Upper Respiratory Infection

Aka: Upper Respiratory Infection, Infectious Rhinitis, Viral Rhinitis, Common Cold

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II. Pathophysiology

  1. Infection of ciliated epithelial cells in nasal mucosa
  2. Nasal Discharge results from mild cell inflammation
    1. Increased local production of mucus, Immunoglobulin
    2. Shedding epithelial cells
  3. Bacterial adherence increases with Viral Infection
    1. Superinfection risk (higher in smoke exposure)
  4. Wet weather and chilling do NOT increase Infectivity

III. Epidemiology

  1. Peak months (related to congregation in confined space)
    1. Temperate climate: September to March
    2. Tropics: Rainy season
  2. Annual Incidence
    1. Children: 6-8 URIs per season (higher in daycare)
    2. Adults: 2-4 URIs per season
  3. Course
    1. Incubation: 48-72 hours (may be as long as 7 days)
    2. Viral Shedding
      1. Peaks with symptoms
      2. Persists as long as 2-3 weeks
    3. Symptoms peak by days 3-5
  4. Transmission
    1. Aerosol transmission predominates
    2. Hand to hand to nose (and eye) transmission is common
      1. Hands are virally contaminated 60% of time
      2. Hand Washing with virucidal agents is effective
    3. Fomite transmission (e.g. toys) is inconsistent

IV. Etiologies

  1. Most Common cause: Rhinovirus (30-50%)
  2. No Etiology identified (35%)
  3. Other Common causes (20-25%)
    1. Coronavirus
    2. Parainfluenza virus
    3. Adenovirus
    4. Enterovirus
    5. Influenza
    6. Respiratory Syncytial Virus (RSV)
  4. Less Common causes (10-15%)
    1. Chlamydia pneumoniae
    2. Mycoplasma pneumoniae
    3. Group A Streptococcal Pharyngitis
  5. Rare Causes
    1. Mumps
    2. Rubella
    3. Rubeola
    4. Cytomegalovirus (CMV)

V. Differential Diagnosis

  1. Purulent Nasal Discharge more than 10-14 days
    1. Acute Sinusitis (especially if Maxillary Tooth Pain and unilateral sinus tenderness)
  2. Purulent cough, fever over 101, and acute debilitation
    1. Tracheobronchitis
    2. Pneumonia
    3. Influenza
  3. Laryngitis and non-productive cough more than 2 weeks
    1. Mycoplasma pneumoniae
    2. Chlamydia pneumoniae
  4. Raspy cough
    1. Pertussis (increasing Incidence in U.S.)
  5. Dysphagia, Drooling, Stridor and high fever
    1. Epiglottitis

VI. Symptoms

  1. Nasal symptoms (precede other symptoms by 1-2 days)
    1. Sneezing
    2. Nasal congestion or stuffiness
    3. Nasal Discharge increased
  2. Sore Throat: mild "scratchy" Sensation
  3. Eye burning and eye tearing
  4. Dry, non-productive cough (40-60% of patients)
    1. Begins on days 2-3 and may persist for 7-10 days
  5. Generalized symptoms
    1. Malaise (mild)
    2. Muscle aches
    3. Low grade fever
  6. Less common symptoms
    1. Hoarseness
    2. Headache
    3. Chills

VII. Signs

  1. Low-grade fever less than 101 F (38.5 C)
  2. Nose
    1. Clear Nasal Discharge
    2. Red, swollen nasal mucosa
  3. Throat with mild erythema

