Diagnosis and Management of Prolonged Cough

Initial Evaluation and Diagnosis

The American College of Chest Physicians recommends that at one week duration with fever, this presentation most likely represents an uncomplicated viral upper respiratory tract infection or acute bronchitis, but pertussis must be actively ruled out, especially if paroxysmal coughing, post-tussive vomiting, or inspiratory whooping is present 1, 2
Vital sign abnormalities such as heart rate ≥100 bpm, respiratory rate ≥24 breaths/min, or temperature ≥38°C suggest pneumonia and warrant chest radiography, according to the American College of Emergency Physicians 3
Focal consolidation on exam, such as asymmetrical lung sounds, rales, egophony, or fremitus, indicate pneumonia requiring imaging, as recommended by the American College of Emergency Physicians 3

The American College of Chest Physicians recommends that if the patient has paroxysmal cough, post-tussive vomiting, or inspiratory whooping, a nasopharyngeal culture or swab for pertussis should be obtained immediately 5, 1
The American College of Chest Physicians suggests that in adults, presence of whooping or post-tussive vomiting rules in pertussis, while absence of paroxysmal cough or presence of fever rules it out 1
The American Academy of Pediatrics recommends that in children, post-tussive vomiting is suggestive but less specific, and all three classical features (paroxysmal cough, post-tussive vomiting, inspiratory whooping) should be assessed 1
The Centers for Disease Control and Prevention recommend prescribing macrolide antibiotics immediately, such as azithromycin or clarithromycin, to reduce coughing severity and prevent transmission, with a strength of evidence rated as high 5, 2, 6
The Centers for Disease Control and Prevention advise isolating the patient for 5 days from the start of treatment, with a strength of evidence rated as high 5

The American College of Emergency Physicians recommends that antibiotics are not indicated for acute bronchitis in otherwise healthy adults, with a strength of evidence rated as high 3
The American College of Emergency Physicians suggests that purulent sputum does not indicate bacterial infection and should not prompt antibiotic prescription, with a strength of evidence rated as high 3
The American Academy of Family Physicians recommends symptomatic treatment with first-generation antihistamine/decongestant combination, with a strength of evidence rated as moderate 6

The American College of Chest Physicians recommends that at 3 weeks duration, subacute post-infectious cough should be treated with inhaled ipratropium bromide as first-line therapy, with a strength of evidence rated as high 2, 7
The American College of Chest Physicians suggests that if treatment fails after 2 weeks, evaluation for asthma/non-asthmatic eosinophilic bronchitis and gastroesophageal reflux disease (GERD) should be performed, with a strength of evidence rated as moderate 6
The American Gastroenterological Association recommends considering empiric GERD treatment with high-dose PPI therapy, dietary modifications, and lifestyle changes, with a strength of evidence rated as moderate 6

The American College of Obstetricians and Gynecologists recommends that inhaled ipratropium bromide remains first-line for post-infectious cough in pregnant women, with a strength of evidence rated as high 2
The American College of Chest Physicians advises scheduling follow-up in 4-6 weeks to reassess if cough persists, with a strength of evidence rated as moderate 4, 2