What is the initial treatment approach for a patient presenting with a cough, considering their age, medical history, and current medications, including conditions such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Initial Treatment Approach for Cough

For most acute coughs (<3 weeks), start with a first-generation antihistamine/decongestant combination plus naproxen, as these are the only proven effective over-the-counter treatments—newer non-sedating antihistamines do not work for cough. 1, 2

Immediate Risk Stratification

Before initiating treatment, you must first exclude life-threatening conditions and identify patients requiring urgent intervention:

• Assess for respiratory distress indicators: markedly elevated respiratory rate, intercostal retractions, cyanosis, altered mental status, or severe breathlessness requiring immediate medical attention 1, 2
• Identify high-risk features: hemoptysis, prominent systemic illness, suspected inhaled foreign body, or concern for lung cancer 1
• Order chest radiograph immediately if pneumonia is suspected (fever, tachypnea, tachycardia, dyspnea, abnormal lung findings) or if the patient has chronic cough 1, 2

Critical First Steps Before Any Treatment

Medication Review

• Discontinue ACE inhibitors immediately if present—they are a common reversible cause of cough and must be stopped before pursuing other treatments 1, 2, 3

Smoking Cessation

• Counsel all smokers on cessation, as 90-94% experience cough resolution within the first year of quitting 1, 3

Duration-Based Treatment Algorithm

Acute Cough (<3 weeks)

Most acute coughs are viral upper respiratory infections that do not require antibiotics, even with colored phlegm. 4

Initial treatment:

• First-generation antihistamine/decongestant combination plus naproxen for common cold-related cough 4, 1, 2
• Home remedies such as honey and lemon are reasonable alternatives 4
• Dextromethorphan-containing cough remedies may be the most effective over-the-counter option 4
• Paracetamol for fever and associated symptoms 4, 2
• Menthol lozenges or vapor may provide symptomatic relief 4

Critical pitfall: Do NOT use newer non-sedating antihistamines—they are ineffective for cough 1, 2

For acute exacerbation of chronic bronchitis:

• Short course (10-15 days) of systemic corticosteroids 2

Seek medical attention if:

• Hemoptysis occurs 4
• Breathlessness develops 4
• Prolonged fever with feeling unwell 4
• Pre-existing conditions (COPD, heart disease, diabetes, asthma) 4
• Recent hospitalization 4
• Symptoms persist beyond 3 weeks 4

Subacute Cough (3-8 weeks)

• Determine if postinfectious or non-infectious 4, 1, 3
• If postinfectious, consider upper airway cough syndrome, transient bronchial hyperresponsiveness, asthma, or pertussis 4, 1
• If non-infectious, manage as chronic cough (see below) 4

Chronic Cough (>8 weeks)

Use a sequential and additive treatment approach targeting the three most common causes, as they frequently coexist—treating only one cause is a critical error. 4, 1, 3

Mandatory Baseline Investigations

• Chest radiograph for all patients with chronic cough 1
• Spirometry to identify obstructive patterns and assess reversibility 1, 3

Sequential Treatment Protocol

Step 1: Upper Airway Cough Syndrome (UACS)

• Oral first-generation antihistamine/decongestant combination as initial empiric treatment 4, 1, 3
• Add topical corticosteroid if prominent upper airway symptoms are present 1, 3

Step 2: Asthma Evaluation

• If spirometry shows reversible airflow obstruction (>12% and >200 mL improvement in FEV1), treat with inhaled bronchodilators and inhaled corticosteroids 4, 1, 5
• If spirometry is normal but asthma is suspected, perform bronchoprovocation challenge (preferred) or initiate empiric trial of inhaled corticosteroids and bronchodilators 4, 1
• For refractory cases, add leukotriene receptor antagonist before escalating to systemic corticosteroids 2

Critical pitfall: Do NOT rely on single peak expiratory flow measurements—they are not as accurate as FEV1 for assessing bronchodilator response 1

Step 3: Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Perform induced sputum test for eosinophils (preferred) 4, 1, 3
• If testing unavailable, empiric trial of inhaled corticosteroids 4, 1, 2

Step 4: Gastroesophageal Reflux Disease (GERD)

• Initiate empiric treatment with intensive acid suppression using proton pump inhibitors for minimum 2 months for patients with typical reflux symptoms before performing esophageal testing 1

Special Populations

Patients with Asthma or COPD

• Patients with pre-existing COPD, heart disease, diabetes, or asthma should see their doctor rather than self-treating 4
• For COPD exacerbations with cough, use short course of systemic corticosteroids 2
• Distinguish asthma from COPD using spirometry: asthma shows reversibility (>12% and >200 mL improvement in FEV1), while COPD shows persistent obstruction (FEV1/FVC <70%) without reversibility 5

Immunocompromised Patients

• Use the same initial algorithm but expand differential diagnosis based on immune defect type and severity 3
• In HIV patients with CD4+ <200 cells/μL, suspect Pneumocystis pneumonia, tuberculosis, and opportunistic infections 3

When to Pursue Advanced Testing

If cough persists after 4-6 weeks of empiric treatment for the top diagnoses:

• Consider high-resolution CT scan or bronchoscopic evaluation for uncommon causes 1, 3
• Refer to specialist cough clinic when diagnosis remains unclear 1, 3
• Bronchoscopy should be undertaken in all patients with suspected foreign body inhalation 4

Treatment Monitoring

• Formally quantify treatment effects using validated instruments such as visual analogue scores or cough-specific quality of life questionnaires 1

Critical Pitfalls to Avoid

• Do NOT rely on cough characteristics alone—they have little diagnostic value 4, 1, 3
• Do NOT treat only one cause—multiple factors often contribute simultaneously, requiring additive therapy 4, 1, 3
• Do NOT use routine cough suppressants when cough clearance is important 3
• Do NOT label as idiopathic until thorough assessment at a specialist clinic excludes uncommon causes 1, 3
• Do NOT use antibiotics for acute viral cough, even with colored phlegm 4