What is the initial treatment for a patient presenting with an acute cough?

Initial Treatment for Acute Cough

For acute cough lasting less than 3 weeks, start with a first-generation antihistamine/decongestant combination (such as brompheniramine with sustained-release pseudoephedrine) plus naproxen if the common cold is suspected, while ruling out serious conditions like pneumonia or pulmonary embolism first. 1, 2

Immediate Assessment Priorities

Before initiating treatment, rapidly determine if the acute cough represents a life-threatening condition:

• Assess for pneumonia or pulmonary embolism by checking for tachypnea, tachycardia, dyspnea, abnormal lung findings, respiratory distress (intercostal retractions, cyanosis, altered mental status), or risk factors for complications 1, 2, 3
• Obtain a chest radiograph if pneumonia is suspected based on these clinical findings 2, 3
• Check medication history for ACE inhibitor use and discontinue immediately if present, as this is a common reversible cause 1, 2, 4
• Identify smoking status and counsel on cessation, as 90-94% of smokers experience cough resolution within the first year of quitting 2, 4

First-Line Treatment for Common Cold

Once serious illness is excluded and the cough appears to be from a viral upper respiratory tract infection:

• Use a first-generation antihistamine/decongestant combination as this has been shown in double-blind placebo-controlled studies to decrease cough severity and hasten resolution of cough and postnasal drip 1, 2, 3
• Add naproxen (a nonsteroidal anti-inflammatory drug) as it has been demonstrated in randomized controlled trials to favorably affect cough 1, 3
• Expect response within 1-2 weeks, though complete resolution may take the full 3-week duration typical of acute bronchitis 1, 5, 6

Critical caveat: Newer non-sedating antihistamines are ineffective for cough and should not be used 3, 4

Treatment for Acute Exacerbation of Chronic Bronchitis

If the patient has underlying chronic bronchitis with an acute exacerbation:

• Prescribe a short course (10-15 days) of systemic corticosteroids as this is the recommended treatment 2, 3

What NOT to Do

• Do not prescribe antibiotics for acute bronchitis in otherwise healthy patients, as viruses cause more than 90% of cases and antibiotics provide minimal benefit (reducing cough by only half a day) while causing adverse effects including allergic reactions, nausea, vomiting, and Clostridium difficile infection 5, 6
• Do not rely on sputum color (green or yellow) to guide antibiotic decisions, as colored sputum does not reliably differentiate bacterial from viral infections 6
• Do not use cough suppressants routinely when cough clearance is important for removing secretions 2
• Do not use over-the-counter cough preparations as first-line therapy, as there is no good evidence for their effectiveness in acute cough 7

Special Considerations

• Consider pertussis if cough persists beyond 2 weeks with paroxysmal coughing, post-tussive vomiting, inspiratory whooping, or recent pertussis exposure, and obtain nasopharyngeal culture for confirmation 1, 5
• Consider early antibiotic therapy only if bacterial infection (such as pertussis) is strongly suspected or if the patient is at high risk for pneumonia (age ≥65 years or immunocompromised) 1, 3, 6
• Identify and eliminate environmental or occupational irritant exposures that may be triggering allergic or irritant-induced rhinitis 1

Patient Education

• Inform patients that acute cough typically lasts 2-3 weeks, as managing expectations reduces unnecessary follow-up and antibiotic requests 5, 6
• Recommend adequate fluid intake (no more than 2 liters per day) to avoid dehydration 3
• Suggest paracetamol for fever and associated symptoms 3
• Consider honey for cough suppression in patients over 1 year of age 3