Acute Cough — Assessment & Management

Safety

Red Flags — Pneumonia, Pulmonary Embolism & Malignancy

Done

Systemically unwell, respiratory distress, hypoxaemia, altered mental state, hypotension, marked tachypnoea, rapid worsening, unable to maintain oral intake, or significant comorbidity/frailty Serious infection, pneumonia with physiological compromise or sepsis — no single feature or CXR is required. → Same-day hospital assessment by clinical severity and the local sepsis pathway (999 if unstable or suspected high-risk sepsis). CRB-65 supports, never replaces, judgement.

Acute cough with pleuritic chest pain, breathlessness or haemoptysis — especially with risk factors (immobility, recent surgery, malignancy, DVT history, OCP) Consider PE — haemoptysis also occurs with infection, bronchiectasis, malignancy and TB. → 999 if haemodynamically unstable. Otherwise Wells (NICE NG158): PE likely → same-day CTPA, do not wait for D-dimer; PE unlikely → D-dimer, imaging if positive. If imaging is delayed, interim therapeutic anticoagulation per NG158/local protocol and bleeding risk. Consider pregnancy, renal function, contrast allergy.

Unexplained haemoptysis aged 40 or over Suspected cancer → lung suspected cancer pathway referral (NICE NG12) — no 3-week or smoking requirement. Urgent CXR if appropriate, but do not delay referral for it. Urgent CXR at 40+ with 2 or more unexplained cough, fatigue, breathlessness, chest pain, weight loss or appetite loss — or 1 if ever smoked. Normal CXR with persisting high suspicion → urgent specialist referral per the local lung pathway.

Cough with stridor (harsh inspiratory noise) at rest, drooling, or rapidly progressive airway symptoms, at any age Upper-airway obstruction (epiglottitis, severe croup and foreign body are distinct). → 999; involve paediatric/ENT/anaesthetic teams. Keep calm in position of comfort; do not force supine; avoid throat examination and unnecessary procedures. Cough + hoarse voice alone is not epiglottitis.

Cough with severe breathlessness and tracheal deviation or unilateral absent breath sounds (with or without recent trauma or COPD) Tension pneumothorax. → 999 with oxygen and resuscitation support; decompression is a procedure for trained pre-hospital/hospital clinicians per local protocol. Do not delay transfer.

Infant with apnoea, cyanosis, significant respiratory distress or poor feeding Apnoea, cyanosis or severe breathing difficulty → 999; poor feeding or other respiratory distress → same-day paediatric assessment — in young infants pertussis may present with apnoea and no whoop. Pertussis is notifiable: follow current UKHSA guidance. Antibiotics (per UKHSA, age-appropriate) reduce transmission if started early in the illness.

Community-acquired pneumonia severity assessment using CRB-65 is a validated scoring tool that every GP should apply at every pneumonia assessment — it takes 30 seconds and directly guides the admission decision. CRB-65 scoring: C (Confusion — new confusion, abbreviated mental test ≤8) = 1 point; R (Respiratory rate ≥30/min) = 1 point; B (Blood pressure — systolic <90 or diastolic ≤60) = 1 point; 65 (age ≥65) = 1 point. Interpretation: 0 = low risk (mortality <1%); 1–2 = intermediate (about 1–10%); 3–4 = high (>10%). NICE NG250 1.2.3: usually primary care at 0; consider hospital referral at ≥2; at 1, decide individually between primary-care-led care, virtual ward, SDEC, hospital-at-home or hospital. Oxygen saturation, heart rate, temperature and CXR are not part of the score. The CURB-65 version adds urea >7 mmol/L but requires a blood test. Important caveat: CRB-65 is a minimum threshold — clinical judgement (including oxygen saturation, comorbidities, social circumstances, patient ability to comply with oral treatment) should always supplement the score.

