How do I diagnose the cause of a cough of less than
3 weeks' duration? If cough is associated with significant breathlessness, see the CKS topic on Breathlessness.
• An upper respiratory tract infection is the most likely cause when:
o There are no other respiratory symptoms such as breathlessness, pleuritic chest pain, haemoptysis, or wheeze, and o Examination of the chest is normal. • If the person has chest signs and/or respiratory symptoms in addition to cough: o Identify people who need emergency admission including people with clinical features of: Pulmonary embolism, pneumothorax, or foreign body aspiration. Severe illness, based on an assessment of their pulse rate, blood pressure, temperature, respiratory rate, peak expiratory flow rate, and oxygen saturation level (if pulse oximetry is available). • If the person has chest signs and/or respiratory symptoms in addition to cough and does not require emergency admission, look for clinical features of: o Lung cancer. Arrange a chest X-ray to be reported within 5 days if features of lung cancer are present. If the person is older than 40 years of age with persistent haemoptysis and smokes, also arrange urgent referral to a respiratory physician. If the person has a chest X-ray that is suggestive of lung cancer (including pleural effusion and slowly resolving consolidation) arrange urgent referral to a respiratory physician. If features of lung cancer are present, arrange a chest X-ray to be reported within 5 days. o Pneumonia. The diagnosis can be confirmed by chest X-ray, but it is not considered necessary if the person is well enough to be managed in the community. Arrange a chest X-ray if the person is older than 50 years of age, smokes, and has clinical features of pneumonia, to look for signs of underlying lung cancer. o Acute bronchitis. The diagnosis is confirmed by clinical features alone. o Acute asthma. The diagnosis is confirmed by demonstrating variable airflow limitation by: Serial peak expiratory flow rate measurements demonstrating greater than a 20% diurnal or day-to-day change, or Where there is doubt, by a large response (more than 400 mL) to either bronchodilators or 30 mg of oral prednisolone daily for 14 days. o An acute exacerbation of chronic obstructive pulmonary disease (COPD) if the person is older than 35 years of age, and smokes or has smoked. The diagnosis is confirmed by: Demonstrating air flow limitation by spirometry that is not fully reversible with treatment. Air flow limitation is defined as a forced expiratory volume in 1 second (FEV1) of less than 80% of the predicted value and FEV1/forced vital capacity ratio less than 70%. o An acute exacerbation of bronchiectasis, especially in non-smokers with chronic productive cough or recurrent chest infections. The diagnosis is confirmed by: Arranging a chest X-ray to exclude other causes for symptoms, and Referring to a respiratory physician for confirmation of the diagnosis by high resolution CT scanning. o Pertussis, especially if the person has cough lasting more than 14 days with paroxysms of coughing or vomiting after coughing or cough associated with an inspiratory whoop, and if they have developed a cough within 3 weeks of being in contact with someone with confirmed pertussis. The diagnosis is confirmed by: Taking nasopharyngeal aspirates or nasal swabs for culture if the person presents up to 2 weeks after the onset of the cough, or by taking blood for serology if the person presents more than 2 weeks after the onset of the cough.
