Links To And Excerpts From The Diagnosis and Treatment of Acute Cough in Adults

In this post I link to and excerpt from  The Diagnosis and Treatment of Acute Cough in Adults [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Dtsch Arztebl Int. 2014 May 16;111(20):356-63.

Here are excerpts:

put in fig1

Cough is the most frequent reason for visits to
primary care physicians, accounting for around
8% of all consultations (1). The annual prevalence of
cough in the general population is reported as circa
10–33% (2). By far the most common causes of acute
cough are infections of the upper respiratory tract and acute bronchitis, which together account for more than 60% of diagnosed cases (1).

The aim of the guideline is to depict the differential diagnoses of the symptom “cough” in adults and to guide the physician in identifying the cause and providing evidence-based treatment, with emphasis on relevance for primary care in practice.

Guideline contents and recommendations

History and clinical examination

In a large proportion of patients with acute cough in the primary care setting, the diagnosis can be established from the medical history and the findings of a symptom oriented physical examination. More technical diagnostic investigations are of little value in these cases (6).
The basic elements of history taking and physical
examination are outlined in Table 2.

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Danger signs

The aim of history taking and physical examination is differentiation of harmless infections from serious
diseases and early detection of potentially endangered patients. In occasional cases a life- threatening illness may be present or imminent (Table 2). The major warning signs (“red flags”) are dyspnea, tachypnea, thoracic pain, hemoptysis, a severely worsened general state, and changes in vital signs (high fever, tachycardia, arterial hypotension), together with the presence of any complicating underlying disease (e.g., malignancy, immune deficiency).

In urgent cases immediate action is required. Usually this means rapid transport to hospital accompanied by a (emergency) physician. [Or EMT or Paramedic ambulance in the United States]

Frequent diseases, diagnosis, and treatment options

The principal differential diagnoses are listed in Table 3. The most frequent causes of acute cough are
discussed in the following [sections].

Put in fig3.

Colds and acute bronchitis

Clinical presentation—Upper respiratory tract infections (URTI; “common cold”) are the most common cause of acute cough. Other typical symptoms are sore throat, runny nose, headache, muscle aches, fatigue, and sometimes a high temperature. Viral infections are usually to blame (adenoviruses, rhinoviruses, influenza- and parainfluenza viruses, coronaviruses, respiratory syncytial virus [RSV], coxsackieviruses).

The cough in acute bronchitis* is first dry, then productive.

*For more information, please see Bronchitis: Should I Take Antibiotics? from Michigan Medicine, current as of Oct 26, 2020:

You may want to have a say in this decision, or you may simply want to follow your doctor’s recommendation. Either way, this information [in the link] will help you understand what your choices are so that you can talk to your doctor about them.

There is no clear cut-off between a cold and acute
bronchitis (involvement of the lower respiratory tract). In two thirds of cases a cold is self-limiting and lasts no longer than 2 weeks, while in bronchitis the cough can persist for several weeks (7).

Acute sinusitis in the context of a cold may also stimulate cough receptors.

*For additional information on Bronchitis, please see Bronchitis
Updated: Sep 18, 2020. From
Author: Jazeela Fayyaz, DO.

*For an additional resource on Bronchitis, please see Bronchitis Empiric Therapy. Updated: Aug 20, 2019. Author: Jazeela Fayyaz, DO. From


Diagnosis—If the history and clinical findings are
compatible with cold or bronchitis, neither a chest
radiograph nor clinical chemistry is necessary,
provided there are no danger signs (Table 2).

It is not necessary to distinguish between viral and bacterial bronchitis by determination of leukocytes or C-reactive protein (CRP), because the findings have no consequences for treatment (8).

The color of the sputum has no predictive value for the diagnosis of bacterial bronchitis or the differentiation between pneumonia and bronchitis (9, 10).

Sputum examination in an otherwise healthy bronchitis patient is pointless, because antibiotics are not required (11).

Spirometry is indicated in the presence of signs of bronchial obstruction, because acute bronchitis can cause temporary airway constriction (9).

A patient whose cough persists should be investigated in more detail after no more than 8 weeks*.

*Please see When ‘Just a Cough’ Is Actually Stage IV Lung Cancer [In A Nonsmoker]: Jeanine Pucci was surprised to learn her persistent cough was something more serious.

Treatment—There is scant evidence on the efficacy
of nonmedicinal treatments.

From the physiological viewpoint it is sensible to maintain an adequate fluid intake, but drinking excessive amounts may bear the risk of hyponatremia (12).

Abstention from smoking is recommended, because active and passive smokers take longer to recover from a cold (13).

The results of RCTs are inconsistent with regard to the efficacy of nasal rinses/sprays with saline solution or steam inhalation (14, 15).

To prevent transmission, it is better to cough into the elbow rather than the hand.

Cough accompanying a cold or acute bronchitis/
sinusitis usually resolves without any specific medicinal treatment. The patient should be told that the illness is self-limiting and harmless, and that therefore no drugs need to be given. Medications to relieve the symptoms can be prescribed, however, if the patient so wishes.

Analgesics such as acetaminophen and ibuprofen are recommended for symptomatic treatment of headache and muscle aches.

No antibiotic treatment is necessary in uncomplicated acute bronchitis. Antibiotics relieve the symptoms only marginally and shorten the recovery times by less than a day, while their disadvantages include potential adverse effects and development of resistance (11).

Administration of antibiotics can be considered in individual patients with serious chronic diseases or immune deficiencies, because in such cases it is often difficult to rule out pneumonia (9). Even in these patients antibiotics should not be prescribed routinely, however, because—as in general—the bronchitis is usually viral in origin.


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