Diagnose

Classification of Acute Cough — Duration and Aetiology

Done

Acute cough (<3 weeks)

Viral upper respiratory tract infection (most common — rhinovirus, coronavirus, influenza): associated coryzal symptoms, pharyngitis, mild fever, self-limiting in 7-14 days — no antibiotics. Acute bronchitis: lower respiratory tract URTI without pneumonia — viral in >90%, dry then productive cough, 3 weeks average duration, NO antibiotic (unless comorbidity changes risk assessment). Community-acquired pneumonia (CAP): productive cough + fever + focal chest signs — a CXR is not required to recognise pneumonia in the community. Influenza: fever + myalgia + sudden onset — antivirals (oseltamivir within 48h for high-risk groups). Pertussis (whooping cough): paroxysmal cough ± whoop ± post-tussive vomiting — not all features are needed; the whoop is often absent in adults and young infants, and apnoea may be the main feature in infants — lasting 6-10 weeks ("100-day cough"). Inhaled foreign body: sudden onset cough + wheeze in child.

Subacute cough (3-8 weeks)

Post-viral cough (post-infectious): most common — persists after URTI; airway hypersensitivity; resolves without treatment (reassure + antitussive if needed). Pertussis (late presentation). Resolving CAP. Subacute sinusitis (post-nasal drip). Atypical pneumonia (Mycoplasma, Chlamydophila, Legionella): gradual onset, dry cough, relatively mild systemic upset for the radiological appearance.

Chronic cough (>8 weeks — most cases in primary care)

Asthma: variable airflow obstruction + eosinophilic inflammation. Post-nasal drip / rhinitis. ACE inhibitor cough (affects approximately 10-15% of ACE inhibitor users — dry persistent cough from bradykinin accumulation). GORD (gastro-oesophageal reflux). COPD / bronchiectasis. Lung cancer. ILD (interstitial lung disease). See the chronic cough algorithm if >8 weeks.

The vast majority of acute cough presentations in UK primary care are viral — approximately 90% of acute bronchitis, the most common lower respiratory presentation, is caused by viruses, and antibiotics provide no meaningful benefit. NICE NG120 recommends self-care and no routine antibiotic for acute cough, which can last 3–4 weeks; a back-up prescription is used if symptoms worsen rapidly or significantly at any time — not on a fixed day, which could delay reassessment of pneumonia, PE, asthma, heart failure or malignancy. The GRACE study showed that an internet-based clinical decision tool (TARGET/CRB-65 combination) could safely reduce antibiotic prescribing for lower respiratory tract infections without increasing adverse outcomes. The key GP message for the patient: 'Most chest infections are caused by viruses. Antibiotics won't help this — they only work on bacteria. This can take 3 to 4 weeks to clear. Here is an information leaflet. If you get rapidly or significantly worse at any point, or develop any of the warning signs I'm going to describe, contact us the same day — call 999 if you are struggling to breathe, have chest pain or become confused.'

Diagnose

Assessment — History, Examination & Investigations

Done

Structured acute cough history

Duration: days (viral, bacterial, PE, foreign body), weeks (pertussis, atypical, post-viral). Onset: sudden (foreign body, PE, pneumothorax), gradual (infection, subacute). Character: dry (viral, PE, ACE inhibitor, post-viral), productive (bacterial infection, bronchiectasis, lung abscess), barking/seal-like (croup). Sputum: colour + quantity (green or yellow sputum does not reliably distinguish bacterial from viral infection and should not alone determine antibiotics; blood-streaked has a wide differential — infection, PE, malignancy, bronchiectasis, TB, anticoagulant-related). Associated symptoms: fever (infection), pleuritic pain (PE, pleurisy), wheeze (asthma, COPD, foreign body), dyspnoea (PE, pneumonia, pneumothorax). Systemic: weight loss (malignancy, TB), night sweats (TB, lymphoma). Travel: TB-endemic area (South Asia, Sub-Saharan Africa), Legionella (hotel/spa pools). Smoking (COPD, lung cancer). Occupational (asbestosis). Immunosuppression (PCP, TB, aspergillosis).

Examination

Vital signs (RR, HR, BP, temperature, SpO₂) when there is breathlessness, chest pain, fever, suspected LRTI, comorbidity, frailty, abnormal chest signs or concern — a normal SpO₂ does not exclude PE, pneumonia, asthma or ACS. Auscultation: crackles (pneumonia, pulmonary oedema, bronchiectasis, ILD), wheeze (asthma, COPD, bronchiolitis), absent breath sounds (pneumothorax, effusion, consolidation). Percussion: dullness (consolidation, effusion), hyperresonance (pneumothorax). Work of breathing: accessory muscle use, intercostal recession (particularly in children). JVP, peripheral oedema (cardiac cause of cough).