What are the clinical features of the common causes
of acute cough? • Upper respiratory tract infections o Conditions include the common cold, influenza, pharyngitis, otitis media, and sinusitis. o Symptoms — may cause cough with or without sputum, general malaise, and possibly fever. Infection and symptoms, such as pain and discharge, may be localized to the nose, ears, throat, or sinuses. o Signs — no focal chest signs. • Acute bronchitis o Symptoms — cough with or without sputum, breathlessness, wheeze, or general malaise. o Signs — no chest signs other than wheeze and crackles. Crackles, if present, should clear with coughing — if they persist, diagnose pneumonia. • Pneumonia o Symptoms — cough associated with at least one other symptom of breathlessness, sputum, wheeze, or pleuritic pain. o Signs — any focal chest sign (such as dull percussion note, bronchial breathing, or coarse crackles) plus at least one systemic feature (such as fever/sweating, or myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion. • Acute asthma o Risk factors — personal history of rhinitis or eczema, or family history of atopy. o Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens). o Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present. o Peak expiratory flow rate (PEFR) is reduced during an acute episode. Acute asthma is: Life-threatening — when PEFR is less than 33% of predicted, and is associated with tachycardia, hypotension, a silent chest, or impaired level of consciousness. Severe — when PEFR is 33–50% of predicted, and is associated with a respiratory rate of more than 25 breaths per minute and an inability to complete full sentences. Moderate — when PEFR is more than 50% of predicted, with a respiratory rate of less than 25 breaths per minute. • Acute exacerbation of chronic obstructive pulmonary disease (COPD) o History — typically, the person is older than 35 years of age, is a smoker or past smoker, and reports slowly progressive breathlessness often associated with wheezing or chest tightness, and a cough (producing purulent sputum). o Symptoms of acute exacerbation — new or worsening cough associated with worsening breathlessness, and wheeze. o Signs — wheeze, hyperinflated chest (in emphysema), crackles (when infection is present). There may be signs of right-side heart failure in people with severe disease, including swollen ankles and increased jugular venous pressure. The person's peripheries (the hands and feet) are often warm to the touch and a dusky colour (cyanosed), with distended veins. • Acute exacerbation of bronchiectasis o History of bronchiectasis — suspect if the person has a history of recurrent or chronic productive cough (present in 75–100% of adults with bronchiectasis), progressive breathlessness (72–83%), haemoptysis (51–45%), and non-pleuritic chest pain between exacerbations (31%). o Symptoms of an acute exacerbation — new or worsening cough that may be associated with worsening breathlessness and wheeze. o Signs — coarse crackles in early inspiration commonest in the lower lung fields (70% of adults), wheeze (34%), and large airway rhonchi (44%). Finger clubbing occurs infrequently. • Pulmonary embolism (PE) o Risk factors — immobilization, surgery, cancer, symptoms or signs of deep vein thrombosis (DVT). o Symptoms — acute-onset breathlessness (in 73% of people with PE), pleuritic pain (66%), cough (37%), haemoptysis (13%). Recurrent acute episodes may lead to chronic breathlessness. o Signs — tachypnoea of more than 20 breaths per minute (in 70% of people with PE), crackles (51%), tachycardia (30%), signs of DVT (11%). • Pneumothorax/tension pneumothorax o Risk factors — smoking, age, and body type (adults who are young, tall, and slim), previous pneumothorax, chronic respiratory disease (such as COPD or asthma), trauma to chest wall (including therapeutic procedures such as injections and aspirations). o Symptoms — collapse, sudden-onset pleuritic pain, breathlessness. o Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension. • Aspiration of a foreign body o Symptoms — sudden onset of cough that may be associated with history suggestive of an inhaled foreign body. o Signs — sudden onset of cough, distress, or stridor if the foreign body lodges in the upper airway. There may be signs of lung or lobar collapse if there is a foreign body in the lower airways. Signs of lung or lobar collapse include reduced chest wall movement on affected side, dull percussion note with bronchial breathing, and reduced or diminished breath sounds. • Lung cancer o Risk factors — smoking, primary cancers at other sites, asbestos exposure, COPD. o Symptoms — haemoptysis or persistent and unexplained cough, chest or shoulder pain, breathlessness, weight loss, hoarseness. o Signs — finger clubbing, cervical or supraclavicular lymphadenopathy, signs of superior vena cava obstruction, stridor. • Pertussis o History — suspect in an adult with a cough: Lasting more than 14 days with paroxysms of coughing or vomiting after coughing or a cough associated with an inspiratory whoop. Paroxysms increase in frequency and severity as the condition progresses and usually persists for 2– 6 weeks. Occasionally the cough may persist for several months. A prolonged cough may be the only symptom in adults. That develops within 2 weeks of being in contact with someone with confirmed pertussis. o Signs — normal chest examination. When should I arrange emergency admission for someone with acute cough? • If the person has chest signs or respiratory symptoms in addition to cough, measure blood pressure, pulse rate, temperature, and oxygen saturation. If asthma is suspected, measure peak expiratory flow rate (PEFR). • Arrange emergency admission if the person has: o A respiratory rate of more than 30 breaths per minute. o Tachycardia greater than 130 beats per minute. o Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them). o Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia). o PEFR less than 33% of predicted. o Altered level of consciousness. o A large respiratory effort (particularly if the person is becoming exhausted). o Clinical features of pulmonary embolism, pneumothorax, or aspiration of a foreign body. • Consider arranging emergency admission, depending on the severity and number of risk factors present, if the person has any of the following: o Elevated respiratory rate (but if it is more than 30 breaths per minute, arrange emergency admission). o Tachycardia (but if it is more than 130 beats per minute, arrange emergency admission). o Hypotension (but if blood pressure is less than 90 mmHg systolic or 60 mmHg diastolic, arrange emergency admission). o High temperature (especially if it is higher than 38.5°C). o PEFR less than 50% of predicted (but if it is less than 33%, arrange emergency admission). o Older than 65 years of age.
