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symptom.cough.ed.v1PRODUCTION
symptom.cough.ed.v1

Acute cough (ED triage — undifferentiated adult)

symptomacuteundifferentiatedadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Cough duration (acute / subacute / chronic), quality (dry / productive / paroxysmal), sputum (color / volume / blood) — anchors initial DDx (Irwin CHEST 2006 PMID 16428686)

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pattern characterized

Patient inputs (43)

Age shifts priors: pneumonia mortality doubles each decade after 65; lung cancer screening 50-80 with 20 pack-year history (USPSTF 2021 PMID 33687470)

Sex-based smoking patterns + pertussis epidemiology + asthma phenotypes (female-predominant adult onset)

Hypotension + cough → septic / cardiogenic / obstructive shock (PE, tamponade); ARDS phase; hypertensive emergency-flash pulmonary edema overlay

Tachycardia + cough → infection / PE / HF / dehydration; relative bradycardia in atypical pneumonia (Legionella, typhoid)

Tachypnea + cough → pneumonia / asthma / COPD / HF / PE / DKA; RR ≥30 → severity escalation

SpO2 <92% on RA → significant respiratory compromise; <90% → escalate; PE often has normal SpO2 early

Fever + cough → infectious DDx (bacterial pneumonia, TB, influenza, COVID-19); afebrile + cough → cardiogenic / asthma / GERD / cancer

Pack-year history drives COPD / lung cancer prior; ≥20 PYH + age 50-80 triggers LDCT screening (USPSTF 2021 PMID 33687470)

Known asthma → exacerbation workup (PEF, GINA Track); known COPD → exacerbation workup (GOLD 2026 ABE)

Recent TB endemic travel / homeless / incarcerated / HIV → active TB workup + airborne isolation (sputum AFB × 3, NAAT, chest CT)

Outbreak / household contact / unvaccinated → COVID-19 / influenza route + droplet precautions + PCR / antigen

Known HF → "cardiac cough" + decompensation workup (BNP, CXR, echo); diuresis + GDMT review

Transplant / HIV / chemo / biologics / chronic steroids → broaden DDx (PCP, fungal, CMV, atypical mycobacteria, nocardia, aspergillus); empiric broad coverage

ACE-inhibitor dry cough (10-15%) — discontinue trial; ARB substitute; chronic cough cause

Recent surgery / immobility / malignancy / OCP / pregnancy / DVT → Wells/PERC for PE-with-cough phenotype

Fever + chills + rigors → pneumonia / influenza / TB / abscess; afebrile → asthma / COPD / HF / GERD / cancer

Dyspnea + cough → pneumonia / asthma / COPD / HF / PE; resting dyspnea raises severity; PNDis pathognomonic for HF

Pleuritic chest pain + cough → PE / pneumonia / pleurisy / pericarditis; sharp non-pleuritic + cough → MSK / costochondritis

Frank hemoptysis → route symptom.hemoptysis.v1; blood-streak common in URI/bronchitis; massive hemoptysis (>200 mL/24 h) is emergent — protect non-bleeding lung

Wheeze + tightness + diurnal variability → asthma; expiratory wheeze + smoker → COPD; biphasic stridor → upper airway

Orthopnea + PND + bilateral leg edema + JVD → cardiogenic cough (acute HF)

Weight loss + night sweats + subacute cough → TB / lymphoma / lung cancer (USPSTF LDCT 2021 PMID 33687470)

Acute <3 wk vs subacute 3-8 wk vs chronic >8 wk (Irwin CHEST 2006 PMID 16428686) — anchors DDx; >8 wk shifts toward asthma/UACS/GERD/CB/cancer/TB

Productive vs dry; purulent sputum → bacterial pneumonia; pink frothy → pulmonary edema; rust-colored → pneumococcal; currant-jelly → Klebsiella; foul-smelling → anaerobic/aspiration

Leukocytosis + left shift → bacterial pneumonia; lymphocytosis → viral / pertussis; eosinophilia → asthma / Loeffler / EGPA

Hyponatremia → SIADH (Legionella, lung cancer); AKI in severe pneumonia / septic shock; glucose for DKA-mimics