Investigations

Uncomplicated viral URTI/bronchitis: no routine tests. · CXR (focal signs or suspected pneumonia where it changes management, haemoptysis, persistent or recurrent infection, suspected malignancy, pneumothorax or heart failure) · Point-of-care CRP (consider only if, after clinical assessment, it is unclear whether antibiotics are needed, and the test is locally validated — CRP <20 mg/L: do not routinely offer an antibiotic; 20–100 mg/L: consider a back-up antibiotic prescription; >100 mg/L: offer an antibiotic; NICE NG237) · Wells-based pathway (suspected PE — see Step 1) · Pertussis PCR (most useful in the first 3 weeks of cough; serology later per local lab) · Blood/sputum cultures and urinary antigens are for higher-severity, hospital-managed or treatment-failure cases, not routine GP care

Pulse oximetry is valuable when the clinical picture warrants it, but no single SpO₂ threshold mandates 999 for everyone: interpretation depends on baseline saturation, COPD and hypercapnia risk, device accuracy and skin pigmentation, and how stable the patient is. Treat hypoxaemia as an emergency when severe, worsening or accompanied by distress, altered mental state or haemodynamic compromise; in COPD at risk of hypercapnia use controlled oxygen targeting 88–92%. Silent hypoxia (significant desaturation without apparent distress) is a well-documented phenomenon, particularly in COVID-19, community-acquired pneumonia, and pulmonary embolism — patients can be talking normally with SaO₂ of 88-90%. The NHS COVID Oximetry @home programme (introduced during the pandemic) established the principle that SpO₂ monitoring is a safety standard in primary care respiratory assessment. Every GP practice should have a calibrated pulse oximeter available and use it when the clinical picture warrants it (breathlessness, chest pain, fever, suspected LRTI, comorbidity, frailty or concern) — it is not mandatory for every cough, and a normal reading does not exclude serious disease. Use the patient's usual target range where known; NICE NG250 uses SpO₂ <90% on air as one marker of clinical instability.

Diagnose

CRB-65 Severity Assessment & Atypical Pneumonia

Done

CRB-65 severity scoring

One point each: Confusion · Respiratory rate ≥30/min · BP systolic <90 or diastolic ≤60 mmHg · age ≥65. Score 0 low risk (mortality <1%) → usually community care. Score 1–2 intermediate (about 1–10%) → at 1, individualise (primary care, virtual ward, SDEC, hospital-at-home); at ≥2, consider hospital referral. Score 3–4 high (>10%) → consider hospital referral, as for ≥2; 999 if septic or clinically unstable. Always add judgement: comorbidity, frailty, oxygenation, ability to take oral treatment, social circumstances and alternative diagnoses (NICE NG250 1.2.3).

Atypical pneumonia pathogens

Mycoplasma pneumoniae (most common atypical — epidemics every 3-4 years; gradual onset dry cough, headache, mild fever; CXR worse than clinical appearance). Atypical pathogens cannot be reliably identified from age, cough character or pulse alone. Chlamydophila pneumoniae (mild illness, slow onset, biphasic — pharyngitis then pneumonia; doxycycline). Legionella pneumophila (severe — 30-day mortality approximately 10%; risk: hotel/spa pools, air conditioning; hyponatraemia; suspected Legionella needs urgent hospital, microbiology and public-health involvement — no routine GP quinolone). Pneumocystis jirovecii (PCP) (immunosuppressed, HIV CD4 <200; bilateral interstitial shadowing on CXR; co-trimoxazole).

COVID-19 cough — primary care assessment

COVID-19 still circulates as endemic respiratory virus. Continuous dry cough + fever + anosmia (less common in Omicron variants) + myalgia + fatigue. Antivirals: for patients at increased risk of progression, check the current NHS England/ICB COVID-19 antiviral pathway (eligibility changes by season). Check renal function, major drug interactions and timing from onset — nirmatrelvir/ritonavir is generally used within 5 days (standard 300/100 mg BD; reduced renal dosing where applicable); molnupiravir 800 mg BD only where commissioned and appropriate. Post-COVID syndrome (long COVID): persistent symptoms >12 weeks — fatigue, breathlessness, brain fog, post-exertional malaise.

