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Upper Respiratory Infection
Aka: Upper Respiratory Infection, Infectious Rhinitis, Viral Rhinitis, Common Cold
- Pathophysiology
- Infection of ciliated epithelial cells in nasal mucosa
- Nasal Discharge results from mild cell inflammation
- Increased local production of mucus, Immunoglobulin
- Shedding epithelial cells
- Bacterial adherence increases with Viral Infection
- Superinfection risk (higher in smoke exposure)
- Wet weather and chilling do NOT increase Infectivity
- Epidemiology
- Peak months (related to congregation in confined space)
- Temperate climate: September to March
- Tropics: Rainy season
- Annual Incidence
- Children: 6-8 URIs per season (higher in daycare)
- Adults: 2-4 URIs per season
- Course
- Incubation: 48-72 hours (may be as long as 7 days)
- Viral Shedding
- Peaks with symptoms
- Persists as long as 2-3 weeks
- Symptoms peak by days 3-5
- Transmission
- Aerosol transmission predominates
- Hand to hand to nose (and eye) transmission is common
- Hands are virally contaminated 60% of time
- Hand Washing with virucidal agents is effective
- Fomite transmission (e.g. toys) is inconsistent
- Etiologies
- Most Common cause: Rhinovirus (30-50%)
- No Etiology identified (35%)
- Other Common causes (20-25%)
- Coronavirus
- Parainfluenza virus
- Adenovirus
- Enterovirus
- Influenza
- Respiratory Syncytial Virus (RSV)
- Less Common causes (10-15%)
- Chlamydia pneumoniae
- Mycoplasma pneumoniae
- Group A Streptococcal Pharyngitis
- Rare Causes
- Mumps
- Rubella
- Rubeola
- Cytomegalovirus (CMV)
- Differential Diagnosis
- Purulent Nasal Discharge more than 10-14 days
- Acute Sinusitis (especially if Maxillary Tooth Pain and unilateral sinus tenderness)
- Purulent cough, fever over 101, and acute debilitation
- Tracheobronchitis
- Pneumonia
- Influenza
- Laryngitis and non-productive cough more than 2 weeks
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Raspy cough
- Pertussis (increasing Incidence in U.S.)
- Dysphagia, Drooling, Stridor and high fever
- Epiglottitis
- Symptoms
- Nasal symptoms (precede other symptoms by 1-2 days)
- Sneezing
- Nasal congestion or stuffiness
- Nasal Discharge increased
- Sore Throat: mild "scratchy" Sensation
- Eye burning and eye tearing
- Dry, non-productive cough (40-60% of patients)
- Begins on days 2-3 and may persist for 7-10 days
- Generalized symptoms
- Malaise (mild)
- Muscle aches
- Low grade fever
- Less common symptoms
- Hoarseness
- Headache
- Chills
- Signs
- Low-grade fever less than 101 F (38.5 C)
- Nose
- Clear Nasal Discharge
- Red, swollen nasal mucosa
- Throat with mild erythema
- Complications (1-2%; higher risk in smoke exposure)
- Bacterial Sinusitis
- Acute Otitis Media
- Bacterial Bronchitis
- Pneumonitis
- Bacterial Pneumonia
- Management
- General
- Cold Preparations do not change course
- No study shows shortened symptom course
- No study shows reduced secondary complications
- Antibiotics not indicated
- Consider discussing contingency plans
- Lays out plan for when antibiotics indicated
- Eliminates pressure for antibiotic prescription
- Example
- If symptoms persist beyond 14 days then...