CXR PA + lateral — first-line imaging for cough with abnormal vitals / fever / pleuritic pain / hypoxia; consolidation, effusion, cavitation, infiltrate, masses, edema (ATS PMID 31573350)

CTA chest if PE suspected after positive D-dimer OR high Wells (>6); diagnostic gold standard

Non-contrast chest CT for chronic cough + weight loss / hemoptysis / smoker → TB / cancer / bronchiectasis / ILD

GERD / UACS (post-nasal drip) → top causes of chronic cough in non-smoker non-asthma adults (Irwin CHEST 2006 PMID 16428686)

Witnessed aspiration / dysphagia / impaired LOC / poor dentition → aspiration pneumonia / pneumonitis (route pulm.aspiration-pneumonia.core.v1)

Sudden cough/choking during eating (peanut, dental hardware, button battery) → FB aspiration → STAT bronchoscopy

Paroxysmal cough + whoop + post-tussive emesis (adult) → pertussis; transmissible; macrolide + droplet precautions

Lactate ≥4 → severe sepsis / shock; supports sepsis bundle activation (SSC 2026)

CRP + PCT (panel.inflammation) — PCT-guided antibiotic decisions; CRP >100 + PCT >0.25 supports bacterial pneumonia (ProACT, Schuetz)

Troponin in severe pneumonia (myocardial injury), HF cough, suspected PE, ACS overlay (panel.cardiac)

NT-proBNP age-adjusted (panel.cardiac) — supports cardiogenic cough phenotype (acute HF)

Age-adjusted D-dimer (panel.coag, ADJUST-PE) — PE rule-out in low/intermediate Wells

Nasopharyngeal PCR or antigen for COVID-19; route id.covid19.core.v1 if positive

Rapid influenza PCR / antigen — early oseltamivir if positive (<48 h symptoms)

Sputum gram stain + culture + AFB × 3 if TB suspected; NAAT for TB (Xpert MTB/RIF)

ECG for HF cough (afib, LVH), PE (S1Q3T3, RBBB, T inversion V1-V4), ACS overlay

Lung POCUS for B-lines (pulmonary edema), consolidation, effusion, pneumothorax (BLUE protocol)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningcough_with_hypoxic_respiratory_failure
    SpO2 <92% on room air OR <88% in known COPD; cough + RR ≥30 + accessory muscle use — hypoxic respiratory failure; O2 + NIV/HFNC; intubate if NIV failure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_community_acquired_pneumonia
    CURB-65 ≥3 OR ATS major criteria (mechanical ventilation OR vasopressor) OR ≥3 minor criteria — severe CAP requiring ICU + early antibiotics within 1 h (ATS/IDSA 2019 PMID 31573350)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_asthma_exacerbation
    PEF <50% personal best + SpO2 <92% + silent chest OR no SABA response — severe asthma exacerbation; SABA + ipratropium + steroids + IV magnesium 2 g + NIV + ICU (GINA 2025)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_copd_exacerbation
    COPD + hypercapnic respiratory failure (pH <7.35, PaCO2 >45) — severe COPD exacerbation; SABA/SAMA + steroids + antibiotics (Anthonisen) + NIV first-line (GOLD 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpe_with_cough_phenotype
    Cough + pleuritic pain + dyspnea + DVT signs OR risk factors + Wells ≥4 OR positive D-dimer → CTA chest; anticoagulation (LMWH/DOAC) → pulm.pe.core.v1; thrombolysis if massive
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningactive_tb_concern
    Subacute/chronic cough + weight loss + night sweats + hemoptysis + TB exposure / endemic travel / homeless / HIV — active TB; airborne IMMEDIATE + sputum AFB × 3 + Xpert MTB/RIF + 4-drug RIPE pending sensitivities (WHO)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_hemoptysis
    Frank hemoptysis >200 mL/24 h OR hemodynamic instability — massive hemoptysis; protect non-bleeding lung (lateral decubitus bleeding-side down) + tranexamic acid + STAT bronchoscopy + IR embolization → symptom.hemoptysis.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfb_aspiration_acute
    Sudden cough + choking + unilateral breath-sound asymmetry + radiopaque or hyperlucent zones on CXR — FB aspiration (adult or peds); STAT rigid bronchoscopy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiogenic_cough_acute_hf
    Cough + orthopnea + PND + bilateral leg edema + JVD + elevated NT-proBNP + B-lines on POCUS — cardiogenic cough / acute HF; IV diuretic + nitrates + O2 ± NIV (AHA/ACC/HFSA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaspiration_pneumonia_witnessed
    Witnessed aspiration / dysphagia / impaired LOC / poor dentition + RLL infiltrate — aspiration pneumonia; broad coverage (pip-tazo + anaerobic if abscess) → pulm.aspiration-pneumonia.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecovid_or_influenza_with_severe_disease
    Cough + fever + hypoxia + positive COVID-19 OR influenza PCR + severe disease (NIV/HFNC/intubation) — route id.covid19.core.v1 OR id.influenza.core.v1; antivirals + steroids per protocol
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechronic_cough_with_red_flag_features
    Cough >8 weeks + weight loss + hemoptysis + smoker OR age ≥50 + ≥20 pack-years — lung cancer concern; chest CT + USPSTF LDCT screen + pulm/onc referral (USPSTF 2021 PMID 33687470)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ed playbook — drug actions (12)

