Upper Respiratory Infection

• Describe the symptoms associated with an upper respiratory infection
• Discuss the signs and symptoms of diagnoses that are often complications of upper respiratory infections
• Understand the limited role of diagnostic testing for patients with upper respiratory infections
• List the treatment options for patients with upper respiratory infections
  

Introduction

An upper respiratory infection (URI), also known as the common cold, is one of the most common illnesses, leading to more health care provider visits and absences from school and work than any other illness every year.  Hundreds of different types of viruses cause inflammation of the membranes in the lining of the nose and throat.   Greater than 50% of URI are caused by viruses from the rhinovirus family.

Initial Actions and Primary Survey

As with all initial assessments in the emergency department, attention should be paid to the patient’s vital signs including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation (if obtained).  Neonates are obligate nose breathers and may be at greater risk for respiratory distress.  The emergency department practitioner should also carefully auscultate the lungs for adequate aeration and assess the quality of breathing.  Certain viruses, such as respiratory syncytial virus, put a neonate at greater risk of apnea.  The cardiovascular examination should include assessing for adequate distal perfusion and an appropriate-for-age heart rate.  Finally, dehydration can be a complication of any viral illness and therefore, an assessment of hydration (capillary refill, skin turgor, mucous membranes, heart rate, responsiveness) should be a part of the initial evaluation.

Presentation

Viruses that cause URI are easily transmitted through sneezing, coughing, or nose blowing.  Signs and symptoms of URI are rhinorrhea, nasal obstruction, and congestion.  Systemic symptoms and signs such as headache, myalgias, and fever are may be absent or present with mild symptoms.

Many viruses that cause rhinitis are also associated with other symptoms and signs such as cough, wheezing, and fever.  The normal immune response to a virus will produce an increase in mucus production (rhinorrhea), swelling of the nasal mucosa (congestion), sneezing (due to irritation of the nose), and cough (due to increased mucus dripping down the throat).

Table 1:  Selected Pathogens and Associated Symptoms

Children are most likely to have URI during the fall and winter, starting in late August or early September until March or April.  The increased incidence of URI’s during the cold season may be attributed to the fact that more children are indoors and in close contact to each other.  Additionally, the humidity drops during this season, making the nasal passages drier and more vulnerable to infection.

Young children have an average of 6-8 URI per year, but 10-15% of children have at least 12 infections per year.  The incidence decreases with age, with 2-3 illnesses per year by adulthood.

Complications

The most common complication of URI is acute otitis media (AOM).  Symptoms of AOM may include new-onset fever and earache after the first few days of the onset of URI symptoms.  AOM has been reported in 5-30% of children with URI.  Younger age and children in daycare are risk factors associated with a higher incidence.

Sinusitis is also a complication of URI’s.  Differentiating the common cold from bacterial sinusitis can be difficult.  The diagnosis of bacterial sinusitis should be considered if rhinorrhea or daytime cough persists without improvement for at least 10-14 days especially if fever, facial pain, or facial swelling develops.

Diagnostic Testing

Routine laboratory studies are not helpful for the diagnosis and management of URI.  The viral pathogens associated with URI can be detected by polymerase chain reaction (PCR), culture, antigen detection, or serologic methods.  These studies are generally not indicated in the majority of patients.

Streptococcal pharyngitis and Bordetella pertussis can be suspected in some patients, especially if there is a history of exposure.  Bacterial cultures or antigen detection is indicated with appropriate antibiotics for positive results.

An important task of the physician caring for a child with an URI is to exclude other conditions that are potentially more serious and/or treatable.  The differential diagnosis of an URI is listed below.

Table 2:  Differential Diagnosis of Upper Respiratory Infections

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Treatment

Antibiotics are ineffective and not indicated to treat URI.  Antibiotic overuse in children has become a common problem and bacterial antibiotic resistance is increasing.

Inhaled corticosteroids and oral steroids are also ineffective when given to children without asthma.  Cough in patients with URI can be due to postnasal drip.  Some providers will use a first-generation antihistamine (anticholinergic properties) but should be used with caution the very young child.  It should be noted that second-generation “nonsedating” antihistamines have no effect on an URI.  Honey (5-10mL in children >1 year old) has a mild effect on relieving nocturnal cough and is unlikely to be harmful.  Honey should be avoided in children younger than 1 year of age because of the risk for botulism.  Codeine, dextromethorphan, and expectorants such as guaifenesin are not effective antitussive agents.

Treatment is based on symptomatic relief and supportive care.  Options for relief of nasal obstruction begin with saline nose drops.  Saline (used as drops or as a spray) can help to thin nasal secretions and improve nasal breathing.  Adrenergic agents such as xylometazoline, oxymetazoline, or phenylephrine are available as drops or sprays and may be used in the older child (> 12 years).  These should be used with caution.  Prolonged use can result in the development of rhinitis medicamentosa, a type of rebound effect that causes the sensation of nasal obstruction when the drug is discontinued.  Generally, it is not recommended for use longer than 3 consecutive days.

Zinc, given as oral lozenges to previously healthy patients, reduces the duration but not the severity of symptoms of URI’s if begun within 24 hours of symptoms.  However, the effect of zinc on symptoms has been inconsistent to date.

Vitamin C and Echinacea, an herbal treatment, are no more effective than placebo for the treatment of URI’s.

Pearls and Pitfalls

• The majority of URI’s are caused by the rhinovirus family
• Younger children have more URI’s than older children and adults
• Acute otitis media and sinusitis are known complications of URI
• There is a limited role for diagnostic testing in the setting of an URI
• Treatment options are limited, supportive, and focus on controlling symptoms
  

References

1. Ballengee, Cortney R., and Ronald B. Turner. “Supportive treatment for children with the common cold.” Current opinion in pediatrics 26.1 (2014): 114-118.
2. Bell, Edward A., and David E. Tunkel. “Article Commentary: Over-the-counter cough and cold medications in children: Are they helpful?.”Otolaryngology–Head and Neck Surgery 142.5 (2010): 647-650.
3. Carr, Brandon C. “Efficacy, abuse, and toxicity of over-the-counter cough and cold medicines in the pediatric population.” Current opinion in pediatrics18.2 (2006): 184-188.
4. Cohen, Herman Avner, et al. “Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study.” Pediatrics130.3 (2012): 465-471.
5. Das, Rashmi Ranjan, and Meenu Singh. “Oral zinc for the common cold.”JAMA 311.14 (2014): 1440-1441.
6. Fashner, Julia, Kevin Ericson, and Sarah Werner. “Treatment of the common cold in children and adults.” American family physician 86.2 (2012): 153.
7. Karsch-Völk, Marlies, Bruce Barrett, and Klaus Linde. “Echinacea for preventing and treating the common cold.” JAMA 313.6 (2015): 618-619.
8. Kliegman, Robert M., et al. Nelson textbook of pediatrics. Elsevier Health Sciences, 2016.
9. Pappas, Diane E., et al. “Symptom profile of common colds in school-aged children.” The Pediatric infectious disease journal 27.1 (2008): 8-11.
10. Thompson, Matthew, et al. “Duration of symptoms of respiratory tract infections in children: systematic review.” BMJ 347 (2013): f7027.
11. World Health Organization. “Cough and cold remedies for the treatment of acute respiratory infections in young children.” (2001).  Available at: http://www.who.int/maternal_child_adolescent/documents/fch_cah_01_02/en/