When a cold has gone deeper: the signs of a chest infection

A cold has a shape to it. It starts in the nose and the throat, it is at its worst around the third day, and by the end of the week it is on the way out. The calls that reach us are about the colds that do not follow that shape: the cough gets deeper instead of quieter, breathing starts to take effort, and a fever turns up late rather than early.

Most of the time that is still an ordinary cold taking its time. Sometimes it is an infection that has moved down into the airways or the lungs. The two are worth telling apart, because they ask different things of you.

Where a cold ends and a chest infection begins

A cold is an infection of the upper airway: the nose, the throat, the sinuses. The cough that comes with it is usually light and dry, and it comes from irritation higher up rather than from the chest itself.

A chest infection has gone deeper. When it settles in the airways that carry air into the lungs it is called bronchitis; when it reaches the lung tissue itself it is pneumonia. Either way the symptoms are heavier, they last longer, and they do not follow the familiar downhill curve of a cold.

Timing is the single most useful clue at home. A cold improves from about the third or fourth day. An infection in the chest tends to keep getting worse after those first few days, or to improve briefly and then turn around.

What a cold looks like

• A runny or blocked nose, and sneezing
• A mild sore throat
• A light, mostly dry cough
• Mild tiredness, but you can still get through the day
• Steady improvement, and gone within a week to ten days without any treatment

What says it has gone into the chest

• A cough that deepens and worsens rather than easing, often bringing up thick yellow, green or brown phlegm
• Chest pain or tightness, worse when breathing in or coughing
• Breathlessness or wheeze, or breathing that has started to feel like work
• A fever of 38°C or above, particularly one that arrives after the cold seemed to be improving
• Deep tiredness and body aching, out of proportion to a head cold
• In an older person, confusion or a sudden loss of their usual energy, sometimes with very little fever at all

Matching the second list more than the first is reason enough to have it looked at. It is not a diagnosis by itself: the same picture can be a chest infection, an asthma flare, or simply a cold in someone who feels every cold badly. That is the question an examination answers.

Antibiotics are not automatically the answer

This is worth saying plainly, because it is the assumption we meet most often. A good many chest infections are viral, and antibiotics do nothing for those. Bronchitis in an otherwise healthy adult usually settles on its own with time, fluids and rest.

Pneumonia and bacterial infections are a different matter and do need treating, sometimes urgently. The point of being seen is not to collect a prescription. It is to find out which of these you have, so that the treatment matches the illness and a course of antibiotics is not taken for a cough that was never going to answer to it.

Who feels it soonest

Anyone can develop a chest infection after a cold. In three groups it tends to arrive faster and show itself less clearly, and in those three it is better seen early than late.

Young children

A small child cannot tell you that breathing has become hard work, so it has to be watched rather than asked about: breathing faster than usual, the ribs or the base of the throat drawing in with each breath, feeding or drinking dropping off, or a child who has gone quiet and flat between coughing bouts. There is a companion piece on the first hour of a child’s fever at night.

Older adults

In an older person a chest infection often presents without the high fever you would expect. What changes first is confusion, appetite, steadiness on the feet, or simply the amount of energy there is in the day. Families who know the person well usually notice it before any thermometer does, and that observation is worth trusting. More on this in caring for an elderly parent at home.

People living with a long-term condition

Asthma, COPD, diabetes, heart disease and the conditions that suppress immunity all make a respiratory infection harder to shake off, and can let it escalate with less warning. If a cold has set off wheeze or shortness of breath in someone with asthma or COPD, that is a call rather than a wait.

What to do at home while you decide

1. Fluids, more than thirst asks for

Fever and mouth-breathing take fluid out faster than thirst puts it back, and fluid is what keeps phlegm loose enough to clear. Water, warm drinks, soup, oral rehydration salts: whatever will actually be taken.

2. Rest, and mean it

Sleep is when the repair happens. Working through a chest infection is the most reliable way of making the second week worse than the first.

3. Paracetamol for the fever and the aching

At the dose printed on the packet. It will not shorten the illness, and it is not meant to. It makes the fever and the aching bearable enough to rest and drink, which is what does shorten it.

4. Sit propped up rather than flat

A cough is nearly always worse lying down. An extra pillow, or sleeping propped up, buys back some of the night.

5. No smoke in the house

Not from the patient, and not around them. Smoke irritates airways that are already inflamed and makes the cough last longer.

