I’ve been postponing this Anxiometer post for at least a year. People periodically call me to chat or come visit when they are on week two or three of a cold, and they just can’t shake their lingering hacks. Finally, I’m ready to confess. When it comes to making coughs disappear, we in medicine are woefully ineffective.

Most folks seem to be aware that coughs are generally viral. However, many remain convinced that they get better quicker with antibiotics; the Z-Pak being a crowd favorite. Unfortunately, sometimes patients are right, because a small fraction of nagging coughs today do represent a resurgence of Pertussis (whooping cough), which is bacterial and does benefit.

We in medicine know that we won’t be dinged for over prescribing Z-Paks (not yet anyways). And we know it’s a drag to spend 5-10 minutes talking about viral illnesses, only to read on Yelp “… and I only got better after I went to the urgent care where I found a smarter doctor who would actually write for an antibiotic!”

Sadly, most OTCs aren’t very effective either. Read linked article “The New Cough and Cold Products for Children: Evidence is Optional and Science is Marketing“.

More important are the following:

Red Flags:

• Shortness of breath
• Fever
• Frail/elderly
• Bloody sputum
• Smoker
• Underlying cancer, CHF, COPD, asthma, cystic fibrosis, TB etc.
• Recent hospitalization or intubation
(BTW: Greenish sputum doesn’t really push us toward thinking bacterial.)

Happy Words

• Less than 3 week duration
• Better after a steam bath, shower or cool air outside
• “Everyone at home had the same cold.”
• “I just need something to help me get some sleep.”

The majority of patients who call me with a cough or who visit the ER, leave without antibiotics. Sometimes I point them to Robitussin, with hopes for a strong placebo effect. Robitussin DM or AC have a little narcotic to help with sleep at least. Rarely Tessalon Perles are helpful just to suppress the urge. On the Big Island of Hawaii I was successful a few times with nebulized lidocaine to suppress cough from the Vog (volcanic fog).

All that said, sometimes I do crumble and prescribe the Z-Pak, but generally while advising folks to take it only if worse in 48-72 hours. Unfortunately, I suspect we’ll see resistance to the Z-Pak climb a fair bit in the coming decades.

At the end of the day, cough is a bit like vomiting and diarrhea, where the problem is your body finding a solution; albeit a miserable one.

I’m sorry to disappoint.

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