What are the best management strategies for a patient with acute cough, considering potential underlying causes such as viral upper respiratory tract infection, allergic rhinitis, or gastroesophageal reflux disease (GERD)?

Managing Acute Cough: Patient Education

For most patients with acute cough lasting less than 3 weeks, the priority is first ruling out serious conditions like pneumonia or pulmonary embolism, then treating the most common cause—viral upper respiratory infections—with supportive care and first-generation antihistamine/decongestant combinations when appropriate. 1, 2

Initial Assessment: What to Watch For

The first critical step is determining whether your cough represents a serious illness or a benign condition. 1, 2

Red flags requiring immediate medical attention include: 1

• Fever with rapid breathing or shortness of breath
• Chest pain or difficulty breathing
• Coughing up blood
• Signs of pneumonia on examination

Key questions to answer: 1, 2

• Are you taking an ACE inhibitor medication (blood pressure medication ending in "-pril")? If yes, this must be stopped immediately as it's a reversible cause 1, 2
• Do you smoke? Smoking cessation should begin immediately as it worsens cough 1, 2
• Did symptoms start after a cold or flu?

Most Common Causes of Acute Cough

Viral upper respiratory infections (the "common cold") are by far the most frequent cause of acute cough. 1, 3 Other common causes include: 1

• Acute bronchitis from viral infections like influenza
• Acute asthma exacerbations
• Environmental or allergic exposures
• Exacerbation of pre-existing conditions (COPD, chronic bronchitis)

Treatment Approach

For Viral Upper Respiratory Infections (Common Cold)

The most effective treatment is a first-generation antihistamine combined with a decongestant, which has been proven in controlled studies to decrease cough severity and hasten resolution. 1, 2, 3 Examples include diphenhydramine (Benadryl) plus pseudoephedrine.

Additional supportive measures: 1

• Nonsteroidal anti-inflammatory drugs like naproxen can favorably affect cough
• Rest and hydration
• Avoid irritants and allergens if identified

Critical Pitfall: Antibiotics Are NOT Indicated

Antibiotics should NOT be used for viral causes of acute cough, as they provide no benefit and contribute to antibiotic resistance. 2, 4, 3 Most acute cough is viral and self-limiting within 3 weeks. 1, 3

When to Obtain Chest X-Ray

Get a chest radiograph if pneumonia is suspected based on: 2, 4

• Rapid breathing (tachypnea)
• Abnormal lung sounds on examination
• Low oxygen levels
• Fever with productive cough and systemic symptoms

If Cough Persists Beyond 3 Weeks

If your cough continues for 3-8 weeks (subacute cough), determine whether it's postinfectious or represents another condition. 1, 4

For postinfectious cough (following a respiratory infection): 1, 4

• Consider inhaled ipratropium as it may attenuate the cough
• If quality of life is significantly affected, inhaled corticosteroids may be tried
• For severe paroxysms, a short course of oral prednisone (30-40 mg daily) can be considered after ruling out other causes
• Central-acting antitussives like codeine or dextromethorphan when other measures fail

If cough persists beyond 8 weeks, it becomes chronic cough and requires systematic evaluation for: 1, 2

• Upper airway cough syndrome (postnasal drip)
• Asthma
• Gastroesophageal reflux disease (GERD)
• Multiple simultaneous causes

Special Considerations

Pertussis (Whooping Cough)

If cough lasts more than 2 weeks with paroxysms, post-cough vomiting, or whooping sounds, consider pertussis. 1 Early treatment with macrolide antibiotics within the first few weeks diminishes symptoms and prevents spread. 1

When Cough Suppression May Be Harmful

Do not suppress cough when clearance of secretions is important, such as in pneumonia or bronchiectasis, as cough serves a protective function. 1, 2

Common Mistakes to Avoid

• Don't rely on cough characteristics (timing, wet vs. dry) for diagnosis—they have minimal diagnostic value 1, 2, 4
• Don't use antibiotics for viral infections—they don't work and cause harm 2, 4
• Don't ignore medication history—ACE inhibitors are a common reversible cause 1, 2
• Don't continue smoking—cessation significantly improves cough symptoms 1, 2

When to Seek Further Evaluation

Return for medical evaluation if: 1

• Cough persists beyond 3 weeks
• You develop fever, shortness of breath, or chest pain
• You cough up blood
• Symptoms worsen despite treatment
• You have underlying lung disease or immunosuppression