What is the best course of treatment for a patient in their 60s with a history of influenza (flu) 15 years ago, presenting with itching throat and cough with clear sputum?

Management of Chronic Cough with Clear Sputum in a Patient in Their 60s

This patient has chronic cough (lasting 15 years), not acute influenza-related illness, and requires evaluation for common causes of chronic cough rather than antiviral or antibiotic therapy. The influenza infection from 15 years ago is irrelevant to current management. 1

Immediate Assessment

Do not prescribe antibiotics or antivirals. This presentation—itching throat and clear sputum without fever, dyspnea, or systemic symptoms—does not indicate active infection requiring antimicrobial therapy. 1, 2

Check for red flag features that mandate urgent investigation: 1

• Hemoptysis (any blood in sputum)
• Significant dyspnea or breathlessness
• Fever or systemic illness
• Weight loss or night sweats
• Suspicion of foreign body aspiration
• Change in voice (possible vocal cord palsy)

If any red flags are present, obtain chest radiograph immediately and consider specialist referral. 1

Most Likely Diagnoses for Chronic Cough with Clear Sputum

The three most common causes of chronic cough (>8 weeks) with clear sputum are: 3

1. Upper airway cough syndrome (post-nasal drip from rhinosinusitis)
2. Cough variant asthma
3. Gastroesophageal reflux disease (GERD)

The itching throat strongly suggests upper airway involvement, making upper airway cough syndrome the leading diagnosis. 4, 3

Recommended Treatment Approach

First-Line Empiric Therapy

Start with a first-generation antihistamine plus decongestant (e.g., brompheniramine with sustained-release pseudoephedrine), which is the most effective treatment for cough related to upper airway symptoms. 2, 5 This combination addresses both the histamine-mediated inflammation and nasal congestion contributing to post-nasal drip.

Alternative symptomatic options include: 1

• Dextromethorphan 60 mg (higher doses more effective than typical over-the-counter preparations)
• Simple home remedies like honey and lemon
• Naproxen for additional anti-inflammatory effect 2

If No Improvement After 2 Weeks

Trial empiric therapy for cough variant asthma: 4, 3

• Inhaled corticosteroid (e.g., beclomethasone or budesonide)
• Consider adding bronchodilator if any wheezing or breathlessness

If Still No Improvement

Trial empiric therapy for GERD: 4, 3

• Proton pump inhibitor (e.g., omeprazole 20-40 mg daily)
• Lifestyle modifications (elevate head of bed, avoid late meals, reduce caffeine/alcohol)

When to Obtain Further Investigation

Order chest radiograph if: 1

• Red flag symptoms develop
• No response to sequential empiric trials after 4-6 weeks
• Patient is at high risk (smoker, age >65, occupational exposures)

Consider sinus imaging (X-ray or CT) if upper airway symptoms persist despite antihistamine/decongestant therapy, as eosinophilic rhinosinusitis may require different management. 4

Common Pitfalls to Avoid

Do not prescribe antibiotics based on sputum color alone. Clear sputum in the absence of fever, abnormal vital signs, or focal chest findings does not indicate bacterial infection. 2, 6 Green or purulent-appearing sputum does not distinguish bacterial from viral causes and should not guide antibiotic decisions. 2

Do not assume this is related to the flu from 15 years ago. Post-infectious cough typically resolves within 8 weeks of the acute infection. 4 A 15-year duration indicates a chronic condition requiring evaluation for the standard causes of chronic cough.

Do not use cough suppressants as monotherapy. While dextromethorphan and other antitussives may provide symptomatic relief, they do not address the underlying cause and should be used adjunctively while pursuing diagnosis-specific therapy. 1