Basis for recommendation
Central cyanosis
• Central cyanosis is reported to be present when the concentration of
deoxygenated haemoglobin is more than 50 g/L. This corresponds to an arterial oxygen saturation of less than 90% in people who are not anaemic [Douglas and Bevan, 2009].
Peak expiratory flow rate (PEFR)
• The SIGN and BTS British guideline on the management of asthma
recommends that people with asthma and PEFR less than 30% of predicted, have life-threatening asthma; and recommends emergency admission [SIGN and BTS, 2009]. How should I manage someone with acute cough waiting for emergency admission? • If the person has an oxygen saturation of less than 92%, give oxygen and continuously monitor their oxygen saturation levels while waiting for transfer to hospital. o ONLY USE A 28% VENTURI MASK AT 4 L/MIN FOR PEOPLE WITH SUSPECTED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), morbid obesity, a chest wall deformity, or a neuromuscular disorder. This is because they are at risk of hypercapnic respiratory failure. o For other people who are acutely ill, use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target oxygen saturation of 94–98%. • Identify and treat if the person has clinical features of acute severe asthma (peak expiratory flow less than 50% of predicted) or an acute exacerbation of COPD. Give a bronchodilator (for example nebulized salbutamol 5 mg, or repeated doses of a metered-dose inhaler via a spacing device). Give prednisolone 30 mg orally (if available). Repeat the bronchodilator treatment as necessary.
How should I manage someone with acute cough who
does not need emergency admission? For people with:
• An upper respiratory tract infection — advise them:
o To use paracetamol or ibuprofen as required to reduce pain or symptoms of malaise. o To rest and drink sufficient fluids to prevent dehydration. o To seek medical advice if symptoms deteriorate significantly or other symptoms develop. o That antibiotics are not likely to be helpful. o That cough medicines may help, but they are not thought to be any more effective than simple remedies such as a honey and lemon drink. How do I diagnose the cause of sub-acute cough of 3- 8 weeks' duration? • If the person has a cough that started with an obvious respiratory infection: o Identify people with clinical features of pneumonia or acute bronchitis. o Identify people with pertussis (whooping cough): Suspect in an adult with cough lasting more than 14 days with paroxysms of coughing or vomiting after coughing or an inspiratory whoop, and in adults presenting with cough who have been in contact with someone with confirmed pertussis in the preceding 3 weeks. Confirm the diagnosis by taking blood for serology. o Identify people with post-infectious cough (who do not have specific features suggestive of pertussis). The following features should all be present: Absence of malaise. A persistent dry cough. A normal respiratory examination. • If the person has sub-acute cough that did not start with an obvious respiratory tract infection, look for a cause of chronic cough.
When should I arrange urgent referral to a
respiratory physician for someone with sub-acute cough? • Identify whether the person has clinical features of: o Lung cancer, including: Haemoptysis, or Any of the following symptoms and signs that are unexplained and persist for longer than 3 weeks: chest and/or shoulder pain, breathlessness, weight loss, chest signs, hoarseness, finger clubbing, cervical/ supraclavicular lymphadenopathy. o Pulmonary tuberculosis, including: Chronic cough which may be associated with sputum, breathlessness, or haemoptysis. Weight loss, fever, night sweats, anorexia, and general malaise. Finger clubbing. o Foreign body aspiration, including: Sudden onset of cough that may be associated with history suggestive of an inhaled foreign body. Stridor, if the foreign body is in the upper airway. There may be signs of lung or lobar collapse if the foreign body is in the lower airways. Signs of lung or lobar collapse include reduced chest wall movement on the affected side, a dull percussion note with bronchial breathing, reduced or diminished breath sounds. • • If the person has clinical features of lung cancer: o Arrange a chest X-ray to be reported within 5 days. o Arrange urgent referral to respiratory physician: For people older than 40 years of age with persistent haemoptysis who smoke. For people with a chest X-ray that is suggestive of lung cancer (including pleural effusion or slowly resolving consolidation). • If the person has clinical features of pulmonary tuberculosis: o Arrange a chest X-ray and, if possible, send three sputum samples (ideally one sample should be taken in the early morning) for microscopy to look for acid-fast bacilli and for mycobacterial culture. o Refer to a specialist for diagnosis and management (ideally within 2 weeks). Do not delay referral to a specialist by waiting for investigation results if symptoms are highly suggestive of active tuberculosis. • If the person has a suspected foreign body aspiration, arrange urgent referral or emergency admission (depending on clinical judgement) to a respiratory physician for bronchoscopy.
