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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Cough and sputum production

Respiratory · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Cough with airway compromise, severe breathlessness, hypoxaemia, sepsis, significant haemoptysis, stridor, suspected foreign body or rapidly progressive neurological swallowing failure needs urgent assessment. Stabilise physiology and protect the airway before pursuing a chronic-cough algorithm.

Synopsis

Classify cough by duration and phenotype, recognise infection, malignancy and suppurative lung disease, and investigate treatable traits without reflex antibiotics, acid suppression or repeated empirical inhalers.

  • Define duration and pattern: acute cough is commonly viral, while chronic cough lasting more than eight weeks needs structured assessment of triggers, imaging, spirometry and treatable traits.
  • Ask whether the cough is dry, productive, nocturnal, meal-related, positional or triggered by cold air, voice, fragrance, exercise or occupational exposure; each pattern changes the differential.
  • Record sputum volume, colour, odour, blood and daily variability. Purulence reflects neutrophilic inflammation but does not by itself prove a bacterial infection needing antibiotics.
  • Red flags include haemoptysis, weight loss, persistent fever, hoarseness, dysphagia, focal chest signs, recurrent same-site infection, clubbing and smoking-related cancer risk.
  • For chronic cough obtain a chest radiograph, quality-assured spirometry and blood count; BTS also supports fractional exhaled nitric oxide where available to identify an eosinophilic airway trait.
  • Review medicines, especially ACE inhibitors, and stop the culprit where clinically safe; improvement may take several weeks, so replacing it for only a few days is not an adequate trial.
  • Treat reflux with acid suppression only when typical acid reflux symptoms or objective evidence supports it; proton-pump inhibitors do not routinely treat isolated throat symptoms or cough.
  • Persistent productive cough, recurrent infections or large sputum volume should prompt culture and consideration of bronchiectasis, aspiration, chronic infection or an obstructing lesion.

Key red flags

Malignancy or focal obstruction

Haemoptysis, weight loss, persistent hoarseness, focal wheeze, lymphadenopathy, clubbing or recurrent pneumonia in one lobe warrants urgent imaging and cancer-pathway assessment, particularly in people aged forty or over with smoking or asbestos exposure.

Investigation priorities

01
Chest radiographFirst step

Detect pneumonia, mass, collapse, interstitial change, heart failure or another structural cause.

Management branches

AcuteAcute cough without instability

Cough of recent onset with stable physiology and no cancer, sepsis or airway red flags.

  1. Assess observations, chest signs, comorbidity and duration; identify pneumonia, asthma exacerbation, COVID-19 or influenza risk, pulmonary embolism and heart failure rather than assuming uncomplicated bronchitis.
  2. Give self-care advice and symptom relief appropriate to the person; NICE advises against routine antibiotics for uncomplicated acute cough because benefit is small and adverse effects and resistance are real.
  3. Use delayed or immediate antibiotics only when the relevant infection guideline and clinical risk support them, documenting allergy, indication, duration and what failure should trigger.
  4. Safety-net for breathlessness, haemoptysis, confusion, dehydration, persistent fever, chest pain or cough beyond the expected course; arrange reassessment when risk or diagnostic uncertainty remains.
Chronic first lineFind common treatable traits

Cough persisting beyond eight weeks without an established explanation.

  1. Review smoking, ACE inhibitors, occupation, rhinitis, heartburn, asthma features, sputum, aspiration and warning symptoms; examine the chest, upper airway, nodes and for clubbing.
  2. Obtain chest radiograph, full blood count and quality-assured spirometry; add FeNO, eosinophils and sputum culture according to the dry or productive phenotype.

Key medicines

ACE-inhibitor withdrawal when clinically appropriateStop the ACE inhibitor and substitute an appropriate alternative through the prescribing clinician; allow at least four weeks before judging cough response.Do not stop heart-failure or renal-protective treatment without an alternative plan. Cough may take longer than four weeks to settle, and persistence should restart structured investigation.
Proton-pump inhibitor for documented acid reflux symptomsUse an adequate guideline-concordant treatment course only when heartburn or other convincing acid-reflux evidence is present, then review and deprescribe if ineffective.Do not prescribe routinely for isolated throat symptoms or unexplained cough. Long-term therapy has adverse-effect and interaction burdens; response does not exclude coexisting causes.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • British Thoracic Society chronic cough statementUK adult chronic-cough assessment, treatable traits and refractory-cough management.
  • NICE NG120 acute cough antimicrobial prescribingNatural history, antibiotic stewardship and risk-based treatment for acute cough.
  • NICE NG12 suspected cancer recognition and referralLung-cancer chest-radiograph and referral triggers; recommendations require age and risk context.
  • NICE NG115 chronic obstructive pulmonary diseaseProductive cough, spirometry and COPD diagnostic context.
  • British Thoracic Society bronchiectasis guidelineStructural investigation, sputum microbiology and airway-clearance principles for bronchiectasis.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
  • Remove supported triggers and use time-limited, outcome-defined treatment trials for eosinophilic airway disease, rhinitis or symptomatic acid reflux rather than treating every pathway simultaneously.
  • Review after the appropriate interval. Confirm adherence and technique, stop ineffective treatment, and escalate persistent productive cough, red flags or abnormal imaging to respiratory assessment.