  1. 1. oxygen supplementation
    Titrate to SpO2 92-96% (88-92% if known CO2 retainer) • NC / mask / NIV / HFNC • continuous
    trigger: SpO2 <92% on room air
    BTS 2017 — target SpO2 92-96% in acute illness; avoid hyperoxia in COPD
  2. 2. albuterol nebulizer ± ipratropium
    Albuterol 2.5-5 mg neb q20min × 3 then q1-4h; ipratropium 0.5 mg neb q20min × 3 (severe asthma/COPD exac) • nebulized • q20min × 3 then PRN
    trigger: Wheeze + cough + asthma/COPD diagnosis OR phenotype suspicion
    GINA 2025 / GOLD 2026 — first-line bronchodilator in exacerbation; route pulm.asthma.core.v1 / pulm.copd.core.v1
  3. 3. methylprednisolone IV (or prednisone PO)
    Methylprednisolone 40-80 mg IV q6h × 24-48 h then PO prednisone 40-50 mg/day × 5 d • IV/PO • q6-24h
    trigger: Asthma OR COPD exacerbation
    GINA / GOLD — systemic steroids in any moderate-severe asthma/COPD exacerbation; reduces relapse
  4. 4. ceftriaxone + azithromycin (CAP empiric)
    Ceftriaxone 1-2 g IV q24h + azithromycin 500 mg IV/PO q24h × 5-7 d • IV • q24h
    trigger: CAP requiring admission (CURB-65 ≥2 or O2 requirement or sepsis criteria)
    ATS/IDSA 2019 PMID 31573350 — beta-lactam + macrolide for inpatient CAP; route pulm.cap.core.v1
  5. 5. amoxicillin-clavulanate ± doxycycline (outpatient CAP)
    Amoxicillin-clavulanate 875/125 mg PO BID + doxycycline 100 mg PO BID × 5 d (or amox 1 g PO TID + macrolide) • PO • BID-TID
    trigger: Outpatient CAP (CURB-65 0-1, healthy)
    ATS/IDSA 2019 — outpatient CAP empiric coverage; route pulm.cap.core.v1
  6. 6. piperacillin-tazobactam + vancomycin (severe / aspiration / immunocompromised)
    Piperacillin-tazobactam 4.5 g IV q6h + vancomycin 25-30 mg/kg load then 15-20 mg/kg q8-12h (level-guided) • IV • q6h / q8-12h
    trigger: Severe CAP (ICU) OR aspiration pneumonia OR immunocompromised OR HCAP risk factors
    ATS/IDSA 2019 — broad coverage including MRSA + Pseudomonas; route pulm.aspiration-pneumonia.core.v1 if aspiration phenotype
  7. 7. IV furosemide (HF cough)
    40-80 mg IV bolus (or 2× home dose) then bolus or infusion 5-20 mg/h titrate to UOP • IV • bolus / infusion
    trigger: Cardiogenic cough + bilateral B-lines + elevated NT-proBNP + JVD/edema + acute HF
    AHA/ACC/HFSA 2022 — loop diuresis for acute HF; route cardio.acute-hf.core.v1
  8. 8. nitroglycerin IV (flash pulmonary edema)
    20-200 mcg/min titrate to BP • IV • continuous
    trigger: Hypertensive flash pulmonary edema (SBP ≥160 + crackles + cough)
    AHA — vasodilators in hypertensive acute HF; route cardio.acute-hf.core.v1
  9. 9. oseltamivir (influenza)
    75 mg PO BID × 5 d (CrCl-adjusted) • PO • BID
    trigger: Influenza PCR positive OR high clinical suspicion + symptoms <48 h OR admitted/severe at any duration
    IDSA — reduces complications + mortality in admitted influenza; route id.influenza.core.v1
  10. 10. azithromycin (pertussis)
    500 mg PO day 1 then 250 mg PO daily × 4 d (adult) • PO • daily
    trigger: Suspected pertussis (paroxysmal + post-tussive emesis + whoop)
