What is the next step in managing a patient with a productive cough with greenish mucous, who is afebrile (without fever) and has stable vital signs (VSS)?

Management of Productive Cough with Green Sputum in an Afebrile Patient with Stable Vital Signs

For this patient with productive cough and greenish mucous who is afebrile with stable vital signs, routine antibiotics are NOT recommended—this presentation most likely represents acute viral bronchitis requiring only supportive care. 1

Clinical Assessment Framework

The key decision point is determining whether this patient has pneumonia versus acute bronchitis, as this fundamentally changes management:

Signs That Would Suggest Pneumonia (and warrant chest X-ray):

• Fever ≥38°C (100.4°F) 1
• Tachycardia 1
• Breathlessness or dyspnea 1
• Tachypnea 1
• New focal chest signs on auscultation (crackles, diminished breath sounds, dull percussion) 1

Since your patient is afebrile with stable vital signs and (presumably) normal lung examination, pneumonia is unlikely and chest radiography is not indicated. 1

The Color of Sputum Does NOT Indicate Bacterial Infection

A critical pitfall: greenish or purulent-appearing sputum does NOT distinguish bacterial from viral infection and should NOT be used to guide antibiotic decisions. 1 The color comes from neutrophil peroxidase enzymes, which are present in both viral and bacterial infections.

Recommended Management

What TO Do:

Supportive care only for this acute viral bronchitis presentation:

• First-generation antihistamine plus decongestant (e.g., brompheniramine with sustained-release pseudoephedrine) to reduce cough severity and hasten resolution 1
• Naproxen can also favorably affect cough 1
• Guaifenesin to help loosen phlegm and thin bronchial secretions 2
• Adequate hydration and supportive measures 3

What NOT To Do:

• Do NOT prescribe antibiotics when vital signs and lung examination are normal, as there is no clinical or radiographic evidence of pneumonia 1
• Do NOT use newer-generation nonsedating antihistamines—they are ineffective for acute cough 1

When to Reassess

Consider Further Evaluation If:

Duration exceeds 3-4 weeks: Chronic wet/productive cough (>4 weeks) warrants different management, including consideration of a 2-week antibiotic trial targeting common respiratory bacteria 3

Development of "red flag" features:

• Fever develops 1
• Vital signs become abnormal 1
• New focal chest findings appear 1
• Hemoptysis occurs 3
• Patient develops systemic symptoms (weight loss, night sweats) 1

Special Consideration for Pertussis:

If the patient develops paroxysmal cough with post-tussive vomiting or inspiratory "whoop," consider pertussis and treat immediately with macrolide antibiotics 3

Common Pitfalls to Avoid

1. Don't be misled by green sputum color—this does not indicate bacterial infection requiring antibiotics 1
2. Don't order chest X-ray in patients with normal vital signs and normal lung examination—the yield is extremely low (2-5%) 1
3. Don't prescribe antibiotics for acute bronchitis—this is almost always viral and antibiotics provide no benefit 1, 4

The Bottom Line

This clinical presentation—productive cough with green sputum but afebrile with stable vitals—represents acute viral bronchitis. 1 The appropriate next action is symptomatic treatment with first-generation antihistamine/decongestant combination, not antibiotics or imaging. 1 Only if pneumonia is suspected based on abnormal vital signs or focal chest findings should you proceed to chest radiography. 1