How should I manage someone with sub-acute cough
who does not need urgent referral? • If the person has pneumonia or acute bronchitis, see the CKS topic on Chest infections - adult. • If the person has post-infectious cough: o Explain that the cough may persist for several months. o Advise them to re-attend for assessment if the cough does not improve after 2 months. • If the person has a sub-acute cough that did not start with an obvious respiratory tract infection, assess and manage as for chronic cough. How should I assess someone presenting with chronic cough of more than 8 weeks' duration? • If the person is taking an angiotensin-converting enzyme (ACE) inhibitor — stop the treatment and prescribe an alternative. o The diagnosis is confirmed by resolution or marked improvement of the cough after stopping the treatment. o For most people the cough resolves within 1 month, but occasionally it may persist for several months. • If the person smokes: o Advise them to stop smoking and offer them support to do so. Smoker's cough is confirmed by resolution or marked improvement of the cough following smoking cessation. Usually cough resolves within 4 weeks, but it may take longer. o Identify whether the person has clinical features of chronic obstructive pulmonary disease (COPD). The diagnosis is confirmed by: Spirometry demonstrating airflow limitation that is not fully reversible with treatment. Air flow limitation is defined as a forced expiratory volume in 1 second (FEV1) of less than 80% of the predicted value and FEV1/forced vital capacity ratio less than 70%. A chest X-ray to exclude other causes for symptoms, such as lung cancer. • If the person has clinical features of chronic sinusitis or allergic rhinitis suggesting a diagnosis of upper airway cough syndrome (post-nasal drip), arrange a 2 week trial of a nasal corticosteroid. o The diagnosis is confirmed by resolution or marked improvement of the cough within 2 weeks. • If the person has clinical features of asthma: o Arrange serial peak expiratory flow rate (PEFR) measurements morning and night and prescribe a 2 week trial of an inhaled corticosteroid and a bronchodilator. o The diagnosis is confirmed by: Serial PEFR measurements demonstrating airflow limitation that is variable or, where there is doubt, by a large response (more than 400 mL) to either bronchodilators or 30 mg of oral prednisolone daily for 14 days, and Resolution or marked improvement of the cough with treatment. • If the person has dyspepsia, or a cough that is worse during or after eating, when bending, or has other clinical features of gastro-oesophageal reflux disease (GORD): o Arrange an 8 week trial of a proton pump inhibitor such as omeprazole 20–40 mg twice daily (or equivalent). If the cough only partially resolves, add in a prokinetic agent such as metoclopramide 10 mg three times daily. o The diagnosis is confirmed by resolution or marked improvement of the cough within 4 months of starting treatment. • If the person has a chronic productive cough, look for features of bronchiectasis and arrange a chest X-ray and spirometry. o If clinical features of bronchiectasis are present and the chest X-ray and spirometry do not indicate another cause refer to a specialist to arrange high-resolution CT scanning to confirm the diagnosis. • If the person has a chronic dry cough: o Look for features of interstitial lung disease and if present arrange a chest X-ray and spirometry. Refer the person for specialist investigations if they have spirometry with a restrictive pattern and/or a chest X-ray suggestive of an underlying cause for interstitial lung disease (such as sarcoidosis or asbestosis). o Look for clinical features of pertussis (whooping cough) especially if the person has a cough lasting more than 14 days with paroxysms of coughing or vomiting after coughing or a cough associated with an inspiratory whoop, and in people who develop a cough within 3 weeks of being in contact with someone with confirmed pertussis. The diagnosis is confirmed by taking blood for serology. • If the person has a persistent unexplained cough, arrange a chest X-ray, and spirometry. o If there is no cause suggested from the history, examination, and investigations, see Further assessment.