Legionella pneumonia (Legionnaires' disease) is a severe pneumonia that must be specifically considered in any patient with moderate-severe pneumonia who has recently travelled (hotels with air conditioning or swimming pools/hot tubs) or been exposed to institutional water systems — it accounts for approximately 2-4% of CAP requiring hospital admission but has a disproportionately high mortality (approximately 10%). The clinical clues: hyponatraemia (serum sodium <130 mmol/L — present in approximately 40-50% of Legionella pneumonia), elevated liver enzymes (hepatitis), elevated CK (myositis), severe headache, gastrointestinal symptoms (diarrhoea, vomiting) preceding respiratory symptoms. The Legionella urinary antigen test (positive within 24h, high sensitivity for L. pneumophila serogroup 1 which causes approximately 85% of cases) is available in all UK acute hospitals. Treatment is specialist-directed in hospital (beta-lactams are ineffective). Legionella is a notifiable disease — public health notification required.

Refer

Referral Pathways

Done

999

Severe or worsening hypoxaemia with distress, altered mental state or compromise · Clinically unstable pneumonia or high-risk sepsis · Suspected PE haemodynamically unstable · Tension pneumothorax · Stridor (epiglottitis/foreign body airway) · Infant with apnoea, cyanosis or severe breathing difficulty

Same-day hospital or acute GP assessment

CRB-65 ≥2 (consider hospital referral, NG250 1.2.3); CRB-65 1 with comorbidity, frailty, low oxygenation, unable to take oral treatment or no support. Suspected PE: Wells likely → CTPA same day; unlikely with positive D-dimer → imaging. Infant with poor feeding or other respiratory distress → same-day paediatrics.

Suspected cancer: lung

Unexplained haemoptysis aged ≥40 → suspected cancer pathway (NICE NG12) — no duration or smoking requirement. CXR suggesting lung cancer. Urgent CXR at 40+ with 2 or more unexplained symptoms (cough, fatigue, breathlessness, chest pain, weight loss, appetite loss) or 1 if ever smoked.

GP treatment + safety-net

Viral URTI/bronchitis (well): self-care, no antibiotic, back-up prescription only if higher risk, safety-net. Where an antibiotic for acute cough is genuinely indicated (NG120): doxycycline 200 mg day 1 then 100 mg OD for 4 days (not in pregnancy); alternatives amoxicillin, clarithromycin or erythromycin (pregnancy: amoxicillin, or erythromycin if a macrolide is needed). Low-severity CAP: amoxicillin 500 mg TDS x 5 days (NG250). COPD exacerbation: antibiotic only by purulence, severity and risk (NG115).

The delayed antibiotic prescription ('back-pocket' prescription) for lower respiratory tract infection has the strongest evidence base of any antibiotic stewardship intervention in primary care — multiple RCTs and a Cochrane review (Little, 2013) demonstrate that when GPs hand patients a back-up prescription to use if symptoms worsen rapidly or significantly, approximately 70-80% of patients do not fill the prescription, antibiotic use is reduced to that extent, and patient-reported outcomes (symptom duration, patient satisfaction, re-consultation rates) are equivalent to immediate antibiotic prescribing. The critical safety-netting component: the GP must specify the warning signs that should trigger use of the prescription or re-consultation: symptoms worsening rapidly or significantly → use the prescription and contact us; increasing breathlessness, blood in sputum or no improvement after 48h of antibiotics → same-day review; confusion or severe breathlessness → 999. Document in clinical notes: 'Delayed antibiotic prescription given — safety-net provided.'

Treat

Antibiotic Prescribing for CAP & LRTI

Done

Low severity CAP (CRB-65 0, home treatment)Amoxicillin 500 mg TDS x 5 days (NICE NG250 (2025) first-line for low severity CAP — S. pneumoniae the most common pathogen). Do not routinely add doxycycline for a young adult with dry cough — atypicals cannot be diagnosed clinically. Penicillin allergy: doxycycline 200 mg day 1 then 100 mg OD (5 days total). Consider local resistance, recent antibiotics, comorbidity and microbiology. Reassess if not improving as expected.