VIII. Complications (1-2%; higher risk in smoke exposure)

  1. Bacterial Sinusitis
  2. Acute Otitis Media
  3. Bacterial Bronchitis
  4. Pneumonitis
  5. Bacterial Pneumonia

IX. Management

  1. General
    1. Cold Preparations do not change course
      1. No study shows shortened symptom course
      2. No study shows reduced secondary complications
    2. Antibiotics not indicated
      1. Consider discussing contingency plans
        1. Lays out plan for when Antibiotics indicated
        2. Eliminates pressure for Antibiotic prescription
      2. Example
        1. If symptoms persist beyond 14 days then...
        2. Antibiotics indicated for Acute Sinusitis
      3. Consider Delayed Antibiotic Prescription
        1. Patient calls, picks up, or fills a prescription after a set time of persistent symptoms
        2. Reduces Antibiotic use by 40%
        3. Little (2014) BMJ 348:g1606 [PubMed]
      4. Reference
        1. Mangione (2001) Arch Pediatr Adolesc Med 155:800 [PubMed]
    3. Avoid cough and Cold Preparations under age 4 years
      1. Symptomatic therapy with Analgesics (Acetaminophen and Ibuprofen) and Nasal Saline are preferred
      2. Cough and Cold Preparations top the list of toxic ingestions in this age group
      3. No evidence of benefit for cough and Cold Preparations in young children
      4. Leads to emergency visits, hospitalizations, and deaths
      5. FDA recommends not using cough and Cold Preparations under age 2 years
      6. De Sutter (2022) Cochrane Database Syst Rev (2):CD004976 +PMID: 22336807 [PubMed]
  2. Symptomatic therapy
    1. See Sore Throat symptomatic management
    2. Muscle aches, fever, chills
      1. Acetaminophen (do not exceed maximum dose)
      2. Ibuprofen (avoid in Dehydration)
    3. Hydration
      1. Maintain adequate hydration
      2. Avoid over-hydration in children due to risk of Hyponatremia
    4. Nasal symptoms
      1. Nasal Saline
        1. First-line, preferred, safe and effective Decongestant
      2. Decongestants reduce nasal congestion and discharge
        1. Topical Decongestants (e.g Afrin) for no more than 3 days (Rhinitis Medicamentosa risk)
          1. Avoid afrin (Oxymetazoline) in children ("One Pill Can Kill")
            1. Risk of central alpha-2 Agonist, Clonidine-like CNS depression
          2. Neo-Synephrine (Intranasal Phenylephrine) is preferred nasal Decongestant in children
        2. Oral Decongestants (e.g. Sudafed, Entex)
          1. Not routinely recommended (systemic effects including Blood Pressure increase)
          2. Pseudoephedrine (Sudafed) may offer benefit in some patients
          3. Phenylephrine orally (Sudafed PE) is ineffective due to reduced absorption
      3. Antihistamines are not effective in acute URI
        1. May also predispose to Acute Sinusitis complication (due to osteomeatal complex plugging)
        2. May be considered in combination with Decongestant if concurrent allergic symptoms
      4. Vaseline at opening of nares may reduce mucosal irritation and fissures
        1. Exercise caution in insertion to prevent aspiration
      5. Cool Mist Humidifier may loosen discharge (however, no evidence)
        1. Avoid warm mist humidifiers due to low efficacy and burn risk
    5. Cough
      1. Intranasal Ipratropium (intranasal Atrovent)
        1. May reduce persistent cough following URI (based on one small study)
          1. Holmes (2019) Respir Med 86(5): 425-9 [PubMed]
      2. Cough Suppressants (e.g. Dextromethorphan, Tessalon)
        1. No Cough Suppressant (including Codeine, Dextromethorphan) has been found effective for URI
        2. Avoid use overall as these are ineffective, and have adverse effects and abuse potential
        3. If used, limit use (e.g. cough interfering with sleep)
        4. Unsuppressed cough may prevent complications
        5. Codeine has found no more effective than Placebo in Cough Suppression
      3. Cough Expectorants
        1. Guaifenesin paradoxically may reduce cough in URI (variable efficacy)
        2. Dicpinigaitis (2003) Chest 124:2178-81 [PubMed]
    6. Wheezing with reactive airway disease (RAD) exacerbation
      1. Consider high dose Inhaled Corticosteroids (especially in children)
        1. However, Intranasal Corticosteroids are NOT effective in the Common Cold
        2. Budesonide (Pulmicort) MDI or nebulizer
        3. Beclomethasone MDI
  3. Alternative Medicine therapies that may be effective
    1. Adults
      1. Andrographis paniculata (Kalmcold) 200 mg daily for 5 days
        1. Hu (2018) PLOS ONE 13(11): e0207713 [PubMed]
      2. Zinc acetate or gluconate lozenges used during symptomatic URI period
    2. Children (use with caution especially under age 4 years)
      1. Honey once (do not use under age 1 year old, Infantile Botulism risk)
        1. Honey 2.5 ml (age 2-5 years), 5 ml (age 6-11 years) or 10 ml (age 12-18 years) once
      2. Zinc acetate or gluconate lozenges used during symptomatic URI period
      3. Vapor rub (camphor, Menthol, eucalyptus) once