Basis for recommendation
• Recommendations are based on expert opinion published in the UK guidelines
for use of erythromycin chemoprophylaxis in persons exposed to pertussis [Dodhia et al, 2002].
How do I assess someone with chronic cough, when
no cause is suggested from the history, examination, spirometry, chest X-ray, and blood tests? • If the person has chronic cough with no cause suggested from the history, examination, spirometry, chest X-ray, and blood tests — arrange a sequential trial of drug treatment: o Upper airway cough syndrome — prescribe a nasal corticosteroid and review after 2 weeks of treatment. The diagnosis is confirmed by resolution or marked improvement of the cough within 2 weeks. o Asthma — prescribe a topical corticosteroid and review after 2 weeks of treatment. The diagnosis of asthma, cough variant asthma, or eosinophilic bronchitis is confirmed by resolution or marked improvement of the cough within 2 weeks. o Gastro-oeophageal reflux disease — prescribe a proton pump inhibitor such as omeprazole 20 to 40 mg twice daily (or equivalent) and review after 8 weeks. The diagnosis is confirmed by resolution or marked improvement of the cough within 8 weeks. • If the person has a chronic cough that partially responds to a trial of therapy, consider if there is more than one cause of the cough. • If the person has a chronic cough that has no identifiable cause following the above assessment — arrange referral to a respiratory physician (preferably to a specialist who runs a cough clinic).
What are the clinical features of the non-pulmonary
causes of chronic cough? • Angiotensin-converting enzyme (ACE) inhibitor induced cough o History — cough may start almost immediately after the person starts an ACE inhibitor or after a dose increase, or it may occur after several years of treatment. Cough settles after the person stops the ACE inhibitor, but may take up to 4 months to completely resolve. o Symptoms — bouts of coughing associated with the perception of airway irritation. Between coughing bouts, the person is asymptomatic. o Signs — no signs of chest disease. • Gastro-oesophageal reflux disease o Symptoms. Cough that may or may not be associated with symptoms of gastro-oesophageal reflux. Symptoms of gastro-oesophageal reflux commonly occur after eating a large meal or with bending. Cough that is worse during or after eating, with talking, and with bending. o Signs — no signs of chest disease. • Upper airway cough syndrome (also called post-nasal drip) caused by: o Chronic sinusitis Symptoms — chronic (more than 12 weeks) nasal blockage or nasal discharge with facial pain or pressure over the affected sinus. A reduced sense of smell is common. Pain may radiate into the upper teeth. Signs — There may be tenderness to palpation of the effected sinus. o Allergic rhinitis History — allergic rhinitis is more likely if there is a personal or family history of atopy (asthma, eczema, or allergic rhinitis). Symptoms — nasal itching, sneezing, discharge, and blockage. Symptoms may be associated with exposure to a known allergen such as house dust mite, animal dander, or pollens. What are the clinical features of the pulmonary causes of chronic cough? • Asthma o Risk factors — personal and family history of atopy. o Symptoms — wheeze, breathlessness, and cough. Symptoms are variable, often worse at night, with exercise, or with exposure to cold or allergens. o Signs — wheeze is present during an acute episode, except when asthma is extremely severe when the chest may be silent. o The peak expiratory flow rate (PEFR) is reduced during an acute episode. Acute asthma is: Life-threatening when the PEFR is less than 33% of predicted. Severe when the PEFR is 33–50% of predicted. Moderate when the PEFR is more than 50% of predicted. • Cough variant asthma o Clinical features — chronic cough with a normal chest examination, and normal spirometry. o May be confirmed by demonstrating hyper-responsiveness to airway provocation, sputum eosinophilia (only available to a specialist), and symptomatic improvement with a trial of an inhaled topical corticosteroid. • Eosinophilic bronchitis o Clinical features: chronic cough, normal chest examination, normal spirometry, and normal response to airway provocation test (only available to a specialist). o May be confirmed by demonstrating sputum eosinophilia (only available to a specialist), and symptom improvement with a trial of an inhaled corticosteroid. • Smoker's cough and chronic bronchitis o Smoker's cough Symptoms — morning cough with little sputum. Signs — normal chest examination. o Chronic bronchitis Symptoms — chronic productive cough on most days for 3 months in each of