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Subject: Upper Respiratory Infection (URI)
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Inflammation of nasal passages resulting from infection with respiratory viruses
Most cases are mild to moderate in severity, self-limited, and amenable to self-treat.
System(s) affected: ENT; pulmonary
Each virus has different seasonal peaks (e.g., rhinovirus: late spring, fall); most infections occur during the winter months.
Symptoms usually peak in 1 to 3 days and can last up to 2 weeks.
Contact with contaminated skin/surface followed by contact with mucous membranes (hand-to-face contact)
Aerosolized particles from sneezing and coughing
Viruses may last up to 2 hours on skin and even longer on environmental surfaces.
Predominant age: children > adults
Preschool children: 5 to 7 URI/year
Kindergarten: 12 URI/year
Schoolchildren: 7 URI/year
Adolescents/adults: 2 to 3 URI/year
Predominant sex: male = female
Histology: edema of subepithelial connective tissue and a scanty cellular infiltrate containing neutrophils, plasma cells, lymphocytes, and eosinophils with exudation of serous and mucinous fluid
Rhinovirus causes a “nondestructive” inflammation of the mucous membranes.
Influenza and parainfluenza viruses denude respiratory epithelium to the basement membrane.
Several hundred viral strains from different families; spread within geographic region and groups with close contact
Rhinovirus (>100 serotypes): 30–50%; incubation period 1 to 5 days
Influenza virus types A, B, C: 10–15%; incubation period 1 to 4 days
Parainfluenza, respiratory syncytial virus (RSV): 5%; more common in children; incubation period 1 week
Enteroviruses, adenoviruses: <10%
In many cases, no specific pathogen is identified.
Exposure to infected people
Touching one’s face with contaminated fingers
Frequent hand washing, especially in children
Limiting exposure to infected persons/children
Nasal congestion: 80–100%
Throat irritation: 50%
Fever >100°F (37.7°C): 0–1%
Low-grade temperature; mild tachycardia common with fever; tachypnea if significant respiratory involvement
Rhinorrhea (clear, yellow, or green)
Mucosal edema and/or inflammation
Dull tympanic membranes
No routine lab testing is typically needed, as diagnosis is based on clinical findings.
In cases of pharyngitis, rapid streptococcal antigen testing with reflex culture can be used to rule out group A streptococcal infection if clinically suspected.
Rapid influenza antigen testing if influenza is suspected.
Heterophile antibody testing if infectious mononucleosis is suspected.
Imaging not routinely indicated
Patients should consider contacting a physician’s office for fever >101°F associated with systemic symptoms, difficulty breathing, or purulent drainage >2 days.
Use of procalcitonin as a guide for directing antibiotic therapy has been increasing in the outpatient and inpatient settings. It has been associated with reduced antibiotic consumption and may help in differentiating between acute viral URI and other bacterial respiratory infections (1).
Vaporizer/humidifier: no consistent benefit proven
Cold preparations do not change course
Antibiotics not indicated
Avoid cough and cold preparations in children under 2 years of age.
Saline nasal irrigation is safe for adults and children.
Antibiotics are not recommended. They produce minimal to no reduction in symptoms or duration, with greater risk of side effects from usage (2)[A].
Analgesics: acetaminophen, and NSAIDs for relieving aches and pains associated with URI
Zinc Acetate lozenges every 3 hours started in first 24 hours of illness may shorten course of illness by over 24 hours
Many mouthwashes, gargles, and lozenges are promoted to relieve the pain of sore throat. The demulcent effects of hard candy, gargling with warm saline, and products with anesthetics (benzocaine/phenol) may provide pain relief.
Aromatic oils (menthol, camphor, eucalyptus), produce a sensation of increased airflow without a significant change in airflow resistance.
Topical decongestants (sympathomimetics) reduce nasal mucosa swelling and airflow resistance, promote drainage. Sprays preferred over drops in patients >6 years of age:
Limit use to 3 days, as rebound congestion may occur after 72 hours of use with resultant rhinitis medicamentosa.
Adults and children aged 6 to 12 years: 0.05% solution, 2 to 3 sprays in each nostril BID
Oral decongestants (sympathomimetic) have some advantages over topical decongestants: longer duration of action, lack of local irritation, and no risk of rebound congestion.
Pseudoephedrine: potential for abuse/misuse or diversion for methamphetamine production
Use with caution for patients with cardiovascular disease, HTN, and BPH:
Adults: 60 mg q4–6h (120 mg sustained-release q12h) superior to placebo in short-term use
Children aged 6 to 12 years: 30 mg q4 to 6h; 2 to 5 years: 15 mg q4 to 6h
Acute cough, postnasal drip, and throat clearing associated with the common cold can be treated with a 1st-generation antihistamine/decongestant preparation (brompheniramine and sustained-release pseudoephedrine).
Antihistamines: minimal benefit when used as monotherapy. Only 1st-generation (sedating) antihistamines show any symptomatic relief, but sedation may be worse than relief:
Adults: 4 mg QID, 8 mg TID, 12 mg BID
Children age 6 to 12 years: 2 mg q4–6h
Children age 2 to 5 years: 1 mg q4–6h
Adults: 25 to 50 mg q4–6h PRN
Children age 6 to 12 years 12.5 to 25 mg q4–6h PRN
Children age 2 to 6 years: 6.25 mg q4–6h PRN
In 2007, the FDA issued a warning to limit use of all cough/cold preparations for children age ≤2 years (3)[A].
Zinc prevents viral replication in vitro:
Avoid intranasal preparations of zinc: risk of potential permanent loss of smell (4)
Has shown moderate benefit in reducing symptoms and duration, but proper dosing has not been determined
Best if taken with 24 hours of onset of symptoms
Echinacea has not proven consistently effective for treatment of common cold symptoms (5)[C].
Probiotics may decrease severity and duration of URIs and possibly reduce episodes (6)[B].
Vitamin C (ascorbic acid) (7)[C]
Regular supplementation trials have shown that vitamin C may reduce the duration of colds.
Vitamin C prophylaxis not recommended for general use but may be beneficial in those exposed to severe physical exertion and cold environments.
Cold medications, especially decongestants and antihistamines, commonly produce adverse effects in older patients and should not be used routinely.
Decongestants: Most are Category B or C.
Antihistamines: Most are Category B or C.
Discuss the difference between viral and bacterial infections; instruct about appropriate antibiotic use.
Good hand hygiene
Symptomatic treatment; no cure
Reinfection is possible with reexposure.
Patient information: www.niaid.nih.gov/factsheets/cold.htm
Excellent; expect full recovery. Usual duration 5 to 7 days but may last up to 2 weeks; for smokers, 3 to 4 additional days
Cough may persist after other symptoms have resolved.
J06.9 Acute upper respiratory infection, unspecified
J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations
B97.4 Respiratory syncytial virus causing diseases classd elswhr
465.9 Acute upper respiratory infections of unspecified site
465.8 Acute upper respiratory infections of other multiple sites
487.1 Influenza with other respiratory manifestations
079.6 Respiratory syncytial virus (RSV)
54150009 upper respiratory infection (disorder)
43692000 Influenzal acute upper respiratory infection
281794004 Viral upper respiratory tract infection (disorder)
55735004 Respiratory syncytial virus infection (disorder)
Supportive therapy is mainstay for most upper respiratory tract infections.
Point of care testing can rule out group A Streptococcus infection in the appropriate clinical setting.
Limit unnecessary use of antibiotics.
URI symptoms last 3 to 4 days longer in smokers.