Moderate severity CAP (CRB-65 1–2 intermediate risk; place of care per NG250 1.2.3)Amoxicillin 500 mg TDS x 5 days, adding clarithromycin 500 mg BD x 5 days if atypical pathogens suspected (NICE NG250). CRB-65 ≥2 generally warrants hospital consideration. High severity (co-amoxiclav + clarithromycin or erythromycin) is hospital treatment, not routine community care. Duration: 5 days, then stop unless microbiology indicates longer or the patient is not clinically stable (NICE NG250, 2025 — shorter courses are as effective as longer).

Acute bronchitis (viral — no antibiotics)No antibiotic (viral in >90%). Antipyretic/analgesic: paracetamol 1g QDS. No routine codeine — limited evidence and not helpful for acute cough (NG120; check MHRA restrictions). A non-codeine suppressant may be considered at 12+ without excess secretions. Honey + lemon: evidence for reducing cough frequency in adults and children. NICE NG120: back-up antibiotic only if higher risk of complications, to use if symptoms worsen rapidly or significantly.

Pertussis (whooping cough)May present without a whoop (adults, young infants). Macrolide per current UKHSA guidance — reduces transmission more reliably than symptoms once paroxysmal. Notifiable — follow UKHSA public-health guidance. Exclusion: until 48 h after starting appropriate antibiotics, or 21 days from onset of paroxysmal cough if untreated. Contact prophylaxis is decided by the Health Protection Team (timing, exposure, vulnerability, onward risk to young infants) — not automatic for every household contact or healthcare worker. Advise: cough can persist for 6-10 weeks despite antibiotic treatment.

The 5-day antibiotic course for low-severity CAP is now the duration recommended in NICE NG250 (2025) — the ESCAPE trial and multiple other RCTs demonstrated that 5-day amoxicillin is non-inferior to 7-day treatment for low-severity CAP, with equivalent clinical cure rates and lower antibiotic exposure (reducing selection pressure for resistance and C. difficile risk). NICE NG250 (2025, which replaced NG138) recommends a 5-day course for adults with low-severity CAP (CRB-65 0), and 5 days for moderate or high severity unless microbiology indicates longer or the patient is not clinically stable. The practical implication: prescribing 28 capsules of amoxicillin 500 mg (equivalent to 9 days) when the recommended course is 5 days (15 capsules) is both wasteful and contributes to antibiotic resistance. GPs should prescribe the exact number of tablets for the recommended course — 15 amoxicillin 500 mg capsules for a 5-day TDS course. Some practices still default to 7-day courses out of habit — 5 days is adequate for most patients with low-severity CAP.

Treat

Influenza, COPD Exacerbation & Non-Antibiotic Management

Done

Influenza antiviral therapy

Oseltamivir 75 mg BD x 5 days when influenza is circulating, started within 48h (later in severe, progressive or hospitalised illness per UKHSA), without waiting for a test, for at-risk groups: age ≥65, pregnant women, immunosuppressed, chronic respiratory disease, chronic heart disease, CKD, chronic liver disease, chronic neurological disease, diabetes, BMI ≥40, care home residents. Reduce dose in renal impairment. Check the current annual UKHSA antiviral guidance. Inhaled zanamivir is not a simple alternative — bronchospasm risk makes it unsuitable for some with asthma or COPD.

COPD acute exacerbation (AECOPD)

Definition: sustained worsening from stable state beyond usual day-to-day variation — breathlessness, cough, sputum volume or colour. Antibiotic by sputum purulence/volume change, severity, previous exacerbations or admissions, complication risk, previous cultures and local guidance — not CRP; without increased purulence usually none unless consolidation or pneumonia (NG115). Choice per NG115/local formulary. Prednisolone 30 mg OD x 5 days — do not routinely extend unless a specific clinical or specialist reason. Bronchodilator: increase SABA dose + frequency (salbutamol 2.5 mg nebulisation in severe cases). Hospital by work of breathing, hypercapnia/acidosis, altered consciousness, response to treatment, baseline oxygenation, comorbidity and ability to cope at home — no single SpO₂ cut-off.

Non-pharmacological cough management

Honey: 2 teaspoons at night — as effective as dextromethorphan for nocturnal cough in children (but not under 1 year — botulism risk). Steam inhalation: limited evidence; scald risk — not for children. Hydration: warm fluids thin secretions, soothe inflamed mucosa. Postural drainage: for patients with productive cough from bronchiectasis (physiotherapy referral). Air quality: advise avoidance of cigarette smoke, strong fumes, polluted environments during recovery from respiratory illness.

