What is the management approach for a cough lasting 2 weeks?

Management of Cough Lasting 2 Weeks

A cough at 2 weeks is still in the acute phase and is most commonly due to viral upper respiratory tract infection, which is typically self-limiting and does not require antibiotics unless pertussis is suspected based on specific clinical features. 1

Initial Clinical Assessment

Determine if this is pertussis or post-viral cough:

• Any cough lasting ≥2 weeks with paroxysmal episodes should be considered pertussis until proven otherwise. 2, 3
• Look specifically for paroxysmal coughing fits, post-tussive vomiting, or inspiratory whooping sound to diagnose pertussis. 2, 3
• Most viral URTI-associated coughs resolve within 2 weeks, so persistence beyond this point raises concern for pertussis or evolving post-viral cough. 1

Check for red flag features requiring immediate investigation:

• Hemoptysis, constitutional symptoms (fever, weight loss), respiratory distress, or hypoxemia mandate immediate further workup. 4
• Risk factors for malignancy (age >40, smoking history) require chest radiography. 4
• Cough pointers such as coughing with feeding, digital clubbing, failure to thrive, or abnormal chest examination findings suggest underlying disease. 1

Review medication history:

• Stop ACE inhibitors if present, as ACE inhibitor-induced cough typically resolves within days to 2 weeks of discontinuation. 2
• Assess smoking status, as smoking cessation is first-line treatment and most coughs resolve within 4 weeks. 2

Treatment Algorithm

If Pertussis is Suspected:

Start treatment immediately without waiting for laboratory confirmation:

• Azithromycin 500 mg once daily for 3-5 days is the preferred first-line treatment. 2, 3
• Alternative: Erythromycin 1-2 g/day for 2 weeks or clarithromycin. 3
• Isolate the patient for 5 days from the start of antibiotic treatment to prevent transmission. 2, 3
• Obtain nasopharyngeal aspirate or Dacron swab for culture confirmation, but do not delay treatment. 2, 3
• Early treatment within the first 2 weeks decreases paroxysms and prevents transmission. 2, 3

If Post-Viral Cough (No Pertussis Features):

Symptomatic management is the mainstay:

• Ipratropium inhalation is first-line for cough suppression. 2, 3
• Dextromethorphan 60 mg (not over-the-counter doses, which are subtherapeutic) when other measures fail. 2, 3
• Consider prednisone 30-40 mg/day for a short period for severe paroxysms. 2, 3
• Do not use antibiotics for viral post-infectious cough—they provide no benefit. 2, 3, 5

For Children with Chronic Wet Cough (>4 weeks):

• If the child has chronic wet or productive cough without specific cough pointers, give 2 weeks of antibiotics targeted to common respiratory bacteria (S. pneumoniae, H. influenzae, M. catarrhalis). 1
• If cough resolves within 2 weeks of antibiotics, diagnose protracted bacterial bronchitis (PBB). 1
• If wet cough persists after 2 weeks of appropriate antibiotics, treat with an additional 2 weeks of antibiotics. 1

Timeline for Reassessment

The classification of cough by duration guides management:

• Acute cough is defined as lasting less than 3 weeks. 1
• At 3 weeks, if cough persists, consider post-infectious cough and trial ipratropium. 2
• Chronic cough is defined as lasting more than 8 weeks and requires full workup including chest radiography and spirometry. 1
• Do not misclassify a 2-week cough as chronic—this has different management implications. 2, 3

Critical Pitfalls to Avoid

• Delaying pertussis treatment while waiting for laboratory confirmation decreases effectiveness. 2, 3
• Using antibiotics indiscriminately for viral post-infectious cough provides no benefit and contributes to resistance. 2, 3, 5
• Using subtherapeutic doses of cough suppressants (over-the-counter dextromethorphan) is insufficient—60 mg is needed for optimal effect. 2, 3
• Forgetting isolation precautions if pertussis is diagnosed can lead to transmission. 2, 3
• Assuming benign etiology without chest radiograph when hemoptysis or risk factors for malignancy are present. 4

When to Escalate

• Any patient with massive hemoptysis requires immediate pulmonology consultation. 4
• Recurrent hemoptysis or risk factors for malignancy require bronchoscopy or high-resolution CT even if initial chest radiograph is normal. 4
• If cough persists beyond 8 weeks, mandatory evaluation includes chest radiography and spirometry. 1