How to assess expiratory wheezing in an adult with a 1-week history of productive cough and no significant past medical history?

Assessment of Expiratory Wheezing in an Adult with Acute Productive Cough

In an adult with 1-week productive cough and expiratory wheezing, perform focused chest auscultation during both normal breathing and forced exhalation to detect wheezing, assess for prolonged expiratory phase, and listen for additional sounds like crackles that may indicate alternative diagnoses. 1

Immediate Clinical Assessment

History Taking - Key Features to Elicit

Focus your history on four critical characteristics that distinguish specific etiologies:

• Paroxysmal nature of cough: Ask specifically if cough occurs in prolonged episodes with multiple bursts and inability to breathe during spells, as this has 93.2% sensitivity for pertussis in adults 1
• Post-tussive vomiting: Inquire whether coughing triggers vomiting, which has 79.5% specificity for pertussis 1
• Inspiratory whooping: Ask if patient or family members have heard a continuous inspiratory sound with whooping quality after cough episodes (77.7% specificity for pertussis) 1
• Fever presence: Document any fever, as its absence has 81.8% sensitivity for pertussis, while presence argues against it 1

Additional historical elements to assess:

• Timing patterns: Determine if cough worsens at night (suggests asthma), if wheezing occurs with exercise, viral infections, or exposure to irritants 1
• Smoking history: Essential as smoking is one of the commonest causes of persistent cough and appears dose-related 1
• Medication review: Specifically ask about ACE inhibitors, as they cause cough in up to 16% of patients with median resolution time of 26 days after cessation 2

Physical Examination - Specific Findings to Document

Chest auscultation technique:

• Listen during normal breathing first: Wheezing audible during quiet breathing indicates more severe bronchospasm 1
• Perform forced exhalation maneuver: Have patient exhale forcefully and completely, as this unmasks wheezing in patients with obstructed airways who may not wheeze during normal breathing 3
• Assess expiratory phase duration: A prolonged forced expiratory phase strongly suggests airflow obstruction 1
• Note accessory muscle use: Look for hunched shoulders, chest deformity, or hyperexpansion suggesting chronic obstruction 1

Upper airway examination:

• Inspect for increased nasal secretion, mucosal swelling, or nasal polyps that suggest upper airway cough syndrome 1
• Examine skin for atopic dermatitis or eczema indicating atopic predisposition 1

Diagnostic Approach at 1 Week Duration

At 1 week, this represents acute cough (defined as <3 weeks), most commonly associated with viral upper respiratory tract infection and normally benign and self-limiting in the absence of significant comorbidity. 1

When to Obtain Immediate Chest Radiograph

Obtain chest x-ray immediately if any of the following red flags are present:

• Hemoptysis 1
• Prominent systemic illness or fever 1
• Suspicion of inhaled foreign body 1
• Suspicion of lung cancer (especially in smokers) 1
• Unintentional weight loss 4

Interpretation of Wheezing in Context

The presence of expiratory wheezing with productive cough at 1 week suggests either:

• Post-infectious bronchial hyperresponsiveness: Most likely given the acute timeframe and productive nature 4
• Unmasking of underlying reactive airway disease: Consider if patient has history of atopy, nocturnal symptoms, or symptom triggers 1, 4

Important distinction: The presence of significant sputum production usually indicates primary lung pathology rather than upper airway causes 1

Management and Monitoring Strategy

Initial Therapeutic Trial

Start albuterol 400 mcg by metered-dose inhaler with spacer as needed, as most patients exhibit onset of improvement in pulmonary function within 5 minutes with maximum benefit at 1 hour. 4, 5

• Clinically significant improvement (defined as 15% or more increase in FEV1) lasts 3-4 hours in most patients 5
• Response to bronchodilator therapy supports diagnosis of bronchospasm 4

Reassessment Timeline

If symptoms persist beyond 2-3 weeks despite bronchodilator therapy:

• Perform spirometry with bronchodilator response testing to assess for airflow obstruction and reversibility 4
• Consider 2-week trial of oral corticosteroids (prednisolone 20-40 mg daily) if spirometry demonstrates obstruction or clinical suspicion for asthma remains high 4
• Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to the 2-week oral steroid trial 1

If symptoms worsen or new dyspnea develops within 48-72 hours:

• Reassess immediately as this may indicate progression requiring more aggressive therapy 4

Critical Pitfalls to Avoid

Common diagnostic errors:

• Do not rely on absence of wheezing to rule out asthma: Physical examination findings may be absent between episodes because asthma is variable 1
• Do not use peak flow meters for diagnosis: They are designed for monitoring, not diagnostic tools, due to wide variability in meters and reference values 1
• Do not assume normal spirometry excludes asthma: Many patients with cough-variant asthma have normal pulmonary function tests between episodes 1, 6
• Do not continue empiric treatment beyond 3 weeks without reassessment: At this point, full diagnostic workup is required rather than continued symptomatic therapy 1

Specific considerations for productive cough:

• Bronchiectasis can present with wheezing, though coarse crackles are typically more prominent than wheezes on examination 6
• Consider protracted bacterial bronchitis in patients with idiopathic chronic productive cough who respond to low-dose macrolide therapy 7