Today, I review, link to, and excerpt from The Curbsiders‘ #457 Cold and Flu Season: Upper Respiratory Infections.*
*Witt L, Heublein M, Bird A, Williams PN, Watto MF. “#457 Cold and Flu Season”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast October 14, 2024.
All that follows is from the above resource.
Transcript available via YouTube
Treating colds, flu, and more with Dr Amber Bird!
Dive deep into upper respiratory viral infections with Dr Amber Bird, MD (Penn).
Feel confident on when to order testing, recommend symptom relieving treatments, and avoid unnecessary antibiotics.
Show Segments
- 00:00 Introduction and Setting the Agenda
- 03:07 Getting to Know the Guest and Rapid Fire Questions
- 05:51 Case from Kashlak: Mateo with Common Cold Symptoms
- 06:12 Defining and Diagnosing the Common Cold
- 09:08 Approach to History and Physical Exam
- 13:23 Viral Respiratory Testing and Its Indications
- 17:36 Symptomatic Treatment Options for the Common Cold
- 24:25 Managing Cough and Nasal Congestion
- 35:03 Home Remedies and natural products
- 42:16 Prescribing Antivirals for Influenza
- 46:33 Antibiotics and Counseling Patients
- 52:07 Contagiousness and Risk to Family Members
- 54:52 Recurring Colds and Risk Factors
- 59:38 Vaccination recommendations
- 01:01:23 Key Takeaways and Conclusion
Upper Respiratory Infections Pearls
- Colds/viral upper respiratory infections are generally benign, common, self-limited illnesses.
- Feel comfortable making recommendations for symptomatic treatments based on the patient’s most bothersome symptoms. For nasal congestion/rhinorrhea, consider nasal spray decongestants or oral pseudoephedrine +/- non-sedating antihistamines. For cough, consider dextromethorphan, guaifenesin, or benzonatate.
- Avoid unnecessary antibiotics in patients without warning features. If a patient has abnormal vital signs, persistent fevers, severe/worsening cold symptoms for more than 7 days, or underlying serious illness evaluate them carefully to not miss bacterial infections.
- Thoughtful counseling as to why you feel the patient has a viral illness and why antibiotics would not be helpful, plus anticipatory guidance on what to expect for symptom duration and when to call back can help avoid unnecessary prescriptions.
Upper Respiratory Infections – Notes
Definitions: The common cold/Viral URIs
The common cold is basically synonymous with a viral upper respiratory infection. Rhinovirus or non-covid coronavirus are most common, although any number of viruses can cause cold symptoms- RSV, influenza, parainfluenza, enterovirus, adenovirus, etc. The hallmark of a cold is that it is usually a benign self-limited infection that is not bacterial (Mäkelä 1998)
History and Physical Exam:
Since colds are so common, Dr. Bird reminds us not to anchor right away on this diagnosis when someone comes in with typical symptoms of rhinorrhea, sore throat, congestion, cough, headache, and/or low grade fever.
Keep an eye out for atypical features, like severe symptoms lasting more than 5-7 days, predominantly constitutional symptoms, or persistent fever. Lower respiratory symptoms would also be atypical for a common cold– dyspnea, shortness of breath, wheezing are suggestive of a more severe infection or lower track involvement. Keep in mind if your patient is at higher risk of severe infections–ie those with older age, chronic underlying lung disease like COPD or bronchiectasis, cardiac disease like heart failure, pregnancy, immunosuppression, or ESRD. Higher risk patients should be more carefully evaluated as they may be at risk for more severe symptoms or complications.
You may not see these patients in-office and might be providing care asynchronously by patient portal message! If you have to go back and forth by message more than two times– Dr. Bird recommends either a phone call or visit to investigate the symptoms. If you do get them on the phone, Dr Bird recommends listening to the cadence of the patient’s speech or their ability to complete full sentences can help you get a sense of if they’re having trouble breathing.
If you are seeing a patient in the office, vitals are key. In a patient with normal vital signs, ie normal temperature, normal respiratory rate, and normal heart rate, the likelihood that they have a more concerning severe infection is really low. The sensitivity of all three of them being normal is 89% for ruling out a more serious lower respiratory/bacterial infection (Marchello 2019). Dr Bird also recommends examining a patient’s nose, throat, and lungs.
Viral Respiratory Testing
Testing options depend on local variation, but many places offer a “complete respiratory viral panel” (more typically used for inpatients) and seasonal respiratory panels (these typically test for influenza, COVID, and RSV). Respiratory viral testing is suggested if it will influence management. So, if we’re considering infections like influenza or covid, think about if the patient is within a window where you may offer antiviral treatment or make specific recommendations about isolation based on the results. Dr Bird may extend testing beyond the standard window to patients who are high risk for whom she may prescribe antivirals beyond the FDA approved timeline.
Treatments: Symptom Relief
Dr Bird highlights that many of our over the counter (and prescription) options have limited data on efficacy, and the benefits will vary from patient to patient. She suggests focusing on the patient’s most bothersome symptom and catering treatment to that.
For congestion and rhinorrhea:
Short term use of Nasal spray decongestants, like oxymetazoline are an appropriate option for patients who don’t mind nasal sprays (DeGeorge 2019). Remember to coach about correct nasal spray use (“if you taste it you waste it”– check out #447 Rhinitis and Environmental Allergies for good nasal spray technique tips from Dr. Fadguba).
Oral decongestants, like pseudoephedrine +/- a non-sedating antihistamine, like cetirizine. The number needed to treat is approximately 4 for symptom benefit (Sutter 2022).
Any kind of nasal spray- nasal steroids like fluticasone, saline nasal sprays, or nasal lavage all offer some benefit in reduction of rhinorrhea. Data is mixed for these, but some studies show a 1-1.5 day reduction in symptoms (Little 2024).
And a brief reminder, oral phenylephrine is not effective for congestion/rhinorrhea, as was covered on Hotcakes #424 (FDA 2023), though phenylephrine may have a role in nasal sprays.
For cough:
