What is the best course of action for a patient with a persistent cough producing yellow or clear sputum, without shortness of breath (SOB) or sore throat, and considering their past medical history and potential underlying conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Management of Persistent Cough with Yellow/Clear Sputum

Begin empiric treatment with a first-generation antihistamine/decongestant combination as the initial therapy, since upper airway cough syndrome (postnasal drip) is the most common cause of persistent cough with sputum production. 1

Initial Assessment and Red Flags

Before initiating treatment, rule out serious conditions that require immediate intervention:

• Check for hemoptysis, weight loss, night sweats, fever with systemic illness, or history of cancer/TB - these mandate chest X-ray and possible specialist referral 2, 3
• Verify medication list - if the patient is taking an ACE inhibitor, stop it immediately and replace with an alternative agent, as this commonly causes persistent cough 1
• Assess smoking status - active smokers require smoking cessation counseling as the primary intervention, since continued exposure to irritants prevents resolution 1
• Examine for respiratory distress, abnormal vital signs, or abnormal lung examination - these findings change management and may indicate pneumonia or other serious pathology 2

Systematic Empiric Treatment Approach

Since chronic cough commonly has multiple simultaneous causes, use sequential and additive therapy rather than switching treatments 1:

Step 1: Treat Upper Airway Cough Syndrome (UACS/Postnasal Drip)

• Start with oral first-generation antihistamine/decongestant combination (e.g., chlorpheniramine with pseudoephedrine) 1, 3
• UACS accounts for 40% of chronic productive cough cases and is the single most common etiology 4
• Yellow or clear sputum does NOT indicate bacterial infection - it simply reflects inflammatory cells and debris, most commonly from postnasal drainage 3
• Trial duration: 1-2 weeks to assess response 1

Step 2: If Cough Persists, Evaluate and Treat for Asthma

• Asthma causes 24% of chronic productive cough and may present without wheezing or dyspnea 4
• Medical history alone is unreliable for ruling in or out asthma 1
• Perform spirometry; if normal, proceed with bronchoprovocation challenge testing 1
• If testing unavailable, initiate empiric trial with inhaled corticosteroids plus inhaled β-agonists or leukotriene inhibitors 1
• Consider short course of oral corticosteroids if suspicion remains high despite negative testing 1

Step 3: If Still Unresolved, Treat for GERD

• Gastroesophageal reflux disease accounts for 15% of chronic productive cough 4
• Initiate proton pump inhibitor therapy even without typical reflux symptoms 1
• GERD-related cough may take 2-3 months to respond to treatment 1

Step 4: Consider Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• If UACS and asthma have been treated without resolution, evaluate for NAEB 1
• Ideally perform induced sputum test for eosinophils 1
• If testing unavailable, trial empiric corticosteroids 1

Important Caveats and Pitfalls

Do NOT prescribe antibiotics - colored sputum in the absence of fever, systemic illness, or pneumonia does not indicate bacterial infection and antibiotics provide no benefit while contributing to resistance 3. The exception is if you suspect acute bacterial exacerbation of underlying COPD or bronchiectasis 1, 5.

Recognize that 62% of chronic productive cough cases have TWO or more simultaneous causes 4. This means you must continue previous treatments while adding new ones rather than stopping and switching.

Chronic bronchitis from smoking requires 3+ months of cough on most days for 2+ consecutive years 1. If the patient doesn't meet these criteria, pursue other diagnoses first.

Chest X-ray is indicated if: abnormal physical examination, high-risk features present, or cough persists beyond 8 weeks despite appropriate empiric therapy 2, 3.

Symptomatic Relief During Workup

While pursuing diagnostic treatment:

• Honey, warm fluids, or simple linctuses provide symptomatic relief through central cough reflex modulation 3
• Dextromethorphan 60 mg has evidence for acute cough suppression 3
• Avoid routine use of codeine due to adverse effects, reserve only for severely distressing cough 3

When to Refer

Refer to pulmonary specialist if: cough remains undiagnosed after systematic evaluation of UACS, asthma, NAEB, and GERD, or if cough persists beyond 8 weeks despite optimal treatment of identified causes 1, 3.