    CDC — macrolide reduces transmission; treat close contacts; droplet precautions × 5 d
  11. 11. 4-drug RIPE (suspected active TB)
    Isoniazid 5 mg/kg PO daily + rifampin 10 mg/kg PO daily + pyrazinamide 25 mg/kg PO daily + ethambutol 15 mg/kg PO daily; max isoniazid 300 mg, rifampin 600 mg • PO • daily
    trigger: Suspected active TB pending NAAT + AFB × 3 (airborne isolation MANDATORY)
    WHO / CDC — empiric 4-drug RIPE; airborne until 3 neg AFB or NAAT negative; route pulm.tuberculosis.v1
  12. 12. tranexamic acid (massive hemoptysis bridge)
    1 g IV over 10 min then 1 g infusion over 8 h OR 500 mg nebulized • IV / nebulized • once + infusion
    trigger: Massive hemoptysis (>200 mL/24 h) pending bronchoscopy / IR embolization
    Anti-fibrinolytic bridge; route symptom.hemoptysis.v1; protect non-bleeding lung (lateral decubitus, bleeding side down)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute cough <3 weeks — usually viral URI / acute bronchitis / pneumonia / asthma / COPD exacerbation (Irwin CHEST 2006 PMID 16428686; CHEST 2018 PMID 29080708); Cough + fever + dyspnea + purulent sputum + crackles — community-acquired pneumonia → route pulm.cap.core.v1 (ATS PMID 31573350); Cough + wheeze + chest tightness + diurnal variability — asthma exacerbation → route pulm.asthma.core.v1 (GINA 2025).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute cough (ED triage — undifferentiated adult)** (symptom.cough.ed.v1).
Phenotype framing: Acute: viral URI/acute bronchitis (≥50%), CAP, asthma exac, COPD exac, influenza, COVID-19, PE-with-cough, acute HF, aspiration, pertussis, FB aspiration. Subacute: post-viral cough, pertussis tail, asthma-cough variant, UACS. Chronic >8 wk: UACS, asthma, GERD, ACE-i, chronic bronchitis, bronchiectasis, lung cancer, TB, ILD, eosinophilic bronchitis (Irwin CHEST 2006 PMID 16428686; CHEST 2018 PMID 29080708)
Scope: Cough duration (acute / subacute / chronic), quality (dry / productive / paroxysmal), sputum (color / volume / blood) — anchors initial DDx (Irwin CHEST 2006 PMID 16428686)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Pattern-anchored triage (acute < 3 wk vs subacute vs chronic; productive vs dry; fever vs afebrile; pleuritic vs cardiogenic vs wheeze); rule out hypoxic respiratory failure, severe pneumonia, asthma/COPD exacerbation requiring NIV/intubation, acute HF, PE-with-cough, aspiration pneumonia, active TB requiring airborne, massive hemoptysis, FB aspiration; activate downstream engine (Irwin CHEST 2006 PMID 16428686; CHEST 2018 PMID 29080708; ATS PMID 31573350; USPSTF LDCT 2021 PMID 33687470)
1. oxygen supplementation Titrate to SpO2 92-96% (88-92% if known CO2 retainer) NC / mask / NIV / HFNC continuous — SpO2 <92% on room air (BTS 2017 — target SpO2 92-96% in acute illness; avoid hyperoxia in COPD)
2. albuterol nebulizer ± ipratropium Albuterol 2.5-5 mg neb q20min × 3 then q1-4h; ipratropium 0.5 mg neb q20min × 3 (severe asthma/COPD exac) nebulized q20min × 3 then PRN — Wheeze + cough + asthma/COPD diagnosis OR phenotype suspicion (GINA 2025 / GOLD 2026 — first-line bronchodilator in exacerbation; route pulm.asthma.core.v1 / pulm.copd.core.v1)
