New or worsening cough
at the bedside
- airway, breathing, circulation; full vitals; SpO₂ against the chart and the baseline oxygen; sit the patient up
- what changed → new tonight or worse since admission; dry or productive, and what the sputum looks like; started after a feed, a drink, lying flat, a new drug, IV fluids or a transfusion
- oxygen need → any new or rising requirement is not just a cough → oxygen desaturation
- listen → wheeze, crackles on one side or both, stridor; a wet or gurgling voice after swallowing
- chart and MAR → fluid balance over 24 h, a diuretic missed, an ACE inhibitor started or increased, sedatives and opioids, feeding route and swallow status
escalate now if
- stridor, drooling, cannot speak, or coughing after choking with distress → upper airway obstruction or aspirated food → dyspnea, anesthesia and ICU now
- SpO₂ below target on oxygen, rising work of breathing, exhausted or drowsy → dyspnea, respiratory and ICU now
- blood in the sputum beyond streaks → hemoptysis
- pink frothy sputum, orthopnea, new crackles after IV fluids or a transfusion → pulmonary edema; transfusion running → stop it, transfusion reaction
- fever with new focal crackles and hypoxemia, or hypotension or confusion → pneumonia, cultures and antibiotics now
- cough with pleuritic pain, tachycardia or a swollen leg → pulmonary embolism → dyspnea
- lip, tongue or throat swelling on an ACE inhibitor → angioedema: stop the drug now → allergic reaction
differentials
- dry cough → ACE inhibitor, viral tracheobronchitis, asthma or cough-variant asthma, reflux, post-nasal drip, dry oxygen, early pulmonary edema, PE, interstitial disease or drug pneumonitis
- productive cough → pneumonia (community-acquired, or hospital-acquired when it starts ≥ 48 h after admission), COPD or bronchiectasis flare, aspiration, pulmonary edema (frothy, pink)
- aspiration → cough with meals or sips, wet voice, stroke or dysphagia, sedation, NG feeding, recent extubation; pneumonitis in the first hours, pneumonia if it persists
- fluid → cough lying flat, orthopnea, positive balance, missed diuretic, transfusion
- drugs → ACE inhibitor (dry, tickly; starts weeks to months in, also after a dose increase); β-blocker unmasking bronchospasm; opioids and sedatives feeding aspiration; amiodarone, nitrofurantoin or methotrexate pneumonitis
- upper airway and reflux → post-nasal drip, rhinitis, an NG tube or unhumidified oxygen drying the mucosa; reflux after meals or lying flat, heartburn, a hoarse morning voice
- weeks of cough → night sweats, weight loss, hemoptysis → TB or cancer: isolate if TB is possible → hemoptysis
focused check
- history → onset and timing (night, after meals, lying flat, after a neb or a feed); dry or productive and the sputum color; baseline cough (COPD, bronchiectasis, asthma, smoking); dysphagia or stroke; recent extubation or NG tube
- drug chart and MAR → ACE inhibitor and when it started; β-blocker; sedatives and opioids; diuretic given or missed; IV fluid rate; inhalers from home not charted; nebs due
- exam → work of breathing and speech; wheeze, crackles, dullness, unequal air entry; JVP and edema; calves; mouth and throat (secretions, pooled saliva); a sip of water if safe: wet voice or cough within a minute means stop oral intake
- chart → SpO₂ and oxygen flow trend, temperature trend, fluid balance and weight, last CXR and what it showed
send now
- nothing routinely → afebrile, on no new oxygen, clear chest and a dry cough: no bloods or film tonight; document and reassess
- new hypoxemia, fever or focal signs → CXR tonight (portable if unwell); CBC, CRP, RFT; blood cultures if febrile; sputum culture if purulent, before the first antibiotic dose; influenza and COVID swab per local policy
- suspected pulmonary edema → CXR, RFT, ECG; NT-proBNP as on the dyspnea page → dyspnea
- suspected aspiration → CXR if hypoxemic or febrile; an early film can be normal; hold oral intake until a swallow screen
- gas → only if drowsy, tiring, at risk of hypercapnia or needing NIV → venous blood gas
- not tonight → CT chest, bronchoscopy, spirometry: treating team decisions unless the result changes tonight’s plan
treat
for everyone: safe relief
- sit up; oxygen only to target 90–94%, 88–92% if at risk of hypercapnia; humidify it if the nose or throat is dry → oxygen desaturation
- warm fluids and small sips if the swallow is safe; mouth care; suction pooled secretions
- thick sputum → nebulized saline, with salbutamol first if wheezy → respiratory medications