Next steps: see Acute cough and chest infections · COPD · Asthma · Whooping cough · Pulmonary embolism

The prednisolone 5-day course for AECOPD is one of the most evidence-based primary care interventions for COPD exacerbations — the REDUCE trial (JAMA 2013) established that 5 days of prednisolone 40 mg OD is non-inferior to 14 days for AECOPD in terms of re-exacerbation at 6 months, with significantly lower cumulative steroid exposure. NICE NG115 recommends 30 mg prednisolone OD for 5 days (UK-standard dose). The key contraindications or cautions: uncontrolled diabetes (blood glucose can rise significantly — advise patient to check; may need temporary insulin or dose adjustment), active peptic ulcer (add PPI), severe osteoporosis (consider bone protection if recurrent courses). Patients on frequent prednisolone courses (>3 per year) should have bone density assessment and be considered for bisphosphonate therapy. Do not issue prednisolone courses repeatedly without reassessing the diagnosis — a patient requiring ≥3 courses of prednisolone annually for 'COPD exacerbations' should be reviewed for: correct diagnosis, inhaler adherence and technique, smoking status, and specialist input.

Lifestyle

Prevention, Vaccination & Smoking Cessation

Done

Annual influenza vaccination NHS-eligible groups (all should be offered every autumn): all adults ≥65 years, pregnant women, eligible children per the current annual NHS England programme letter, healthcare workers, care home residents, those with chronic respiratory, cardiovascular, renal, liver, or metabolic disease, immunosuppressed, BMI ≥40. Vaccine type and cohorts follow the current Green Book chapter 19 and annual programme letter. Record vaccination + consent. Seasonal timing: September-November (before the influenza season).

Pneumococcal vaccination Check the current UKHSA Green Book chapter 25 schedule for age, risk group, previous PCV/PPV23 doses and timing — the adult programme has moved to PCV20. Do not combine PCV13, PCV15, PCV20 and PPV23 by a generic schedule. Higher-risk groups (asplenia, CKD, immunosuppression): follow the Green Book or specialist advice.

Smoking cessation — single most important LRTI prevention Smoking impairs mucociliary clearance, reduces alveolar macrophage function, and disrupts the respiratory epithelial barrier — increasing susceptibility to all respiratory infections including CAP, influenza, and TB. GP brief advice + NHS Stop Smoking Service referral at every respiratory consultation. Pharmacotherapy (varenicline, cytisine, combination NRT) chosen by preference, contraindications and local service availability. Vaping (e-cigarettes) as a cessation aid: NICE NG209 lists nicotine-containing e-cigarettes among the options — support stopping combustible tobacco completely.

Cough hygiene and respiratory etiquette Cover nose and mouth with a tissue when coughing — bin immediately. If no tissue: cough into elbow crease, not into hands. Handwashing after coughing or blowing nose. Respiratory infection with a high temperature or feeling unwell: try to stay at home until no longer feverish and well enough; after a positive COVID-19 test, try to stay at home for 5 days (3 days if under 18). Lateral flow testing when available.

Air quality and respiratory health Indoor air quality: ventilate rooms adequately (open windows regularly, even briefly in winter). Wood-burning stoves: significantly increase indoor PM2.5 levels — avoid in patients with COPD or asthma. Outdoor pollution: on high-pollution days (UKHSA AQI website), advise COPD and asthma patients to avoid outdoor exercise and remain indoors in the afternoon (peak traffic pollution). Occupational respiratory hazards: refer to occupational physician for work-related cough (baker's asthma, farmer's lung, asbestosis).

COPD self-management and rescue packs Consider a rescue pack for someone who has had an exacerbation in the last year, remains at risk, understands when and how to use it and its harms, and will notify the practice after use (NG115). Prednisolone 30 mg x 5 days; include an antibiotic only when clinically indicated — some patients appropriately have steroids alone (local guidance). Patient instructions: start pack when: increased breathlessness + increased sputum (colour change or quantity) and self-monitoring confirms deterioration. Contact the GP the same day if not improving after 48h or new symptoms; call 999 for confusion, severe breathlessness at rest, cyanosis or SpO₂ <90% (home oximeter).