3. methylprednisolone IV (or prednisone PO) Methylprednisolone 40-80 mg IV q6h × 24-48 h then PO prednisone 40-50 mg/day × 5 d IV/PO q6-24h — Asthma OR COPD exacerbation (GINA / GOLD — systemic steroids in any moderate-severe asthma/COPD exacerbation; reduces relapse)
4. ceftriaxone + azithromycin (CAP empiric) Ceftriaxone 1-2 g IV q24h + azithromycin 500 mg IV/PO q24h × 5-7 d IV q24h — CAP requiring admission (CURB-65 ≥2 or O2 requirement or sepsis criteria) (ATS/IDSA 2019 PMID 31573350 — beta-lactam + macrolide for inpatient CAP; route pulm.cap.core.v1)
5. amoxicillin-clavulanate ± doxycycline (outpatient CAP) Amoxicillin-clavulanate 875/125 mg PO BID + doxycycline 100 mg PO BID × 5 d (or amox 1 g PO TID + macrolide) PO BID-TID — Outpatient CAP (CURB-65 0-1, healthy) (ATS/IDSA 2019 — outpatient CAP empiric coverage; route pulm.cap.core.v1)
6. piperacillin-tazobactam + vancomycin (severe / aspiration / immunocompromised) Piperacillin-tazobactam 4.5 g IV q6h + vancomycin 25-30 mg/kg load then 15-20 mg/kg q8-12h (level-guided) IV q6h / q8-12h — Severe CAP (ICU) OR aspiration pneumonia OR immunocompromised OR HCAP risk factors (ATS/IDSA 2019 — broad coverage including MRSA + Pseudomonas; route pulm.aspiration-pneumonia.core.v1 if aspiration phenotype)
7. IV furosemide (HF cough) 40-80 mg IV bolus (or 2× home dose) then bolus or infusion 5-20 mg/h titrate to UOP IV bolus / infusion — Cardiogenic cough + bilateral B-lines + elevated NT-proBNP + JVD/edema + acute HF (AHA/ACC/HFSA 2022 — loop diuresis for acute HF; route cardio.acute-hf.core.v1)
8. nitroglycerin IV (flash pulmonary edema) 20-200 mcg/min titrate to BP IV continuous — Hypertensive flash pulmonary edema (SBP ≥160 + crackles + cough) (AHA — vasodilators in hypertensive acute HF; route cardio.acute-hf.core.v1)
9. oseltamivir (influenza) 75 mg PO BID × 5 d (CrCl-adjusted) PO BID — Influenza PCR positive OR high clinical suspicion + symptoms <48 h OR admitted/severe at any duration (IDSA — reduces complications + mortality in admitted influenza; route id.influenza.core.v1)
10. azithromycin (pertussis) 500 mg PO day 1 then 250 mg PO daily × 4 d (adult) PO daily — Suspected pertussis (paroxysmal + post-tussive emesis + whoop) (CDC — macrolide reduces transmission; treat close contacts; droplet precautions × 5 d)
11. 4-drug RIPE (suspected active TB) Isoniazid 5 mg/kg PO daily + rifampin 10 mg/kg PO daily + pyrazinamide 25 mg/kg PO daily + ethambutol 15 mg/kg PO daily; max isoniazid 300 mg, rifampin 600 mg PO daily — Suspected active TB pending NAAT + AFB × 3 (airborne isolation MANDATORY) (WHO / CDC — empiric 4-drug RIPE; airborne until 3 neg AFB or NAAT negative; route pulm.tuberculosis.v1)
12. tranexamic acid (massive hemoptysis bridge) 1 g IV over 10 min then 1 g infusion over 8 h OR 500 mg nebulized IV / nebulized once + infusion — Massive hemoptysis (>200 mL/24 h) pending bronchoscopy / IR embolization (Anti-fibrinolytic bridge; route symptom.hemoptysis.v1; protect non-bleeding lung (lateral decubitus, bleeding side down))