X. Management: Ineffective measures (avoid)

  1. Antibiotics
    1. Spurling (2017) Cochrane Database Syst Rev (9):CD004417 [PubMed]
    2. Kenealy (2013) Cochrane Database Syst Rev (6): CD00247 [PubMed]
  2. Antihistamines
  3. Antivirals
  4. Cough Suppressants (including Dextromethorphan and Codeine, see above)
    1. Freestone (1997) J Pharm Pharmacol 49(10): 1045-9 [PubMed]
  5. Echinacea
    1. Echinacea purpurea previously recommended 20 drops three times daily for 10 days)
    2. Karsch-Volk (2014) (2):CD000530 [PubMed]
  6. Intranasal Corticosteroids
    1. Hayward (2015) Cochrane Database Syst Rev (10): CD008116 [PubMed]
  7. Pelargonium sidoides (geranium extract, Umcka Coldcare)
    1. Previously recommended 30 drops (or based on age in children) three times daily for 10 days
    2. Timmer (2013) Cochrane Database Syst Rev (10): CD006323 [PubMed]
  8. Steam vaporizer
    1. Singh (2017) Cochrane Database Syst Rev (8): CD001728 [PubMed]
  9. Vitamin C
    1. Hemila (2013) Cochrane Database Syst Rev (1): CD000980 [PubMed]
  10. Vitamin D
    1. Murdoch (2012) JAMA 308(13): 1333-39 [PubMed]
  11. Vitamin E
    1. Graat (2002) JAMA 288(6): 715-21 [PubMed]

XI. Prevention

  1. Frequent Hand Washing or hand sanitizer to prevent spread of infection
    1. Single most effective strategy
  2. Probiotic milk (with live culture lactobacillus)
    1. May reduce respiratory infections in children age <7
    2. Hatakka (2001) BMJ 322:1-5 [PubMed]

XII. References

  1. DeGeorge (2019) Am Fam Physician 100(5):281-9 [PubMed]
  2. Clemens (1997) J Pediatr 130:463-6 [PubMed]
  3. Fashner (2012) Am Fam Physician 86(2): 153-9 [PubMed]

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Related Studies

Ontology: Common Cold (C0009443)

Definition (MSH) A catarrhal disorder of the upper respiratory tract, which may be viral or a mixed infection. It generally involves a runny nose, nasal congestion, and sneezing.
Definition (MEDLINEPLUS)

Sneezing, sore throat, a stuffy nose, coughing - everyone knows the symptoms of the common cold. It is probably the most common illness. In the course of a year, people in the United States suffer 1 billion colds.

You can get a cold by touching your eyes or nose after you touch surfaces with cold germs on them. You can also inhale the germs. Symptoms usually begin 2 or 3 days after infection and last 2 to 14 days. Washing your hands and staying away from people with colds will help you avoid colds.

There is no cure for the common cold. For relief, try

  • Getting plenty of rest
  • Drinking fluids
  • Gargling with warm salt water
  • Using cough drops or throat sprays
  • Taking over-the-counter pain or cold medicines

However, do not give aspirin to children. And do not give cough medicine to children under four.

