When should I consider a chest X-ray for a patient presenting with acute cough?

A chest X-ray should be considered for a patient presenting with an acute cough in the following situations:

• If the patient is aged 40 or over with an unexplained cough, especially if they have ever smoked or have been exposed to asbestos, to rule out lung cancer or mesothelioma. This should be done urgently, ideally within 2 weeks ².
• If the patient has persistent or recurrent chest infections and is aged 40 or over, an urgent chest X-ray should be offered within 2 weeks ².
• If the patient presents with clinical features suggesting a serious illness such as pneumonia, or if there are chest signs consistent with lung cancer or pleural disease, or finger clubbing in patients aged 40 or over, a chest X-ray should be considered urgently ².
• If the patient has symptoms or signs suggesting complications or more serious conditions such as sepsis, pulmonary embolism, or lung cancer, further investigation including chest X-ray is warranted ⁴.
• If the patient is systemically very unwell with acute cough (e.g., respiratory rate >30/min, tachycardia >130 bpm, low blood pressure, oxygen saturation <92%, altered consciousness, use of accessory muscles), emergency admission and chest X-ray should be arranged ¹.
• In cases of suspected tuberculosis or extrapulmonary TB, a chest X-ray is part of the diagnostic workup ⁶.

For patients with uncomplicated acute cough without these risk factors or signs, chest X-ray is not routinely recommended as acute cough usually resolves within 3–4 weeks and is often due to self-limiting upper respiratory tract infections ¹,⁴.