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management of acute cough in primary care

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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):

 

Pneumonia suspected:

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

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

Last edited 02/2019 and last reviewed 03/2020

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