NIH: National Institute of Allergy and Infectious Diseases
Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the nasal mucosal.
Definition (NCI) An inflammatory process affecting the nasal mucosa, usually caused by viruses (e.g., rhinovirus, adenovirus, parainfluenza virus, and coronavirus). It is characterized by chills, headaches, mucopurulent nasal discharge, coughing, and facial pain.
Definition (NCI) An acute inflammatory process that affects the nasopharynx. It is caused by viruses. Signs and symptoms include fever, coughing, sneezing, and sore throat.
Definition (CSP) catarrhal disorder of the upper respiratory tract, which may be viral or a mixed infection; marked by acute coryza, slight rise in temperature, chilly sensations, and general indisposition.
Concepts Disease or Syndrome (T047)
MSH D003139
ICD9 460
ICD10 J00
SnomedCT 82272006, 232342002, 155497009, 232341009, 266377009, 195648002, 280771000009103, 54150009
English Cold, Common, Colds, Common, Common Cold, Common Colds, Acute nasopharyngitis (common cold), Acute nasopharyngitis [common cold], acute rhinitis, acute rhinitis (diagnosis), rhinitis acute, common cold, common cold (diagnosis), Common cold syndrome, Rhinitis (infective), Infective nasopharyngitis, NOS, Acute nasopharyngitis, NOS, Infectious Rhinitis, acute nasopharyngitis, acute nasopharyngitis (diagnosis), Common Cold [Disease/Finding], Nasopharyngitis;acute, Rhinitis;acute, colds, common colds, Coryza (acute), Infective nasopharyngitis NOS, Nasal catarrh, acute, acute coryza, Nasopharyngitis - acute, Coryza - acute, Rhinitis - acute, (Acute nasopharyngitis or rhinitis) or (common cold), (Acute nasopharyngitis or rhinitis) or (common cold) (disorder), Nasal catarrh - acute, Acute rhinitis (disorder), Cold (Disease), viral upper respiratory infection, viral upper respiratory infection (diagnosis), upper respiratory infection viral, Rhinitis infective, Head cold, Cold, Common cold, Acute coryza, Acute nasal catarrh, Acute rhinitis, Infective rhinitis, Acute infective rhinitis, Acute nasopharyngitis, Common cold (disorder), Infective nasopharyngitis, Upper respiratory infection acute, catarrh; nasal, acute, catarrh; nasopharyngeal, acute, cold; common, cold, common; cold, infective; rhinitis, acute; rhinitis, nasal; catarrh, acute, nasopharyngeal; catarrh, acute, rhinitis; acute, rhinitis; infective, Head cold, NOS, Acute Nasopharyngitis, Coryza, Rhinitis, acute, Rhinitis, infective, Coryza, acute, Nasopharyngitis, acute, head cold
