What is the best treatment approach for a patient with a non-productive cough and runny nose, who has stable vital signs and clear lung sounds?

Treatment Approach for Non-Productive Cough and Runny Nose

For this resident with stable vital signs, clear lung sounds, and no fever, symptomatic treatment without antibiotics is the appropriate management, starting with simple measures like honey or warm fluids, followed by dextromethorphan or codeine if the cough is particularly distressing. 1

Initial Assessment and Risk Stratification

The clinical presentation strongly suggests a post-viral upper respiratory infection rather than bacterial pneumonia or other serious pathology:

• Normal vital signs (BP 150/74, RR 17, Temp 98.6°F, O2 99%, HR 73) rule out acute critical illness—the shock index (HR/SBP = 0.49) is well within normal range (0.5-0.7), indicating hemodynamic stability 2
• Clear bilateral lung sounds on examination make pneumonia extremely unlikely 3, 1
• Absence of fever (temperature 98.6°F, well below the 38°C threshold) further argues against bacterial infection 3
• Non-productive cough with runny nose is the classic presentation of viral upper respiratory infection 1

No chest radiography, antibiotics, or laboratory testing (including C-reactive protein or procalcitonin) is indicated for this patient with normal vital signs and clear lung examination 3, 1.

Recommended Treatment Algorithm

First-Line Symptomatic Management

Start with simple, evidence-based measures that provide symptomatic relief through central modulation of the cough reflex 1:

• Honey (if no contraindications)
• Warm fluids to maintain hydration
• Simple linctuses or cough syrups available over-the-counter 1

Second-Line: Antitussive Therapy

If the cough remains distressing after 24-48 hours of simple measures:

Dextromethorphan 60 mg has been shown in meta-analysis to suppress acute cough effectively 1. This can be administered as a single evening dose in combination products containing paracetamol (600 mg), doxylamine succinate (7.5 mg), and ephedrine sulfate (8 mg), which showed significant improvement in nasal congestion, runny nose, and cough within 3 hours, with benefits persisting through the night 4.

Third-Line: Opioid Antitussives

If dextromethorphan is insufficient and the cough is particularly distressing, consider short-term use of codeine-based preparations 1, 5:

• Codeine linctus 15-30 mg every 4-6 hours 5
• Codeine phosphate tablets as an alternative 1

The British Thoracic Society specifically recommends these for severe non-productive cough, preceded by a β-agonist inhaler (2-4 actuations) if there is any bronchospasm component, with patients advised to remain nil by mouth for one hour after administration 3.

Management of Nasal Symptoms

For the runny nose component:

First-generation antihistamine plus decongestant can decrease symptom severity and hasten resolution if postnasal drip is contributing to the cough 1. The combination product mentioned above (containing doxylamine and ephedrine) addresses both cough and nasal symptoms simultaneously 4.

Guaifenesin compound with pseudoephedrine showed an 82.9% improvement rate for combined symptoms of cough, expectoration, nasal congestion, and runny nose in a large multicenter trial, with excellent safety profile (adverse event rate 0.92%) 6.

What NOT to Do

Avoid Antibiotics

Antibiotics provide no clinical benefit and contribute to antimicrobial resistance in this setting 1. The European Respiratory Society explicitly states that patients with resolved fever, clear lung examination, and normal vital signs do not require antibiotics 1. The presence of a runny nose or even colored sputum does not indicate bacterial infection—it simply reflects inflammatory cells and debris from viral infection 1.

Avoid Unnecessary Testing

• No chest X-ray needed: The British Thoracic Society indicates chest radiography is not routinely indicated for acute or subacute cough in otherwise healthy patients with normal physical examination 1
• No microbiological testing: Routine testing is not indicated when there is no clinical or radiographic evidence of pneumonia 3

Red Flags Requiring Re-evaluation

Instruct the resident to seek immediate medical attention if any of the following develop:

• Fever (temperature ≥38°C/100.4°F) 3
• Respiratory rate >24 breaths/minute 5
• New or worsening dyspnea 1
• Hemoptysis 1
• Inability to tolerate oral intake or continued vomiting 5
• Cough persisting beyond 8 weeks (would meet criteria for chronic cough requiring systematic evaluation) 1
• Development of abnormal lung examination findings 1

Follow-up Recommendations

Reassess within 48 hours if symptoms are not improving with conservative management 3. The European Respiratory Society recommends instructing patients on symptoms and signs of worsening and appropriate action to take 3.

Most post-viral coughs resolve within 3-8 weeks with symptomatic treatment alone 1. Maximum benefit from symptomatic treatments may take several days to achieve 3.