Doctor, I'm coughing.

It's that time of year again. Those of us on the front lines will be seeing patient after patient with the chief complaint of cough. The possible causes are many, from post-nasal drip to acute pneumonia to an aberrant innominate artery. Often multiple approaches are utilized on a given day. A few questions still weave their way through my clinical work:
1. In patients with bronchitis or post-viral cough, what interventions best help relieve symptoms?
2. What are recommended antibiotics for community acquired pneumonia?
3. What criteria are used to decide whether admission is needed?

The last two are addressed in a recent update by the British Thoracic Society and can be reviewed here:
http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPGuideline-full.pdf

"Amoxicillin remains the preferred choice [for low-severity CAP]". If you have prescribed amoxicillin for pneumonia in the past 3 years raise your hand... I know no one who does this. Many clinicians prescribe a zpak (for convenience to the partient I assume, not to cover atypicals). Respitory floroquinolones are another common choice, again I think becuase we feel comfortable they will treat the pneumonia appropriately, somehow better than beta-lactams. Any thoughts here? What is your approach?

Regarding when to admit, both the British guidelines and the article below give good advice:
http://www.jfponline.com/Pages.asp?AID=5978&issue=March_2008
And here's a link to an online PSI calculator: http://pda.ahrq.gov/clinic/psi/psicalc.asp

And of course, as I am writing this I'm seeing an 86 yo female nursing home resident with 3d of cough, found to have O2 sat = 78% (???) at the home and sent in to urgent care. Her primary doctor is away on vacation, apparently. So ok, her BP os 119/72 and O2 is 92% on RA in my office, RR= 28, she doesn't appear in much distress and is not acutely confused. She has a RML infiltrate on xray. Her CRB65 score = 1. So I spoke to the head nurse at her home and found out they will keep her on 02 there, monitor her fluid intake, BP, temp, etc. I gave her levoquin for a nursing home acquired PNA for 10 days with recommendations that she see her PCP sometime soon after that and to watch her INR. But I also think she could have been easily admitted too. Has the pendulum swung too far, biasing us against costly interventions that might actually be necessary? Thoughts?

Getting back to the first question, what can be done for patients who have acute bronchitis or post-viral cough, here's what I do. First, with acute bronchitis, I usually check a peak-flow and do use bronchodilators for those with >10% reduction in PF from expected values. Where appropriate I offer phenergan/codeine syrup. I use this over guaifenesin/codeine because a) patients can get guaifenesin OTC and b) I think this works better for night-time symptoms. It's generally not for those >65 years old though. Supportive care with humidifiers is also helpful. I also read that naprosyn reduces the production of some of  the inflammatory mediators that cause cough, so I recommend that often. The same source also suggested ipatropium in refractory cases.

JFPonline has this series: http://www.jfponline.com/pages.asp?id=7145 which at first looks like a great resource but looking it over has a few limitations. First, it's sponsored by Nature's Way, the manufacturer of a natural remedy named Pelargonium sidoides which is mentioned in every section of the newsletter. Second, it doesn't really offer anything that new. I will say that the studies mentioned there that support Pelargonium sidoides do look pretty good for both URI and bronchitis, but again if the manufacturer of the product is sponsoring the newsletter, I am intinctively skeptical. Anyone have experience using or prescribing this product?

Lastly, those who know me know I've been a bit of a vitamin D maven the past few years, and there is some evidence that beefing up on vitamin D before cold and flu season can reduce one's chances of developing a viral illness. Here's a large retrospective trial finding an inverse relationship betwen serom 25OHVitD levels and incidence of viral infections : Arch Intern Med. 2009 Feb 23;169(4):384-90. I also found a prospective trial that finished earlier this year but hasn't reported results: http://clinicaltrials.gov/ct2/show/NCT00656929 .
For now I'm generally recommending patients try vitamin D supplementation this winter, especially with H1N1 concerns. I recommend 2000-5000u daily of Vitamind D-3, but truthfully one just needs to average this dose, ie 14,000u taken once a week is equivalent to 2000u daily, at least as it pertains to maintaining serum levels. I assume this would apply to the health benefits as well. As alsways, I recommend http://www.vitamindcouncil.org/ for updates on the latest research and thinking among vitamin D "converts."

Please share any pearls you have when approaching the coughing patient.