I have had a cough and wheeze for one week without a prior diagnosis; what evaluation and management are recommended?

Acute Cough with Wheezing: Evaluation and Management

At one week of cough and wheezing without prior diagnosis, you should perform focused chest auscultation during forced exhalation, start albuterol 400 mcg by metered-dose inhaler with spacer as needed, and reassure the patient that this is most likely a self-limiting viral respiratory infection with post-infectious bronchial hyperresponsiveness. 1

Immediate Clinical Assessment

Key Physical Examination Findings

• Perform focused chest auscultation during both normal breathing and forced exhalation to detect wheezing, assess for prolonged expiratory phase, and listen for crackles that may indicate pneumonia rather than simple bronchitis 1
• Check vital signs; in healthy, non-elderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds 2
• The presence of expiratory wheezing with productive cough at 1 week suggests either post-infectious bronchial hyperresponsiveness or unmasking of underlying reactive airway disease 1

Critical History Elements

• Document smoking history, as smoking is one of the commonest causes of persistent cough and appears dose-related 1
• Ask about timing patterns: cough that worsens at night suggests asthma, while wheezing with exercise, viral infections, or irritant exposure points toward reactive airway disease 1
• Assess for paroxysmal cough (93.2% sensitivity for pertussis), post-tussive vomiting (79.5% specificity for pertussis), or inspiratory whooping (77.7% specificity for pertussis) 1
• Absence of fever has 81.8% sensitivity for pertussis 1

Initial Management Strategy

Bronchodilator Therapy

• Start albuterol 400 mcg by metered-dose inhaler with spacer as needed; most patients exhibit onset of improvement in pulmonary function within 5 minutes with maximum benefit at 1 hour 1
• Response to bronchodilator therapy supports the diagnosis of bronchospasm 1
• At 1 week, acute cough is most commonly associated with viral upper respiratory tract infection and is normally benign and self-limiting in the absence of significant comorbidity 1

Patient Education

• Explain that acute bronchitis is self-limiting, with cough typically lasting 2-3 weeks 3
• Significant sputum production usually indicates primary lung pathology rather than upper airway causes 1

When to Escalate Evaluation

Spirometry Indication

• If symptoms persist beyond 2-3 weeks despite bronchodilator therapy, perform spirometry with bronchodilator response testing to assess for airflow obstruction and reversibility 1
• Lung function tests should be considered in patients with at least two of the following: wheezing, prolonged expiration, history of smoking, and symptoms of allergy 2

Corticosteroid Trial

• Consider a 2-week trial of oral corticosteroids if spirometry demonstrates obstruction or clinical suspicion for asthma remains high 1
• This approach helps differentiate eosinophilic airway inflammation from other causes 1

Common Pitfalls to Avoid

Antibiotic Overuse

• Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough 2
• Antibiotics decrease cough duration by only approximately 0.5 days while exposing patients to adverse effects 3
• Conditions that can mimic acute bronchitis include acute asthma, acute exacerbation of chronic bronchitis, and the common cold 2

Missed Underlying Chronic Disease

• Up to 45% of patients with acute cough >2 weeks actually have asthma or COPD 2
• Wheezing, prolonged expiration, pack-years of smoking, history of allergy, and female sex have predictive value for underlying asthma/COPD 2

Inadequate Follow-Up

• If cough persists beyond 3 weeks, it transitions to subacute cough and should be evaluated differently 2
• Subacute cough that does not appear postinfectious should be evaluated and managed as chronic cough 2

Alternative Diagnoses to Consider

• Pertussis: Consider if paroxysmal cough, post-tussive vomiting, or inspiratory whooping are present; if suspected, perform diagnostic testing and initiate antimicrobial therapy 2, 1
• Acute asthma exacerbation: More likely if nocturnal symptoms, exercise-induced symptoms, or known history of atopy 1
• Pneumonia: Suspect if vital sign abnormalities, asymmetrical lung sounds, or systemic symptoms are present 2