two consecutive years, if the person does not have another cause for chronic cough. Signs — normal chest examination. • Chronic obstructive pulmonary disease o History — slow progressive breathlessness in a person older than 35 years of age who smokes or who has smoked. o Symptoms — persistent progressive breathlessness usually associated with wheezing or chest tightness. Acute exacerbations of symptoms are common, and usually caused by respiratory tract infections. o Signs — wheeze, hyperinflated chest, may have signs of right sided heart failure such as swollen ankles and increased jugular venous pressure. • • • Bronchiectasis o History — suspect in people with a history of recurrent or chronic productive cough, especially if they do not smoke. o Symptoms — cough with daily sputum production (present in 75– 100% of adults with bronchiectasis), progressive breathlessness (72– 83%), haemoptysis (51–45%), non-pleuritic chest pain between exacerbations (31%). o Signs — coarse crackles in early inspiration most common in the lower lung fields (70% of adults), wheeze (34%), large airway rhonchi (44%). Finger clubbing occurs infrequently. • Interstitial lung disease (ILD) o Causes — include idiopathic pulmonary fibrosis, sarcoidosis, pneumoconioses, ILD associated with drug therapy, ILD associated with connective tissue disease, and hypersensitivity pneumonitis/extrinsic allergic alveolitis (following sensitization to inhaled environmental allergens, for example from birds, hay, or mushrooms). o Symptoms — cough and slowly progressive breathlessness. When it is caused by extrinsic allergic alveolitis there may be a history of recurrent episodes of flu-like illness following exposure to the responsible allergen. There may be symptoms of the underlying cause (for example joint pains when the ILD is associated with connective tissue disease). o Signs — there may be none in sarcoidosis. When present, there may be fine end inspiratory crepitations (indicative of fibrosis), finger clubbing, cyanosis, and signs of right heart failure. • Pertussis o History — suspect in an adult with a cough: Lasting more than 14 days with paroxysms of coughing or vomiting after coughing or a cough associated with an inspiratory whoop. Paroxysms increase in frequency and severity as the condition progresses and usually persist for 2– 6 weeks. Occasionally the cough may persist for several months. A prolonged cough may be the only symptom in adults. That develops within 2 weeks of being in contact with someone with confirmed pertussis. o Signs — normal chest examination. When should I arrange urgent referral to a respiratory physician for someone with chronic cough? • Identify whether the person has clinical features of: o Lung cancer, including: Haemoptysis, or Any of the following symptoms and signs that are unexplained and persist for longer than 3 weeks; chest and/or shoulder pain, breathlessness, weight loss, chest signs, hoarseness, finger clubbing, cervical/ supraclavicular lymphadenopathy. o Pulmonary tuberculosis, including: Chronic cough which may be associated with sputum, breathlessness, or haemoptysis. Weight loss, fever, night sweats, anorexia, and general malaise. o Foreign body aspiration, including: Recurrent pneumonia in the same lobe, which may indicate an aspirated foreign body. Sudden onset of cough that may be associated with history suggestive of an inhaled foreign body. Stridor, if the foreign body is in the upper airway. There may be signs of lung or lobar collapse if the foreign body is in the lower airways. Signs of lung or lobar collapse include reduced chest wall movement on the affected side, a dull percussion note, and reduced or diminished breath sounds. • If the person has clinical features of lung cancer: o Arrange a chest X-ray to be reported within 5 days. o Arrange urgent referral to a respiratory physician: If the person is older than 40 years of age with persistent haemoptysis, and they smoke. If the person has a chest X-ray that is suggestive of lung cancer (including pleural effusion or slowly resolving consolidation). • If the person has clinical features of pulmonary tuberculosis: o Arrange a chest X-ray and, if possible, send three sputum samples (ideally one sample should be taken in the early morning) for microscopy to look for acid-fast bacilli and for mycobacterial culture. o Refer to a specialist for diagnosis and management (ideally within 2 weeks). Do not delay referral to a specialist by waiting for investigation results if symptoms are highly suggestive of active tuberculosis. • If the person has a suspected foreign body aspiration, arrange urgent referral to a respiratory physician for bronchoscopy.