Acute Cough Management in Primary Care

Initial Assessment and Red Flags

The American College of Physicians recommends checking for signs requiring urgent intervention or immediate chest X-ray, including respiratory distress, vital sign abnormalities, systemic illness, and high-risk features, in patients with a 2-day acute cough 1.
The American Thoracic Society suggests that high-risk features, such as hemoptysis, weight loss, night sweats, and history of cancer/TB/AIDS, should be considered red flags for further evaluation 2, 3.

A focused history should include medication review, smoking status, associated symptoms, comorbidities, and exposure history to guide management, according to the American Academy of Family Physicians 1, 4, 2, 5.
The European Respiratory Society recommends a targeted physical examination, including lung auscultation, upper airway examination, and general appearance, to identify findings that change management 6, 1.

The American College of Chest Physicians suggests treating presumed viral upper respiratory infection with first-generation antihistamine/decongestant combination, naproxen, adequate hydration, honey for cough suppression, and acetaminophen for fever and associated symptoms 5, 1, 4.
The Infectious Diseases Society of America recommends considering empiric antibiotics for suspected bacterial pneumonia, and treating asthma/COPD exacerbation with inhaled bronchodilators and systemic corticosteroids 1, 5, 4.

The American Academy of Pediatrics recommends returning immediately or calling if breathing difficulty develops, and considering follow-up if cough worsens or persists beyond 7 days 1.

The American College of Chest Physicians recommends against prescribing antibiotics unless there is clinical evidence of bacterial pneumonia, as the presentation is almost certainly viral at 4 days with clear breath sounds 7
The American College of Chest Physicians suggests that first-generation antihistamine/decongestant combination can be used as primary therapy to address post-nasal drip and upper airway symptoms 8

The American College of Chest Physicians recommends reassessing the patient at 3 weeks if cough persists, as this transitions to subacute cough requiring systematic evaluation for post-infectious complications, upper airway cough syndrome, asthma, or other causes 8
The American College of Chest Physicians suggests considering alternative diagnoses such as pertussis if paroxysmal cough, post-tussive vomiting, or inspiratory whoop emerge, although this typically presents after 1-2 weeks 7