What is the standard of care for a patient presenting with rhinorrhea, nasal congestion, and a productive cough?

Standard of Care for Runny Nose, Nasal Congestion, and Productive Cough

For a patient presenting with rhinorrhea, nasal congestion, and productive cough—symptoms consistent with an acute viral upper respiratory tract infection (common cold)—the evidence-based standard of care is a first-generation antihistamine combined with a decongestant, specifically brompheniramine 12 mg plus sustained-release pseudoephedrine 120 mg twice daily, which has demonstrated efficacy in randomized controlled trials. 1, 2

Initial Assessment and Diagnosis

The clinical presentation of runny nose, nasal congestion, and productive cough lasting less than 3 weeks is most commonly caused by viral upper respiratory tract infection (common cold), which accounts for the vast majority of acute respiratory presentations in primary care. 1

Key diagnostic considerations:

• Confirm symptom duration is less than 3 weeks to classify as acute cough (versus subacute 3-8 weeks or chronic >8 weeks). 1
• Rule out "red flag" features requiring further investigation: hemoptysis, prominent systemic illness, suspicion of inhaled foreign body, or suspicion of lung cancer. 1
• Do not diagnose bacterial sinusitis during the first week of symptoms, even if purulent nasal discharge is present, as viral infections commonly produce colored sputum and these findings are indistinguishable from viral rhinosinusitis. 1, 3
• Physical examination may reveal inflamed nasal mucosa, adherent or draining secretions in the posterior pharynx, and widespread rhinosinusitis on imaging that clears with resolution of infection. 1

First-Line Treatment: Antihistamine-Decongestant Combination

The most effective evidence-based treatment is a first-generation antihistamine combined with a decongestant. 1, 2

Recommended regimens for adults:

• Brompheniramine 12 mg + sustained-release pseudoephedrine 120 mg twice daily 1, 2
• Dexbrompheniramine 6 mg + sustained-release pseudoephedrine 120 mg twice daily 1, 2, 3
• Azatadine 1 mg + sustained-release pseudoephedrine 120 mg twice daily 1, 2, 3

Expected response: Improvement typically occurs within days to 2 weeks of initiating therapy. 1, 2

Mechanism of action: First-generation antihistamines work primarily through their anticholinergic properties (not antihistamine effects), which decrease nasal secretions and limit inflammatory mediators that trigger the cough reflex. 2, 3 This explains why newer non-sedating antihistamines are ineffective for this indication. 1, 2

Dosing strategy to minimize sedation: Start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy. 2, 3

What NOT to Prescribe

Second-generation antihistamines are ineffective and should not be used:

• Cetirizine, loratadine, fexofenadine, and other non-sedating antihistamines (with or without decongestants) have been shown ineffective for treating cough associated with the common cold. 1, 2, 3
• These agents lack the anticholinergic properties necessary to reduce secretions and suppress cough. 2, 3

Antibiotics are contraindicated:

• Antibiotics have no role in treating viral upper respiratory infections and should not be prescribed during the first week of symptoms. 1, 2, 4
• Even purulent nasal discharge does not indicate bacterial infection requiring antibiotics during the first 7-10 days. 1, 3, 4

Adjunctive Symptomatic Treatments

For additional symptom relief:

• Nasal saline irrigation: High-volume saline irrigation (150 mL) mechanically removes mucus, improves mucociliary function, and reduces nasal edema. 3, 5 This is more effective than saline spray because irrigation better expels secretions. 3
• NSAIDs: Naproxen has been shown to favorably affect cough and relieve headache, ear pain, and muscle pain associated with the common cold. 1, 2
• Simple home remedies: Honey and lemon may provide symptomatic relief through central modulation of the cough reflex. 1, 6
• Dextromethorphan: At 60 mg dosing (higher than typical over-the-counter doses), this provides maximum cough reflex suppression, though it is less effective than the antihistamine-decongestant combination. 1, 6

Contraindications and Safety Monitoring

Absolute contraindications to decongestant-containing combinations:

• Narrow-angle glaucoma 2
• Symptomatic benign prostatic hypertrophy or urinary retention 2, 3
• Severe uncontrolled hypertension 2
• Congestive heart failure 2

Monitor for side effects:

• Blood pressure elevation, tachycardia, palpitations, and insomnia from pseudoephedrine 2, 3
• Sedation, dry mouth, constipation, and urinary retention from first-generation antihistamines 2
• Increased intraocular pressure in glaucoma patients 3

When to Escalate or Reassess

If symptoms persist beyond 7-10 days without improvement:

• Consider adding intranasal corticosteroids (fluticasone 100-200 mcg daily) for a 1-month trial if allergic rhinitis is suspected. 2, 3
• Reassess for bacterial sinusitis only if symptoms persist beyond 10 days without improvement or if "double sickening" occurs (initial improvement followed by worsening). 3, 4

If cough persists 3-8 weeks (subacute cough):

• Reclassify as post-infectious cough and consider inhaled ipratropium bromide as first-line therapy. 3, 6

If cough persists beyond 8 weeks (chronic cough):

• Systematically evaluate for upper airway cough syndrome (UACS), asthma/cough-variant asthma, and gastroesophageal reflux disease (GERD), as these account for approximately 90% of chronic cough cases. 1, 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral upper respiratory infections—they provide no benefit, contribute to antimicrobial resistance, and cause adverse effects. 1, 2, 6
• Do not use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa (rebound congestion). 3
• Do not rely on purulent nasal discharge as an indication for antibiotics—colored sputum is typical of viral infections and does not distinguish bacterial from viral etiology. 3, 4
• Do not overlook contraindications to decongestants in patients with cardiovascular disease, glaucoma, or urinary symptoms. 2, 3