- Antibiotics indicated for Acute Sinusitis
- Consider Delayed Antibiotic Prescription
- Patient calls, picks up, or fills a prescription after a set time of persistent symptoms
- Reduces antibiotic use by 40%
- Little (2014) BMJ 348:g1606 [PubMed]
- Reference
- Mangione (2001) Arch Pediatr Adolesc Med 155:800 [PubMed]
- Avoid cough and Cold Preparations under age 4 years
- Cough and Cold Preparations top the list of toxic ingestions in this age group
- Leads to emergency visits, hospitalizations, and deaths
- FDA recommends not using cough and Cold Preparations under age 2 years
- Symptomatic therapy
- See Sore Throat symptomatic management
- Muscle aches, fever, chills
- Acetaminophen (do not exceed maximum dose)
- Ibuprofen (avoid in Dehydration)
- Hydration
- Maintain adequate hydration
- Avoid over-hydration in children due to risk of Hyponatremia
- Nasal symptoms
- Nasal Saline
- First-line, preferred, safe and effective Decongestant
- Decongestants reduce nasal congestion and discharge
- Topical Decongestants (e.g Afrin) for no more than 3 days (Rhinitis Medicamentosa risk)
- Avoid afrin (Oxymetazoline) in children ("One Pill Can Kill")
- Risk of central alpha-2 agonist, Clonidine-like CNS depression
- Neo-Synephrine (Intranasal Phenylephrine) is preferred nasal Decongestant in children
- Oral Decongestants (e.g. Sudafed, Entex)
- Not routinely recommended (systemic effects including Blood Pressure increase)
- Pseudoephedrine (Sudafed) may offer benefit in some patients
- Phenylephrine orally (Sudafed PE) is ineffective due to reduced absorption
- Antihistamines are not effective in acute URI
- May also predispose to Acute Sinusitis complication (due to osteomeatal complex plugging)
- May be considered in combination with Decongestant if concurrent allergic symptoms
- Vaseline at opening of nares may reduce mucosal irritation and fissures
- Exercise caution in insertion to prevent aspiration
- Cool Mist Humidifier may loosen discharge (however, no evidence)
- Avoid warm mist humidifiers due to low efficacy and burn risk
- Cough
- Intranasal Ipratropium (intranasal Atrovent)
- May reduce persistent cough following URI (based on one small study)
- Holmes (2019) Respir Med 86(5): 425-9 [PubMed]
- Cough Suppressants (e.g. Dextromethorphan, Tessalon)
- No Cough Suppressant (including Codeine, Dextromethorphan) has been found effective for URI
- Avoid use overall as these are ineffective, and have adverse effects and abuse potential
- If used, limit use (e.g. cough interfering with sleep)
- Unsuppressed cough may prevent complications
- Codeine has found no more effective than Placebo in Cough Suppression
- Cough Expectorants
- Guaifenesin paradoxically may reduce cough in URI (variable efficacy)
- Dicpinigaitis (2003) Chest 124:2178-81 [PubMed]
- Wheezing with reactive airway disease (RAD) exacerbation
- Consider high dose Inhaled Corticosteroids (especially in children)
- However, Intranasal Corticosteroids are NOT effective in the Common Cold
- Budesonide (Pulmicort) MDI or nebulizer
- Beclomethasone MDI
- Alternative Medicine therapies that may be effective
- Adults
- Andrographis paniculata (Kalmcold) 200 mg daily for 5 days
- Hu (2018) PLOS ONE 13(11): e0207713 [PubMed]
- Zinc acetate or gluconate lozenges used during symptomatic URI period
- Children (use with caution especially under age 4 years)
- Honey once (do not use under age 1 year old, Infantile Botulism risk)
- Honey 2.5 ml (age 2-5 years), 5 ml (age 6-11 years) or 10 ml (age 12-18 years) once
- Zinc acetate or gluconate lozenges used during symptomatic URI period
- Vapor rub (camphor, Menthol, eucalyptus) once
- Management: Ineffective measures (avoid)
- Antibiotics
- Spurling (2017) Cochrane Database Syst Rev (9):CD004417 [PubMed]
- Kenealy (2013) Cochrane Database Syst Rev (6): CD00247 [PubMed]
- Antihistamines
- Antivirals
- Cough Suppressants (including Dextromethorphan and Codeine, see above)
- Freestone (1997) J Pharm Pharmacol 49(10): 1045-9 [PubMed]
- Echinacea
- Echinacea purpurea previously recommended 20 drops three times daily for 10 days)
- Karsch-Volk (2014) (2):CD000530 [PubMed]
- Intranasal Corticosteroids
- Hayward (2015) Cochrane Database Syst Rev (10): CD008116 [PubMed]
- Pelargonium sidoides (geranium extract, Umcka Coldcare)
- Previously recommended 30 drops (or based on age in children) three times daily for 10 days
- Timmer (2013) Cochrane Database Syst Rev (10): CD006323 [PubMed]
- Steam vaporizer
- Singh (2017) Cochrane Database Syst Rev (8): CD001728 [PubMed]
- Vitamin C
- Hemila (2013) Cochrane Database Syst Rev (1): CD000980 [PubMed]
- Vitamin D
- Murdoch (2012) JAMA 308(13): 1333-39 [PubMed]
- Vitamin E
- Graat (2002) JAMA 288(6): 715-21 [PubMed]
- Prevention
- Frequent Hand Washing or hand sanitizer to prevent spread of infection
- Single most effective strategy
- Probiotic milk (with live culture lactobacillus)
- May reduce respiratory infections in children age <7
- Hatakka (2001) BMJ 322:1-5 [PubMed]
- References
- DeGeorge (2019) Am Fam Physician 100(5):281-9 [PubMed]
- Clemens (1997) J Pediatr 130:463-6 [PubMed]
- Fashner (2012) Am Fam Physician 86(2): 153-9 [PubMed]