What is the best course of treatment for a patient with a 3-day history of cough and congestion, potentially with a background of asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Management of Acute Cough and Congestion (3 Days Duration)

For a patient with 3 days of cough and congestion, first-line treatment should be a first-generation antihistamine-decongestant combination (such as brompheniramine with sustained-release pseudoephedrine), as this addresses the most common cause—upper airway cough syndrome from viral upper respiratory infection—and antibiotics should NOT be prescribed as most cases are viral and self-limiting. 1, 2

Initial Assessment Priorities

Key Historical Features to Obtain

• Smoking status: If current smoker, smoking cessation is the single most important intervention and will resolve cough in 90% of cases within 4 weeks 1, 3
• Medication history: Determine if patient takes ACE inhibitors (can cause cough) or beta-blockers (contraindicated in COPD/asthma) 1, 3
• Underlying lung disease: Establish if patient has known asthma or COPD, as this changes the clinical picture from simple acute bronchitis to acute exacerbation requiring different management 2, 4
• Recurrent episodes: If patient has repeated episodes of "acute cough," this suggests underlying chronic lung disease rather than recurrent viral infections 2

Physical Examination Red Flags

• Severity indicators: Inability to complete sentences, respiratory rate >25/min, heart rate >110/min indicate need for corticosteroids 4
• Sputum character: Development of purulent sputum (along with increased breathlessness and increased sputum volume—2 of 3 criteria) indicates bacterial superinfection requiring antibiotics 1, 4

Treatment Algorithm for Simple Acute Viral Cough (No Underlying Lung Disease)

First-Line Non-Pharmacologic Treatment

• Honey and lemon: As effective as pharmacological treatments at no cost 2

First-Line Pharmacologic Treatment

• First-generation antihistamine-decongestant: Brompheniramine with sustained-release pseudoephedrine addresses upper airway cough syndrome, the most common cause 1, 2
• Expected response: Some improvement within days to 1-2 weeks; complete resolution may take several weeks 1

If Cough Suppressant Needed

• Dextromethorphan 60 mg: Standard OTC doses (15-30 mg) are subtherapeutic; maximum cough reflex suppression occurs at 60 mg 2
• Avoid codeine: No greater efficacy than dextromethorphan but significantly more adverse effects 2

What NOT to Do

• Do NOT prescribe antibiotics: Most cases are viral and antibiotics contribute to antimicrobial resistance 2
• Do NOT prescribe newer non-sedating antihistamines: These are ineffective for acute cough 1

Treatment Algorithm for Patients with Known Asthma

Initial Bronchodilator Therapy

• Short-acting beta-agonist: Salbutamol 200-400 mcg or terbutaline 500-1000 mcg via handheld inhaler four times daily 4
• If inadequate response: Add ipratropium bromide 500 mcg 4
• For severe symptoms: Use nebulized salbutamol 2.5-5 mg plus ipratropium 250-500 mcg together 4

Add Corticosteroids If:

• Patient meets severity criteria (cannot complete sentences, RR >25/min, HR >110/min) 4
• Regimen: Short course (1-2 weeks) of oral corticosteroids followed by inhaled corticosteroids 1

Safety Precaution

• First dose supervision required in elderly: Beta-agonists may precipitate angina 4, 3

Treatment Algorithm for Patients with Known COPD

Recognize This is an Acute Exacerbation, Not Simple Acute Bronchitis

• Cough is the commonest symptom of COPD exacerbations 2
• Diagnostic criteria for exacerbation: Two or more of: increased breathlessness, increased sputum volume, development of purulent sputum 1, 4

Initial Bronchodilator Therapy

• Start with: Short-acting beta-agonist (salbutamol 2.5-5 mg via nebulizer or 200-400 mcg via inhaler) 4
• If inadequate response: Add ipratropium bromide 500 mcg 4
• Combination therapy: Salbutamol 2.5-10 mg plus ipratropium 250-500 mcg together in nebulizer for severe cases 4

Add Antibiotics If:

• Two or more present: Increased breathlessness, increased sputum volume, purulent sputum 1, 4
• Duration: 7-14 days 4
• First-line options: Amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid targeting S. pneumoniae, H. influenzae, M. catarrhalis 4
• Azithromycin alternative: 500 mg once daily for 3 days shows 85% clinical cure rate at Day 21-24 for acute exacerbations 5

Add Oral Corticosteroids If:

• Patient meets severity criteria (cannot complete sentences, RR >25/min, HR >110/min) 4
• Give alongside nebulized beta-agonists 4

Critical Safety Considerations

• Oxygen delivery: If patient requires oxygen and has CO2 retention/acidosis, drive nebulizer with air (not high-flow oxygen) and use 24% Venturi mask between treatments 4
• Beta-blockers: Must be avoided in all COPD patients 3
• Ipratropium precaution: Can worsen glaucoma—use mouthpiece rather than face mask 4

When Patient Has Features of Both Asthma and COPD (Asthma-COPD Overlap)

Recognition

• Persistent airflow limitation in patient >40 years with either history of asthma or large bronchodilator reversibility 6
• These patients have worse symptoms, poorer quality of life, and increased exacerbation risk compared to asthma or COPD alone 6

Treatment Approach

• Primarily follow asthma guidelines: Always include inhaled corticosteroids plus bronchodilators 7
• Add COPD-specific approaches: As needed for symptom control 8

When to Suspect Something Other Than Simple Viral Infection

Perform Chest X-ray and Spirometry If:

• Repeated episodes of what appears to be "recurrent acute cough" (likely represents undiagnosed chronic lung disease) 2
• Cough persists beyond 3 weeks 2
• Patient is current smoker with chronic productive cough 1

Consider Pertussis If:

• Characteristic paroxysmal cough pattern 2
• Action: Perform diagnostic testing, prescribe macrolide antibiotics, isolate for 5 days from treatment start 2

Follow-Up Strategy

Reassess If:

• Cough persists beyond 3 weeks 2
• Patient deteriorates or not fully improved in 2 weeks 1
• New concerning symptoms develop 2

At Follow-Up Visit (If Needed):

• Measure FEV1 if underlying lung disease suspected 1
• Reassess inhaler technique 1
• Consider chest radiography if not improving 1

Common Pitfalls to Avoid

1. Reflexive antibiotic prescribing: Contributes to resistance; most acute cough is viral 2
2. Subtherapeutic dextromethorphan dosing: Standard OTC doses (15-30 mg) are ineffective; use 60 mg if needed 2
3. Missing underlying chronic lung disease: "Recurrent" acute episodes usually represent undiagnosed asthma or COPD requiring disease-specific therapy 2
4. Using newer antihistamines: Non-sedating antihistamines are ineffective for acute cough 1
5. Prescribing antibiotics during first week of symptoms: Cannot distinguish viral from bacterial sinusitis in first week 1