible cause of cough 2, 3
• Smoking status: Counsel on cessation, as 90-94% of smokers experience cough resolution within the first year of quitting 2
• Duration of symptoms: Classify as acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) to guide diagnostic approach 1, 2
• Occupational history: Detailed assessment for inhalational exposures 1
• Associated symptoms: Fever, sputum production, wheezing, chest pain, weight loss, night sweats 1, 3

Physical Examination Focus

• Lung auscultation: Listen for wheezes (suggesting asthma/COPD), crackles (suggesting pneumonia, bronchiectasis, or interstitial disease), or prolonged expiratory phase 1
• Upper airway examination: Assess for signs of rhinosinusitis or postnasal drip 1
• General examination: Check for finger clubbing (suggesting malignancy or bronchiectasis), signs of heart failure, or pleural effusion 1

Mandatory Baseline Investigations

Chest Radiograph

Order a chest radiograph for all patients with chronic cough and those with acute cough demonstrating atypical symptoms (fever, tachypnea, tachycardia, dyspnea, abnormal lung findings). 1, 2, 3 In general respiratory clinics, 31% of chest radiographs requested for persistent cough were abnormal or yielded a diagnosis. 1

Spirometry

Perform spirometry in all patients with chronic cough. 1, 2 This helps identify:

• Obstructive pattern: Chronic airways obstruction from asthma or COPD 1
• Reversibility testing: If obstruction is present, measure FEV1 before and after inhaling a short-acting β2 agonist (salbutamol 400 mcg by metered dose inhaler with spacer or 2.5 mg by nebulizer) 1, 4

Critical caveat: Normal spirometry does not exclude asthma as a cause of chronic cough, as many patients with cough-variant asthma lack spirometric reversibility. 1

Initial Management Based on Duration

Acute Cough (<3 weeks)

Most commonly caused by viral upper respiratory tract infection. 1

For common cold with cough:

• First-generation antihistamine/decongestant combination plus naproxen 2, 3
• Do not use newer non-sedating antihistamines as they are ineffective for cough 3

For acute exacerbation of chronic bronchitis:

• Short course (10-15 days) of systemic corticosteroids 2, 3

If pneumonia is suspected based on tachypnea, tachycardia, dyspnea, or abnormal lung findings:

• Obtain chest radiograph and initiate appropriate antibiotic therapy 3

Subacute Cough (3-8 weeks)

Determine if postinfectious or non-infectious. Consider upper airway cough syndrome, transient bronchial hyperresponsiveness, asthma, or pertussis. 2 Pertussis can cause persistent cough, with 10% of chronic cough cases showing positive nasal swabs for Bordetella. 1

Chronic Cough (>8 weeks)

Use a sequential and additive treatment approach targeting the three most common causes, which frequently coexist. 2, 3

Empiric Treatment for Common Causes

Upper Airway Cough Syndrome (UACS)

• Oral first-generation antihistamine/decongestant combination 2, 3
• Add topical corticosteroid if prominent upper airway symptoms are present 2

Asthma

If spirometry shows reversible airflow obstruction:

• Inhaled bronchodilators and inhaled corticosteroids 2, 3

If spirometry is normal but asthma suspected:

• Consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids and bronchodilators 2
• For patients with normal spirometry and bronchodilator response in whom cough-predominant asthma or eosinophilic bronchitis is being considered, offer a therapeutic trial of prednisolone 1

Non-Asthmatic Eosinophilic Bronchitis

• Perform induced sputum test for eosinophils (>3% eosinophil count indicates eosinophilia) 1
• Use empiric treatment with inhaled corticosteroids if testing is unavailable 2

Gastroesophageal Reflux Disease (GERD)

• Initiate empiric treatment for patients with typical reflux symptoms before performing esophageal testing 2
• Intensive acid suppression with proton pump inhibitors for a minimum of 2 months 1

Critical Pitfalls to Avoid

• Do not rely on cough characteristics alone (productive vs. dry, timing, quality) as they have little diagnostic value 2, 3
• Do not treat only one cause - multiple factors often contribute simultaneously, requiring additive therapy 2, 3
• Do not use single peak expiratory flow (PEF) measurements for assessing bronchodilator response, as they are not as accurate as FEV1 1
• Do not label as idiopathic until thorough assessment excludes uncommon causes 2

When to Pursue Advanced Testing

If cough persists after 4-6 weeks of empiric treatment for the top diagnoses:

• Consider high-resolution CT scan or bronchoscopic evaluation for uncommon causes 2, 3
• Consider referral to a specialist cough clinic when diagnosis remains unclear 2

Bronchoscopy should be undertaken in all patients in whom inhalation of a foreign body is suspected 1

Treatment Monitoring

Formally quantify treatment effects using validated instruments. 1 Assess cough severity using visual analogue scores or cough-specific quality of life questionnaires. 1 The decrement in quality of life from chronic cough is comparable to severe COPD. 1