For an adult patient with intermittent cough, yellow sputum, and occasional wheeze that improves with albuterol rescue inhaler and no other symptoms, what is the appropriate next management?

Management of Persistent Cough with Yellow Sputum and Occasional Wheeze

This patient has post-infectious cough with possible underlying asthma, and the next step is to initiate inhaled ipratropium bromide 2-3 puffs four times daily while continuing albuterol as needed, with consideration for adding an inhaled corticosteroid if symptoms persist beyond 1-2 weeks.

Clinical Assessment

This presentation is consistent with post-infectious cough, defined as cough persisting 3-8 weeks following an acute respiratory infection 1. The yellow mucus does not indicate bacterial infection—most short-term coughs produce colored phlegm even when viral 1. The wheeze that improves with albuterol suggests either post-viral bronchial hyperresponsiveness or underlying cough-variant asthma 2, 3.

Key Diagnostic Considerations

• Post-infectious cough is driven by ongoing airway inflammation and bronchial hyperresponsiveness—not ongoing infection—and antibiotics have no role 1
• The pathophysiology includes mucus hypersecretion, impaired mucociliary clearance, and heightened cough-reflex sensitivity 1
• Cough-variant asthma accounts for 14-24% of subacute cough cases following upper respiratory infection and may present with wheeze responsive to bronchodilators 2, 3
• Wheezes that appear only on forced expiration or immediately after coughing are characteristic of cough-variant asthma 2

Immediate Management Algorithm

First-Line Treatment (Weeks 1-3)

• Prescribe inhaled ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily 1
  • This has the strongest evidence for attenuating post-infectious cough 1
  • Clinical improvement typically occurs within 1-2 weeks 1
  • Continue albuterol rescue inhaler as needed for wheeze 1

Second-Line Treatment (If No Improvement After 1-2 Weeks)

• Add an inhaled corticosteroid such as fluticasone 220 mcg or budesonide 360 mcg twice daily 1
  • Indicated when cough persists despite ipratropium and adversely affects quality of life 1
  • Suppresses airway inflammation and bronchial hyperresponsiveness 1
  • Allow up to 8 weeks for full therapeutic response 1

Third-Line Treatment (For Severe Cases Only)

• Oral prednisone 30-40 mg daily for 5-10 days should be reserved only for severe paroxysms that significantly impair quality of life 1
  • Use only after ruling out upper airway cough syndrome, asthma, and GERD 1

Critical Rule-Outs and Red Flags

Mandatory Baseline Investigations

• Chest radiograph is required if cough persists beyond 8 weeks, or if any red-flag symptoms develop 4, 2
• Spirometry with bronchodilator testing should be performed to detect airflow obstruction and assess reversibility 4, 2

Red-Flag Symptoms Requiring Urgent Evaluation

• Hemoptysis 4, 2
• Fever or night sweats 2, 1
• Unintentional weight loss 2
• Significant dyspnea at rest 2
• Symptoms persisting beyond 8 weeks 4, 1

What NOT to Do

• Do NOT prescribe antibiotics for post-infectious cough—they provide no benefit, contribute to resistance, and cause adverse effects 1
  • Antibiotics are contraindicated unless there is documented bacterial sinusitis or early pertussis infection 1
• Do NOT jump to oral prednisone for mild post-infectious cough—reserve it for severe cases that have failed other therapies 1

Evaluation for Chronic Cough (If Symptoms Persist Beyond 8 Weeks)

If cough extends beyond 8 weeks, reclassify as chronic cough and systematically evaluate for 4, 2, 1:

Upper Airway Cough Syndrome (UACS)

• Accounts for 19-82% of chronic cough cases 2
• Treat with first-generation antihistamine-decongestant combination plus intranasal corticosteroid 1
• Response typically occurs within days to 1-2 weeks 1

Asthma (Including Cough-Variant)

• Accounts for 15-41% of chronic cough cases 2
• Normal spirometry does NOT exclude asthma 4, 2
• Consider bronchoprovocation challenge or empiric trial of inhaled corticosteroids 1
• Response may take up to 8 weeks 1

Gastroesophageal Reflux Disease (GERD)

• Accounts for 5-85% of chronic cough cases 2
• GERD-related cough frequently occurs WITHOUT gastrointestinal symptoms 4, 2
• Initiate high-dose PPI therapy (omeprazole 40 mg twice daily) with dietary modifications 1
• Response may require 2 weeks to several months 1

Follow-Up Plan

• Schedule follow-up in 1-2 weeks to assess response to ipratropium 1
• If partial improvement occurs, continue that therapy and add the next intervention rather than stopping and switching 1
• Up to 67% of chronic cough patients have multiple concurrent causes requiring combination therapy 2
• Instruct patient to return immediately if fever develops, hemoptysis occurs, or symptoms worsen 1