Children and acute cough — parent education Most childhood coughs are viral and self-limiting — antibiotics do not help and should not be expected. Honey (2 teaspoons at bedtime) for children over 1 year: evidence from Cochrane review for reducing cough severity and duration. Adequate fluid intake. No codeine or unsuitable cough medicines in children; humidifiers are not recommended for croup. Assess with age-specific respiratory rates and NICE fever/bronchiolitis/croup guidance. Warning signs — call 999 for pauses in breathing, lips turning blue, stridor at rest or working very hard to breathe; same-day review if refusing to drink or getting rapidly worse.

TB awareness and latent TB testing TB notifications in England have risen again since 2021 (UKHSA annual TB reports) — concentrated in urban areas, foreign-born communities, homeless, prison populations, immunosuppressed. Latent TB testing is targeted (NICE NG33) by country of origin, exposure, clinical risk and immunosuppression, via local TB service pathways. Suspected active TB (persistent cough, weight loss, night sweats, haemoptysis) → CXR and urgent TB-service assessment; samples per local TB/microbiology arrangements — do not delay referral for tests. Notify UKHSA if suspected or confirmed. Isoniazid-resistant and MDR-TB: specialist management only.

The COPD rescue pack prescription is one of the most evidence-based and cost-effective primary care interventions for COPD management — a Cochrane review (2018) of self-management plans including rescue medication showed significant reductions in hospital admissions (RR 0.77) and ED visits in patients with COPD. The self-management plan components: (1) written action plan specifying when to start the rescue pack (increase in breathlessness + change in sputum beyond baseline); (2) course of prednisolone 30 mg OD x 5 days; (3) an antibiotic only where clinically indicated; (4) instructions to contact GP within 48h if not improving; (5) instructions for when to call 999 (confusion, severe breathlessness at rest, cyanosis, SpO₂ <90%). NICE NG115 does not use exacerbation count alone: a rescue pack suits patients at risk who understand its use, its harms and the need to tell the practice.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

CAP follow-up

Review by severity, comorbidity, frailty, setting and concern (48 h for higher-risk or per local pathways — not universal). Reassess promptly if rapidly or significantly worse, systemically unwell, unable to maintain oral intake, more breathless, or not improving as expected. No routine follow-up CXR for everyone (NG250): consider it if symptoms or signs persist, recovery is incomplete, pneumonia recurs, lobar collapse/consolidation, or malignancy concern — per local pathways.

Antibiotic failure — when to escalate

No improvement after 48-72h antibiotics: reassess diagnosis (PE? Lung cancer? Empyema?). Review antibiotic choice against microbiology, local guidance and severity. CXR if not yet done. Consider same-day hospital if deteriorating.

Pertussis contacts

Notify per UKHSA. The Health Protection Team decides prophylaxis by timing, exposure, vulnerability and onward risk (priority: contacts who could infect young infants or are at high risk) — not a blanket regimen.

Post-COVID (long COVID)

Any symptoms persisting beyond 12 weeks post-COVID: assess for long COVID syndrome (fatigue, breathlessness, cognitive impairment, POTS — postural orthostatic tachycardia, post-exertional malaise). Refer to long COVID clinic. NICE NG188.

999 / Same-day

Severe/worsening hypoxaemia with compromise · CRB-65 ≥2 (consider hospital) · Suspected PE · Stridor · Infant with apnoea, cyanosis, respiratory distress or poor feeding

Review by risk

CAP at home: review by risk; reassess if not improving as expected. Back-up antibiotic (higher-risk only): use if symptoms worsen rapidly or significantly at any time. Tell the patient: call 999 for severe breathlessness at rest, chest pain, confusion or coughing up a lot of blood; contact us the same day for coughing up any blood, a high fever, feeling very unwell, or a cough that is getting rapidly worse.

NICE NG250 does not require a routine follow-up CXR after pneumonia. Repeat imaging is for persisting symptoms or signs, incomplete recovery, recurrent pneumonia, lobar collapse or consolidation, or concern about underlying malignancy that may have predisposed to, or been hidden by, the consolidation. Obstructive post-obstructive pneumonia (pneumonia distal to a bronchial carcinoma) is one of the most important causes of 'slow to resolve' or recurrent pneumonia in this age group. Code the indication and set a recall when follow-up imaging is genuinely indicated, following local respiratory/radiology pathways.