Non-pharmacologic actions:
- Two large-bore IVs; arterial line if vasopressors / NIV failure
- Airborne isolation (negative pressure room) if TB suspected; droplet for pertussis / COVID / influenza
- NIV (BiPAP) for COPD exac with hypercapnia OR cardiogenic pulmonary edema; HFNC for hypoxemic respiratory failure
- Intubation for impending respiratory failure (RR ≥30, accessory muscle use, somnolence, pH <7.25, SpO2 <88% despite NIV)
- STAT bronchoscopy for FB aspiration OR massive hemoptysis OR airway obstruction
- STAT IR / thoracic surgery for massive hemoptysis (bronchial artery embolization)
- Lateral decubitus with bleeding-side DOWN to protect non-bleeding lung in massive hemoptysis
- Pulmonary toilet, suctioning, incentive spirometry, chest physiotherapy
- NPO if intubation likely or aspiration phenotype
- Telemetry for HF cough / severe CAP / PE

Monitoring

Setting (ed) monitoring:
- Continuous SpO2 + telemetry
- Vitals q1h × 4 then q4h once stable
- RR + accessory muscle use + tripoding (early respiratory failure signs)
- NIV tolerance (mask fit, comfort, ABG q1-2h initially)
- ABG / VBG at admission and after intervention (CO2 trending)
- Fever curve + sputum production + cough frequency
- CXR repeat at 24-48 h if no improvement; at 6-8 wk for >50 y / smoker (rule out cancer)
- Daily weight + I/O + BMP for HF cough
- PEF q4h for asthma (target >80% personal best for discharge)
- BUN/Cr + K daily if diuresing
- Sputum AFB / Xpert MTB result trending if TB suspected

Follow-up plan: Pneumonia: CXR at 6-8 wk in >50 y or smoker (rule out cancer); pneumococcal/flu vaccines. Asthma: ICS + GINA Track 1; spirometry + plan. COPD: GOLD ABE; pulm rehab; smoking cessation. HF cough: GDMT optimization. TB: DOT + contact tracing + ID f/u. ACE-i cough: discontinue + ARB. Smoker + cough: USPSTF LDCT screen (PMID 33687470). Chronic cough algorithm (Irwin 2006 PMID 16428686): UACS/asthma/GERD empiric trials
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Pneumonia: vitals q4h, sputum, fever curve, follow CXR. Asthma: PEF + symptoms; ABG if severe. COPD: NIV tolerance, ABG. HF cough: diuresis, weight, BUN/Cr, K. PE: anticoagulation safety. TB: airborne until 3 neg AFB; LFT on RIPE. Pertussis: cough paroxysms; secondary bacterial superinfection. Cancer-concern: outpatient pulm/onc clinic + CT chest

Disposition

Current setting: ed — Pattern-anchored triage (acute < 3 wk vs subacute vs chronic; productive vs dry; fever vs afebrile; pleuritic vs cardiogenic vs wheeze); rule out hypoxic respiratory failure, severe pneumonia, asthma/COPD exacerbation requiring NIV/intubation, acute HF, PE-with-cough, aspiration pneumonia, active TB requiring airborne, massive hemoptysis, FB aspiration; activate downstream engine (Irwin CHEST 2006 PMID 16428686; CHEST 2018 PMID 29080708; ATS PMID 31573350; USPSTF LDCT 2021 PMID 33687470)

Disposition criteria:
- Discharge: viral URI / acute bronchitis with normal vitals + SpO2 ≥94% + no concerning features; outpatient CAP CURB-65 0-1 + reliable follow-up + oral antibiotics; resolved pertussis on macrolide + droplet at home; ACE-i cough — discontinue + ARB substitution + follow-up
- Observation: mild-moderate asthma/COPD exacerbation after sustained improvement; pneumonia with borderline SpO2; PE PESI low-risk with home anticoagulation arranged
- Ward: CAP CURB-65 2 + needing IV antibiotics / O2; HF cough with diuresis needed; COPD exac stable on PO steroids + IV/PO antibiotics; non-massive hemoptysis stabilized
- Telemetry / step-down: cardiogenic cough HF / PE non-massive / severe COPD on NIV
- ICU: respiratory failure on NIV/HFNC/intubation; CURB-65 ≥3 / SMART-COP ≥5; severe asthma / COPD with intubation; cardiogenic shock; massive PE; massive hemoptysis bridging to bronchoscopy/IR
- Airborne-isolated room: suspected/confirmed TB until ruled out (3 neg AFB OR neg NAAT)
- Bronchoscopy suite: FB aspiration; massive hemoptysis; suspected airway tumor; unable to clear secretions

