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Upper Respiratory Infection

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

  • 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
  • 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
  • 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)
  • Differential Diagnosis
  1. Purulent Nasal discharge more than 10-14 days (especially if Maxillary Tooth Pain and unilateral sinus tenderness)
    1. Acute Sinusitis
  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
  • 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
  • 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
  • Complications (1-2%; higher risk in smoke exposure)
  • 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. Cough and Cold Preparations top the list of toxic ingestions in this age group
      2. Leads to emergency visits, hospitalizations, and deaths
      3. FDA recommends not using cough and Cold Preparations under age 2 years
  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
          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 the 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 predispose to Acute Sinusitis complication (due to osteomeatal complex plugging)
      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 loosens discharge
        1. Avoid warm mist humidifiers due to burn risk
    5. Cough
      1. Cough Suppressants (e.g. Dextromethorphan, Tessalon)
        1. Limit use (e.g. cough interfering with sleep)
        2. Unsuppressed cough may prevent complications
        3. Codeine has found no more effective than Placebo in cough suppression
      2. Cough Expectorants
        1. Guaifenesin paradoxically reduces cough in URI
        2. Dicpinigaitis (2003) Chest 124:2178-81 [PubMed]
    6. Wheezing with reactive airway exacerbation
      1. Consider high dose Inhaled Corticosteroids (especially in children)
        1. Budesonide (Pulmicort) MDI or nebulizer
        2. Beclomethasone MDI
  3. Alternative Medicine therapies that may be effective
    1. Adults
      1. Andrographis paniculata (Kalmcold) 200 mg daily for 5 days
      2. Echinacea purpurea 20 drops three times daily for 10 days
      3. Pelargonium sidoides (geranium extract, Umcka Coldcare) 30 drops three times daily for 10 days
      4. Zinc acetate or gluconate lozenges used during symptomatic URI period
    2. Children (use with caution especially under age 4 years)
      1. Honey or buckwheat once (do not use under age 1 year old)
      2. Pelargonium sidoides (geranium extract, Umcka Coldcare) dose based on age three times daily for 7 days
      3. Zinc acetate or gluconate lozenges used during symptomatic URI period
      4. Vapor rub once
  • Prevention
  1. Frequent hand washing 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]