Management of acute cough in primary care

Managing acute cough

The important part in the management of an acute cough is to identify whether it is an indication of a

• life threatening illness such as foreign body aspiration, pneumonia, pulmonary embolism or
• non-life-threatening diagnosis such as respiratory tract infection, exposure to allergens or irritants (1).

Consider referring the following patients to a hospital (1):

• patients with lower respiratory tract infections with severe illness
• age over 80
• cormorbidity - upper respiratory tract infection together with asthma or COPD (1)
• suspected pulmonary embolism or malignancy (1)

Be aware that an acute cough (2):

• is usually self-limiting and gets better within 3 to 4 weeks without antibiotics
• is most commonly caused by a viral upper respiratory tract infection, such as a cold or flu
• can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial
• can also have other infective or non-infective causes

For children under 5 with an acute cough and fever, follow the NICE guideline on fever in under 5s: assessment and initial management.

For adults with an acute cough and suspected pneumonia, follow the NICE guideline on pneumonia in adults: diagnosis and management (3)

Acute cough - decision schemata (2,7):

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Pneumonia suspected:

• BTS guidance indicates where a patient should be treated, as well as suggested antibiotic regimen (4):

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See linked item for choice of antibiotic in acute cough.

Notes:

• patients at higher risk of complications - these are defined as:
  • if they:
    • have a pre-existing comorbidity, such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression or cystic fibrosis
    • are young children who were born prematurely
    • are older than 65 years with 2 or more of the following criteria, or older than 80 years with 1 or more of the following criteria:
      • hospitalisation in previous year
      • type 1 or type 2 diabetes
      • history of congestive heart failure
      • current use of oral corticosteroids
        
        
• the need of urgent medical admission (in an adult) can be based on the assessment of:
  • respiratory rate - more than 30 breaths per minute
  • blood pressure - systolic pressure <90 mmHg, or diastolic pressure <60 mmHg
  • pulse - more than 130 beats per minute
  • temperature
  • altered level of consciousness (1,5)
  • oxygen saturation level - < 92%, or central cyanosis
  • peak expiratory flow rate - < 33% of predicted (6)
    
    
• reassess people with an acute cough
  • if their symptoms worsen rapidly or significantly, taking account of:
    • alternative diagnoses, such as pneumonia any symptoms or
    • signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
    • previous antibiotic use, which may have led to resistant bacteria
      
      
• referral and seeking specialist advice
  • refer people with an acute cough to hospital, or seek specialist advice on further investigation and management, if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis, a pulmonary embolism or lung cancer)
    
    
• when an immediate antibiotic prescription is given, give advice about possible adverse effects of the antibiotic, particularly diarrhoea and nausea
  
  
• when a back-up antibiotic prescription is given, give advice about:
  • an antibiotic not being needed immediately
  • using the back-up prescription if symptoms worsen rapidly or significantly at any time
    
    
• Acute cough associated with an upper respiratory tract infection
  • do not offer an antibiotic to treat an acute cough associated with an upper respiratory tract infection in people who are not systemically very unwell or at higher risk of complications
    
    
• limited evidence suggests that antihistamines, decongestants and codeine-containing cough medicines do not help cough symptoms

Reference

1. Dicpinigaitis PV et al. Acute cough: a diagnostic and therapeutic challenge. Cough. 2009;5:11
2. NICE (February 2019). Cough (acute): antimicrobial prescribing
3. NICE (December 2014).Pneumonia- Diagnosis and management of community- and hospital-acquired pneumonia in adults
4. 2015 - Annotated BTS Guideline for the management of CAP in adults (2009)
5. Subbe CP. Validation of a modified Early Warning Score in medical admissions. QJM. 2001;94(10):521-6
6. Scottish Intercollegiate Guidelines Network and British Thoracic Society 2009. British guideline on the management of asthma: a national clinical guideline
7. Public Health England (June 2021). Managing common infections: guidance for primary care