6. Watch the breathing, not just the cough

The cough is the noisiest symptom and the least informative. What tells you how deep this has gone is the breathing: how fast it is, whether it takes effort, whether a sentence can be finished without stopping for air.

When to call a doctor

Not every chest infection needs a hospital, but all of them are worth a proper look. Call if:

• Things are worse after the first three or four days rather than better
• There is a fever of 38°C or above that is not settling, or a fever that returns after the cold seemed to be over
• There is any breathlessness, wheeze, or breathing that takes visible effort
• There is chest pain on breathing or coughing
• The cough is bringing up thick discoloured phlegm, or has gone past three weeks
• The patient is over 65, pregnant, a baby, or lives with asthma, COPD, diabetes or heart disease
• There is unusual confusion or drowsiness, particularly in an older person

And if you are simply unsure, that is reason enough. A short conversation with a doctor settles a question that otherwise sits in the house all night.

Do not wait for a home visit. Go to the nearest hospital emergency department or call SAMU on 114 if there is severe breathlessness or breathing that cannot be caught, blue or grey lips or face, chest pain that is heavy or spreading to the arm or jaw, coughing up blood, collapse, confusion or unusual drowsiness, a fit, or a fever in a baby under three months.

What a doctor does at the house

The chest is listened to on both sides, front and back, which is what separates an upper airway infection from something in the lungs. Alongside that: temperature, pulse, blood pressure, breathing rate, and the oxygen level read off a clip on the finger. Those few minutes are the difference between knowing and supposing.

Where the picture is bacterial, first-line treatment can begin during the same visit. Where it is viral, the useful outcome is being told so, and being told what would change the answer. If blood tests would help, blood can be taken at the address, and inhalers or oxygen needs can be assessed on the spot.

Doctors work from dispatch points spread around the island rather than from one clinic, which is what keeps the wait reasonable wherever you are: how a doctor gets to you. Consultation fees are the same everywhere and are published in full: what a home visit costs.

Reducing the chance of the next one

• Wash hands after public places, clinics and time around anyone unwell
• Do not smoke, and keep the house clear of other people’s smoke
• Take fluids and rest seriously in the first days of a cold, not the second week
• Keep long-term conditions well controlled, and have inhaler technique checked if you use one
• Do not sit on a cold that is getting worse after a week: that is the moment to call, rather than later

A cold that turns into a chest infection is common and usually straightforward when it is caught early. Nearly all of the difficulty we see comes from waiting, and it is one of the things we are called out for most.

Frequently asked questions

How long should a cough last after a cold?

Longer than most people expect. A cough often outlasts the rest of a cold by two to three weeks, and that on its own is not a sign of infection. What matters is the direction: a cough that is slowly easing is doing what it should, and a cough that is deepening, bringing up discoloured phlegm or making breathing harder is worth having listened to. Beyond three weeks, have it seen even if you feel otherwise well.

Do I need antibiotics for a chest infection?

Not always, and often not. A good many chest infections are viral, and antibiotics do nothing at all for those. Bronchitis in an otherwise healthy adult usually settles without them. Pneumonia and bacterial infections are a different matter and do need treating. Telling the two apart is the reason to be examined rather than to start a course left over in the cupboard.

Is bronchitis the same as pneumonia?

No. Bronchitis is inflammation of the airways that carry air into the lungs, and it is the milder and more common of the two. Pneumonia is infection of the lung tissue itself, and it makes people more unwell: higher fever, faster breathing, more exhaustion. They can feel similar at the start, which is why the chest is listened to rather than guessed at.

Can a chest infection be treated at home in Mauritius?

In most cases yes. A doctor can examine the chest, check the oxygen level and the breathing, start treatment where it is needed and arrange blood tests at the address. A day consultation between 7am and 7pm is Rs 2,000 and a night consultation between 7pm and 7am is Rs 3,000, at the same rate anywhere on the island. Where someone needs oxygen or hospital care, the visit is how that gets recognised early.

How do I know if my child’s cough is serious?

Watch the breathing rather than the cough. A loud cough in a child who is breathing comfortably, drinking and playing between bouts is usually less worrying than a quiet cough in a child who is breathing fast, drawing in at the ribs, refusing fluids or unusually flat. Breathing effort, fluids and alertness are the three things to judge it on.