Spanish resfriado común, Nasofaringitis aguda, Resfriado, Rinitis aguda, Rinitis (infecciosa), Resfriado de cabeza, Resfriado común, Síndrome catarral común, Rinitis infecciosa, Nasofaringitis aguda (resfriado común), Catarro, catarro nasal agudo, coriza aguda, nasofaringitis aguda, nasofaringitis infecciosa, resfrío común (trastorno), resfrío común, rinitis aguda, rinitis infecciosa, Resfriado Común
Dutch acute nasofaryngitis (verkoudheid), acute rhinitis, hoofdverkoudheid, rhinitis infectieus, verkoudheid, rhinitis (infectieus), infectieuze rhinitis, acute nasofaryngitis, kou, verkoudheidssyndroom, Acute infectie bovenste luchtwegen, acuut; rinitis, catarre; nasofaryngeaal, acuut, catarre; neus, acuut, gewoon; verkoudheid, infectieus; rinitis, nasofaryngeaal; catarre, acuut, neus; catarre, acuut, rinitis; acuut, rinitis; infectieus, verkoudheid; gewoon, Acute nasofaryngitis [verkoudheid], Gewone verkoudheid, Nasofaryngitis, acute, Verkoudheid
French Nasopharyngite aiguë, Rhinite aiguë, Syndrome de rhume ordinaire, Rhinite (infectieuse), Nasopharyngite aiguë (rhume), Rhume, Rhume de cerveau, Rhinite infectieuse, Rhinite infectante, Rhinite aigüe épidémique, Rhume banal
German Rhinitis (infektioes), akute Nasopharyngitis, Erkaeltung, akute Nasopharyngitis (Erkaeltung), infektiose Rhinitis, infektioeser Schnupfen, akuter Schnupfen, Schnupfensyndrom, Akute Rhinopharyngitis [Erkaeltungsschnupfen], Schnupfen, Erkältung
Italian Rinite infettiva, Rinite acuta, Raffreddore, Rinite (infettiva), Rinofaringite acuta, Freddo, Freddo al capo, Rinofaringite acuta (raffreddore comune), Sindrome da raffreddore, Raffreddore comune
Portuguese Frio, Nasofaringite aguda, Rinite aguda, Síndrome de constipação, Constipação, Rinite infecciosa, Rinite (infecciosa), Nasofaringite aguda (constipação), Frio na cabeça, Resfriado (Constipação), Catarro, Resfriado Comum
Japanese 急性鼻炎, 急性鼻咽頭炎（感冒）, 鼻炎（感染性）, 急性鼻咽頭炎, 感冒症候群, 頭部感冒, 感染性鼻炎, ｷｭｳｾｲﾋﾞｲﾝﾄｳｴﾝ, ｷｭｳｾｲﾋﾞｲﾝﾄｳｴﾝｶﾝﾎﾞｳ, ﾋﾞｴﾝｶﾝｾﾝｾｲ, ｷｭｳｾｲﾊﾅｲﾝﾄｳｴﾝｶﾝﾎﾞｳ, ｶﾝﾎﾞｳ, ｶﾝﾎﾞｳｼｮｳｺｳｸﾞﾝ, ﾄｳﾌﾞｶﾝﾎﾞｳ, ｶﾝｾﾝｾｲﾋﾞｴﾝ, 急性コリーザ, 普通感冒, コリーザ-急性, かぜ, 感冒-普通, 風邪, 感冒, かぜ症候群, かぜひき, ｷｭｳｾｲﾋﾞｴﾝ
Swedish Förkylning
Czech nachlazení, Infekční rinitida, Akutní rinitida, Nachlazení, Syndrom prostého nachlazení, Nachlazení hlavy, Akutní nazofaryngitida, Akutní zánět nosohltanu (prosté nachlazení), Prosté nachlazení (common cold), Infekční rýma, nastuzení
Finnish Nuhakuume
Russian NASMORK OSTRYI, PROSTUDA, OSTRYI RINIT, НАСМОРК ОСТРЫЙ, ОСТРЫЙ РИНИТ, ПРОСТУДА
Korean 급성 코인두염[감기]
Polish Choroba przeziębieniowa, Przeziębienie
Hungarian acut nasopharyngitis, megfázás, Acut nasopharyngitis (meghűlés), közönséges nátha, Száraz nátha, fertőző rhinitis, rhinitis (fertőző), Acut rhinitis, közönséges nátha syndroma, Rhinitis, fertőző
Norwegian Forkjølelse
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Upper Respiratory Infections (C0041912)

Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the upper respiratory tract (nose, paranasal sinuses, pharynx, larynx, or trachea).
Definition (NCI) An infectious process affecting the upper respiratory tract (nose, paranasal sinuses, pharynx, larynx, or trachea). Symptoms include congestion, sneezing, coughing, fever, and sore throat.
Concepts Disease or Syndrome (T047)
MSH D012141
ICD10 J06.9
SnomedCT 266338006, 155547007, 195711002, 54150009
English Infections, Upper Respiratory, Respiratory Infection, Upper, UPPER RESP TRACT INFECTION, Upper respiratory infect.NOS, Upper Respiratory Infections, UPPER RESPIRATORY INFECT, INFECT UPPER RESPIRATORY, Upper respiratory tract infecn, Infection of upper resp tract, Infection of the upper respiratory tract, URTI - Infectn upper resp trct, URI, URI (upper respiratory infection), upper respiratory infection, upper respiratory infection (diagnosis), Infections, Upper Respiratory Tract, Upper Respiratory Tract Infections, Upper resp tract infection, Upper respiratory tract infection NOS, URTI (upper respiratory tract infection), Infection upper respiratory, URTI, Upper respiratory infection NOS, upper respiratory infection (URI), upper respiratory infections, upper respiratory tract infection (URTI), Upper respiratory infection NOS (disorder), Infection of the upper respiratory tract (disorder), INFECTION, UPPER RESPIRATORY TRACT, Upper respiratory infection, Upper respiratory tract infection, URTI - Infection of the upper respiratory tract, Upper respiratory infection (disorder), Upper respiratory tract infections, Upper respiratory infection, NOS, Upper Respiratory Tract Infection, Infection;upper resp tract, upper resp tract infection, URI - Upper respiratory infection
Italian Infezione delle vie respiratorie superiori, Infezione delle vie respiratorie superiori, NAS, Infezione delle vie aeree superiori, Infezioni delle vie respiratorie superiori, Infezioni del tratto respiratorio superiore
Dutch infectie bovenste luchtwegen, URI, bovenste luchtweginfectie NAO, bovenste luchtweginfectie, infecties van bovenste luchtwegen, Bovensteluchtweginfectie
French IVRS, IRS, IVRS (infection des voies respiratoires supérieures), Infection des voies resp supérieures, Infection des voies respiratoires supérieures SAI, Infections des voies respiratoires supérieures, INFECTION VOIES RESPIRATOIRES SUP, Infection des voies aériennes supérieures, Infection des voies respiratoires supérieures, Infections des voies aériennes supérieures, Infections des voies respiratoires hautes
German URTI, URTI (Infektionen der oberen Atemwege), Infektion der oberen Atemwege NNB, Infektionen der oberen Atemwege, URI, Infektion der ob Atemw, Obere Luftwege, Infektionen der, ATEMWEGINFEKTION OBERE, Infektion der oberen Atemwege, Infektionen der oberen Luftwege
Portuguese Infecção respiratória superior, Infecção das vias respiratórias superiores NE, Infecções respiratórias superiores, INFECCAO DAS VIAS RESPIRATORIAS S, Infecções do Trato Respiratório Superior, Infecção das vias respiratórias superiores, Infecções das vias respiratórias superiores
Spanish Infección de las vías respiratorias altas NEOM, IRTS (Infección respiratoria del tracto superior), IRA, Infección de las vías respiratorias superiores, Infección respiratoria alta, IRTS, INFECCION RESPIRATORIA ALTA, Infecciones del Tracto Respiratorio Superior, infección de vías respiratorias superiores, SAI, infección de vías respiratorias superiores, SAI (trastorno), infección de vías respiratorias altas, infección de vías respiratorias superiores (trastorno), infección de vías respiratorias superiores, infección respiratoria superior, SAI (trastorno), infección respiratoria superior, SAI, Infecciones del tracto respiratorio alto, Infección del tracto respiratorio superior
Japanese 上気道感染, 上気道感染ＮＯＳ, ｼﾞｮｳｷﾄﾞｳｶﾝｾﾝ, ｼﾞｮｳｷﾄﾞｳｶﾝｾﾝNOS
Czech Infekce horních cest dýchacích, Infekce horních dýchacích cest, Infekce horních cest dýchacích NOS, infekce horních cest dýchacích
Hungarian Felső légúti fertőzés, URI, felső légúti fertőzés k.m.n., Felső respiratorikus fertőzés, URTI (felső légúti fertőzés), Fertőzés felső légúti, Felső respiratorikus rendszer fertőzés, Felső légút fertőzései, URTI
Norwegian Øvre luftveisinfeksjoner, Infeksjoner i øvre luftveier
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Viral rhinitis (C0748412)

Concepts Disease or Syndrome (T047)
Dutch virale rhinitis
French Rhinite virale
German Virusschnupfen
Italian Rinite virale
Portuguese Rinite viral
Spanish Rinitis viral
Japanese ウイルス性鼻炎, ｳｲﾙｽｾｲﾋﾞｴﾝ
Czech Virová rinitida
English rhinitis viral, viral rhinitis, Viral rhinitis
Hungarian vírusos rhinitis
Derived from the NIH UMLS (Unified Medical Language System)

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