‘ I ’ ve got my usual cough – it ’ s

gone to my chest with green phlegm , so I need antibiotics ’

This statement illustrates one of two common presentations with a cough , alongside the newly named ‘ Schrödinger ’ s cough ’ ( a cough at once so bad as to need antibiotics , and so mild that the person feels no need to test for Covid-19 and self-isolate ). The belief that a cough with green or yellow phlegm has ‘ gone to the chest ’ and needs antibiotics is one of the most pervasive myths around .

The reality Deciding whether a patient has a bacterial or viral infection is not as simple as ‘ white phlegm = viral ; green phlegm = bacterial ’.

NICE defines acute bronchitis as ‘ a lower respiratory tract infection which causes inflammation in the bronchial airways ’. ¹ Around 44 per 1,000 adults will get acute bronchitis every year , usually caused by a viral infection . Common viruses include rhinovirus , enterovirus , influenza and coronavirus .

Conversely , pneumonia , defined as ‘ an infection of the lung tissue in which the air sacs … become filled with microorganisms … affecting the function of the lungs ’, is usually caused by a bacterial infection and does need antibiotics . ¹ But pneumonia is much less common , affecting 5 to 10 per 1,000 people per year . Both bronchitis and pneumonia are more common in the winter .

Deciding whether a patient with a cough has a bacterial or viral infection is not simple , even though the general public ( and some healthcare professionals ) seem to think it is . We need to look at the whole patient and make a holistic assessment .

A patient with pneumonia is likely to be more unwell than one with acute bronchitis . They may have constitutional symptoms such as shivering , fever and body aches , and there may be focal chest signs such as decreased chest sounds , dullness to percussion or coarse crackles . Older people may present with confusion as their main clinical sign , and are less likely to spike a temperature .

The CRB-65 score may be useful – one point is given for each of Confusion , Raised respiratory rate ( ≥30 breaths / minute ), low Blood pressure ( diastolic ≤60 mmHg or systolic ≤90 mmHg ) and age 65 or more . Scoring zero gives the patient a less than 1 % risk of dying from their infection , rising to 1-10 % with a score of 1-2 , and more than 10 % for a score of 3-4 .

In primary care we largely use clinical judgment to make our decisions , although a sputum culture may be indicated if the infection seems moderately severe , or a chest X-ray if underlying pathology ( such as lung cancer ) is suspected . Neither of these investigations will deliver immediate results .

It is important to remember that not all cough is

Table 1 Symptoms and signs of acute bronchitis and community-acquired pneumonia ¹

Acute bronchitis

History Cough Cough

Examination

Investigations ( not usually considered necessary in general practice )

May or may not have sputum , wheeze or breathlessness

Substernal or chest-wall pain may be present when coughing

Sometimes mild constitutional symptoms

Mildly ill

Wheeze often present ; rhonchi that improve with coughing may be present

May have systemic features with or without a raised temperature .

Chest X-ray normal

Community-acquired pneumonia

Dyspnoea , sputum production , pleural pain , sweating , fever , shivers , aches and pains

Note : Unusual presentations can indicate certain atypical pathogens ( for example dry cough , no fever , headache , confusion , diarrhoea , hyponatraemia in Legionella pneumonia ; upper respiratory involvement , skin changes , encephalitis , uveitis , myocarditis , haemolytic anaemia in Mycoplasma pneumonia )

Moderately to severely ill

Focal chest signs such as decreased or asymmetric breath sounds , bronchial breath sounds , dullness to percussion , course crepitations , vocal fremitus

Typically tachypnoea , tachycardia , dyspnoea

Temperature 38 ° C or above May be hypoxia

Confusion ( uncommon , but may be seen in older people )

Chest X-ray abnormal ( new infiltrate provides definitive diagnosis of pneumonia )

Nursing in Practice Spring 2022 | Page 38

‘ I ’ ve got my usual cough – it ’ s

gone to my chest with green phlegm , so I need antibiotics ’