What is the best course of action for a patient with intermittent cough and fever, potentially with underlying conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Management of Intermittent Cough and Fever

The priority is to rule out pneumonia and other serious illness first, then systematically evaluate for underlying chronic airway disease (asthma/COPD) if symptoms persist beyond 2-3 weeks, as up to 45% of patients with prolonged cough actually have undiagnosed chronic lung disease. 1

Initial Assessment: Rule Out Serious Illness

Immediately assess for pneumonia by checking vital signs and performing lung auscultation. In healthy adults, pneumonia is uncommon without vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated unless these findings are present. 1, 2

Red Flags Requiring Chest X-ray:

• Vital sign abnormalities (tachypnea, fever >100°F, tachycardia) 3
• Asymmetrical lung sounds or focal crackles 1
• Respiratory distress or hypoxemia 4
• Hemoptysis, weight loss, night sweats 3
• History of cancer, TB, or immunosuppression 3

If pneumonia is suspected based on clinical findings, obtain chest radiography and consider empiric antibiotics for bacterial pneumonia. 3

Evaluate for Chronic Airway Disease

If cough persists beyond 2-3 weeks, strongly consider underlying asthma or COPD, as studies show 45% of patients with acute cough lasting >2 weeks have undiagnosed chronic lung disease. 1

Key Predictive Features for Asthma/COPD:

• Wheezing on examination 1
• Prolonged expiration 1
• Smoking history (pack-years) 1
• History of allergy (suggests asthma) 1
• Female sex (more likely asthma) 1

Perform spirometry if the patient has at least two of these features. 1 This is critical because approximately one-third of patients diagnosed with "acute bronchitis" actually have acute asthma. 1

Spirometry Interpretation:

• Asthma: Reversible obstruction (>12% and >200 mL improvement in FEV1 after bronchodilator) 5
• COPD: Fixed obstruction (FEV1/FVC <70% without reversibility) 5
• Asthma-COPD overlap: Reversibility present but with persistent baseline limitation 5

Treatment Based on Diagnosis

If Acute Viral Upper Respiratory Infection (No Pneumonia, No Chronic Disease):

Do NOT use antibiotics - routine antibiotic treatment of uncomplicated acute bronchitis is not recommended regardless of cough duration. 1

Treat symptomatically with: 3

• First-generation antihistamine/decongestant combination 3
• Naproxen for inflammation 3
• Honey for cough suppression 3
• Acetaminophen for fever 3
• Adequate hydration 3

If Asthma or Asthma Exacerbation Identified:

Initiate bronchodilator therapy and inhaled corticosteroids immediately, as these have proven benefit in asthma exacerbations. 1, 4

For suspected asthma without spirometric confirmation, consider empiric trial of inhaled bronchodilators and inhaled corticosteroids if bronchoprovocation testing is unavailable. 4

If COPD Exacerbation:

Treat with inhaled bronchodilators and systemic corticosteroids. 3 Consider antibiotics only if there is increased sputum purulence along with increased dyspnea or sputum volume. 6

If Pertussis Suspected:

Perform diagnostic testing and initiate antimicrobial therapy (azithromycin 500 mg daily for 3 days). 1 Pertussis should be suspected with prolonged paroxysmal cough, especially if lasting >3 weeks. 1

Follow-up and Persistent Symptoms

If cough persists ≥3 weeks despite appropriate treatment, obtain chest radiography to evaluate for other causes including cough-variant asthma, upper airway cough syndrome, or gastroesophageal reflux disease. 1, 2

For patients with recurrent episodes (≥2 similar episodes in past 5 years), 65% have undiagnosed mild asthma and should undergo formal asthma evaluation with spirometry or methacholine challenge. 1

Common Pitfalls to Avoid

• Don't prescribe antibiotics for viral acute bronchitis - this is inappropriate regardless of cough duration or sputum color. 1, 3
• Don't miss underlying asthma - one-third of "acute bronchitis" diagnoses are actually acute asthma. 1
• Don't rely on cough characteristics alone - timing and quality have minimal diagnostic value. 2
• Don't delay spirometry in patients with risk factors - early identification of chronic lung disease changes management significantly. 1