What is the appropriate evaluation and management for an adult presenting with chest congestion?

Evaluation and Management of Chest Congestion in Adults

For an adult presenting with chest congestion, immediately determine whether this represents cardiac pulmonary congestion from heart failure versus respiratory tract infection—this distinction fundamentally changes management from diuretics/vasodilators to supportive care/antibiotics. 1

Initial Diagnostic Approach

Key Clinical Distinctions

Cardiac vs. Respiratory Congestion:

• Heart failure congestion presents with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, third heart sound (S3), and bilateral basal rales that may extend throughout lung fields 1, 2
• Acute bronchitis presents with cough (with or without phlegm) as the predominant feature, often with upper respiratory symptoms like sore throat or rhinorrhea, but WITHOUT vital sign abnormalities or asymmetric lung sounds 1

Critical Red Flags Requiring Immediate Workup

Obtain chest X-ray and ECG immediately if:

• Vital sign abnormalities (hypotension, tachycardia, fever >38°C, hypoxia) 1
• Asymmetric lung sounds suggesting pneumonia 1
• Signs of heart failure: elevated JVP, S3 gallop, bilateral rales, peripheral edema 1, 2
• Chest pain with exertion or at rest 3

In healthy, non-elderly adults with cough and normal vital signs, chest radiography is usually NOT indicated 1

Algorithmic Management Based on Diagnosis

If Heart Failure/Pulmonary Congestion is Suspected:

Immediate diagnostic tests:

1. Transthoracic echocardiogram (TTE)—the preferred initial imaging test with 90% accuracy for confirming decompensated heart failure 2
2. Natriuretic peptides (BNP or NT-proBNP) for diagnostic confirmation 2
3. Chest X-ray to assess pulmonary congestion severity 1, 4

Treatment priorities:

• Oxygen administration for hypoxia 1
• Loop diuretics (furosemide) as first-line for volume overload 1
• Intravenous vasodilators (nitroglycerin 0.25 μg/kg/min, titrated every 5 minutes) if severely symptomatic with fluid overload and NOT hypotensive 1
• Target pulmonary capillary wedge pressure <20 mmHg and cardiac index >2 L/min/m² 1

Common pitfall: Pulmonary congestion can be present WITHOUT audible rales—do not rely solely on auscultation 1. Up to 1 in 4 patients have disproportionate right-sided versus left-sided pressures 5.

If Acute Bronchitis is Diagnosed:

Key management principle: Antibiotics are NOT recommended for uncomplicated acute bronchitis, regardless of cough duration 1

Appropriate evaluation:

• Focus on ruling out pneumonia (check vital signs, lung auscultation for asymmetry) 1
• If cough persists >3 weeks, consider chest X-ray to exclude other pathology 1
• Consider pertussis testing only if epidemiologically suspected 1

Treatment approach:

• Supportive care (hydration, rest, symptomatic relief)
• Patient education that antibiotics do not improve outcomes 1
• Reassess if fever develops, vital signs become abnormal, or symptoms worsen 1

Common pitfall: Purulent sputum does NOT indicate bacterial infection requiring antibiotics in acute bronchitis 1

If Upper Airway Cough Syndrome (UACS) is Suspected:

First-line empiric therapy:

• First-generation antihistamine-decongestant combination for 1-2 weeks 1
• Expect noticeable improvement within days to 2 weeks; complete resolution may take several weeks to months 1

If partial response:

• Add intranasal corticosteroid, anticholinergic, or antihistamine spray 1
• Consider sinus imaging if nasal symptoms persist despite topical therapy 1

If Asthma/Reactive Airway is Suspected:

Consider when:

• Persistent cough >2-3 weeks without wheezing 1
• Cough worsens at night, with cold exposure, or after exercise 1
• Normal pulmonary function tests initially 1

Diagnostic approach:

• Trial of bronchodilator therapy 1
• Methacholine challenge test if diagnosis uncertain 1

Special Considerations

Multifactorial causes are common: Many patients have TWO or even all THREE common causes (UACS, asthma, GERD)—cough will not resolve until ALL contributing factors are treated 1

Systemic infections: Moderate exercise can begin when temperature normalizes, white blood cell count normalizes, and cultures are negative 1

Lung ultrasound can detect B-lines indicating extravascular lung water in heart failure—useful for real-time assessment of pulmonary congestion and response to diuretics 6, 7