Escalation triggers (move to higher acuity):
- SpO2 <92% despite supplemental O2 OR RR ≥30 OR pH <7.25 OR somnolence → NIV / HFNC / intubation → ICU
- CURB-65 ≥3 OR SMART-COP ≥5 OR ATS major criteria → ICU + early antibiotic delivery → pulm.cap.core.v1
- Asthma severe exacerbation (PEF <50%, SpO2 <92%, silent chest, no SABA response) → IV magnesium 2 g + NIV + ICU → pulm.asthma.core.v1
- COPD exacerbation with hypercapnic respiratory failure (pH <7.35, PaCO2 >45) → NIV first-line; intubation if NIV failure → pulm.copd.core.v1
- Acute HF with cardiogenic shock or hypotension → vasopressors + ICU → cardio.acute-hf.core.v1
- Wells ≥6 OR positive CTA → therapeutic anticoagulation; massive PE (hemodynamic instability) → systemic thrombolysis OR embolectomy → pulm.pe.core.v1
- Aspiration with progressive infiltrate / shock → broad coverage + ICU → pulm.aspiration-pneumonia.core.v1
- Suspected active TB → airborne isolation IMMEDIATE + 4-drug RIPE → pulm.tuberculosis.v1
- Massive hemoptysis (>200 mL/24 h OR hemodynamic instability) → STAT bronchoscopy + IR embolization → symptom.hemoptysis.v1
- FB aspiration → STAT bronchoscopy + airway management
- COVID-19 with severe disease (NIV/HFNC/intubation) → dexamethasone + IL-6 inhibitor + remdesivir → id.covid19.core.v1
- Influenza with respiratory failure → oseltamivir + ICU → id.influenza.core.v1
- Immunocompromised cough + infiltrate + hypoxia → broad coverage (bacterial + PCP + fungal + viral) + early bronchoscopy with BAL

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SpO2 <92% on room air OR <88% in known COPD; cough + RR ≥30 + accessory muscle use — hypoxic respiratory failure; O2 + NIV/HFNC; intubate if NIV failure
- [LIFE_THREATENING] CURB-65 ≥3 OR ATS major criteria (mechanical ventilation OR vasopressor) OR ≥3 minor criteria — severe CAP requiring ICU + early antibiotics within 1 h (ATS/IDSA 2019 PMID 31573350)
- [LIFE_THREATENING] PEF <50% personal best + SpO2 <92% + silent chest OR no SABA response — severe asthma exacerbation; SABA + ipratropium + steroids + IV magnesium 2 g + NIV + ICU (GINA 2025)

Citations

- 2006 Irwin CHEST cough algorithm + 2018 CHEST acute cough + 2021 USPSTF LDCT lung cancer screening + 2019 ATS/IDSA CAP + 2025 GINA asthma + 2026 GOLD COPD + 2022 AHA/ACC/HFSA HF + 2020 Stevens ACP PE + IDSA influenza + CDC pertussis + WHO TB + RECOVERY dexamethasone for COVID [PMID:29080708](https://pubmed.ncbi.nlm.nih.gov/29080708/)
- Cited evidence (PMID 30296998) [PMID:30296998](https://pubmed.ncbi.nlm.nih.gov/30296998/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 2006 Irwin CHEST cough algorithm + 2018 CHEST acute cough + 2021 USPSTF LDCT lung cancer screening + 2019 ATS/IDSA CAP + 2025 GINA asthma + 2026 GOLD COPD + 2022 AHA/ACC/HFSA HF + 2020 Stevens ACP PE + IDSA influenza + CDC pertussis + WHO TB + RECOVERY dexamethasone for COVID — PMID:29080708
  • Cited evidence (PMID 30296998) — PMID:30296998