- chest wall pain from coughing → paracetamol 1 g QDS, max 4 g/day, less if under 50 kg, frail or liver disease → analgesia
- no codeine or sedating cough suppressant at night → in the frail, on opioids, at risk of hypercapnia, or with secretions to clear; over-the-counter cough mixtures add nothing; an antitussive is a treating-team decision by day
aspiration
- nil by mouth now, including tablets; sit upright; suction; oxygen to target
- NG feed running → stop it, check the tube position before it restarts → NG tube problems
- chest exam and SpO₂ again within the hour; CXR if hypoxemic or febrile
- pneumonitis (coughing, hypoxemic, infiltrate within hours) → supportive; no antibiotics unless septic, worsening, or still febrile with an infiltrate at 48 h → pneumonia
- swallow screen and speech therapy in the morning; sedatives and opioids reviewed with the treating team
pneumonia
- fever, focal signs, hypoxemia or a new infiltrate → cultures first, then antibiotics within the hour if septic; community-acquired, or hospital-acquired if onset ≥ 48 h after admission → empiric antibiotics
- suspected aspiration pneumonia → same regimens; no routine anaerobic cover unless abscess or empyema (ATS/IDSA 2019)
- purulent sputum alone → afebrile, no new oxygen, clear film: no antibiotic tonight; COPD with more sputum and more dyspnea → dyspnea
- influenza season → swab; antiviral and isolation per local policy
pulmonary edema
- stop the IV fluids or the transfusion; sit up; oxygen to target
- furosemide → 40 mg IV if diuretic-naive, or double the daily oral dose given IV; full pathway and NIV criteria → dyspnea
- within hours of a transfusion → TACO versus TRALI → transfusion reaction
bronchospasm
- wheeze → salbutamol 2.5–5 mg neb; moderate or severe → add ipratropium 0.5 mg neb; steroids and escalation → asthma, COPD
- β-blocker started this admission with new wheeze → tell the treating team; cough-variant asthma is a treating-team diagnosis, not an overnight one
drug-induced cough
- ACE inhibitor → dry cough with no infection, edema or hypoxemia: document it for the treating team; stopping or switching to an ARB is their decision, and the cough takes 1–4 weeks to settle after stopping; angioedema is the only reason to stop it tonight
- opioids and sedatives with a wet cough → aspiration risk: review the dose and the need tonight → aspiration
- amiodarone, nitrofurantoin, methotrexate → dry cough with hypoxemia or new infiltrates: possible pneumonitis; CXR tonight, respiratory review in the morning, do not stop or start anything else overnight
reflux and upper airway
- reflux pattern → head of the bed up, no late feeds, no lying flat straight after a meal; a PPI is not an overnight fix and is for heartburn or regurgitation, not for cough alone → gastro medications
- post-nasal drip or dry mucosa → saline, humidified oxygen, review whether the nasal cannula or the NG tube is still needed; antihistamines and decongestants are a treating-team decision
- NG tube and coughing → check the external length and position before anything goes down it → NG tube problems
reassess
- when → within the hour after any treatment or a witnessed aspiration, then each round
- what → cough frequency and sputum; SpO₂ and oxygen flow against the chart; respiratory rate and work of breathing; temperature; fluid balance; new crackles or wheeze
- not settling → back to the escalate box; new oxygen need or work of breathing is a dyspnea call now
- hand over → working cause, oxygen need and trend, what was given and when, CXR and cultures pending, oral intake status, drug review needed (ACE inhibitor, sedatives), escalation trigger
evidence
| source | type |
|---|---|
| Irwin et al. 2018 · Classification of cough and management algorithms (CHEST guideline) ↗︎ | specialty-society guideline |
| ATS/IDSA 2019 · Community-acquired pneumonia in adults ↗︎ | international guideline |
| IDSA/ATS 2016 · Hospital-acquired and ventilator-associated pneumonia ↗︎ | international guideline |
| Mandell & Niederman 2019 · Aspiration pneumonia (NEJM) ↗︎ | review |
| Dicpinigaitis 2006 · ACE inhibitor-induced cough (ACCP guideline) ↗︎ | specialty-society guideline |
| Kahrilas et al. 2016 · Chronic cough due to gastroesophageal reflux (CHEST guideline) ↗︎ | specialty-society guideline |
| Malesker et al. 2017 · Treatment of acute cough, over-the-counter preparations (CHEST expert panel) ↗︎ | expert panel report |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
updated Oct 2026file complaint/cough