Upper Respiratory Infection

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Objectives

Upon finishing this module, the student will be able to:

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.

Contributors

Update Author: Jamie Nong, MD.

Original Author: John M. Cox, MD.

Update Editor: Steven Lindsey, MD.

Original Editor: S. Margaret Paik, MD.

Last Updated: 2024

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. Children on average experience six-nine URIs per year. Hundreds of different types of viruses cause inflammation of the membranes in the lining of the nose and throat.

Case Study

A seven-year-old male presents to the emergency department (ED) with two days of cough, congestion, and intermittent fevers. He has had worsening cough but no difficulty breathing. He continues to drink well but his appetite is decreased. The patient is well-appearing on exam, with notable congestion and a dry, intermittent cough. His lungs are clear and he has a normal cardiac exam. Vitals: T 38.2 C, HR 92, RR 28, O2 saturation 98% in room air.

Initial Actions and Primary Survey

As with all initial assessments in the ED, attention should be paid to the patient’s vital signs including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation. Special attention should be given to neonates, as they are obligate nose breathers and may be at greater risk for respiratory distress. The ED 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 URIs are easily transmitted through sneezing, coughing, or nose blowing. Typical signs and symptoms of URI include rhinorrhea, nasal obstruction, and congestion. Systemic symptoms and signs such as headache, myalgias, and fever may be absent or present with mild symptoms.

Many viruses that cause rhinitis may also produce cough, sore throat, 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 post-nasal drip). Commonly-encountered pathogens in URI and their symptoms include:

Human Rhinoviruses: Cough, congestion, sneezing.
Coronaviruses: Runny nose, cough.
Respiratory Syncytial Viruses: Bronchiolitis under two years old.
Human Metapneumovirus: Pneumonia, bronchiolitis.
Influenza Viruses: Myalgias, malaise, headaches.
Parainfluenza Viruses: Croup, bronchiolitis.
Adenoviruses: Palpebral conjunctivitis, eye discharge, pharyngeal erythema.
Enteroviruses: Herpangina, aseptic meningitis.

Children are most likely to have URIs during the fall and winter. The increased incidence of URIs during the cold season may be attributed to the fact that more children are indoors and in close contact. Additionally, the humidity drops during this season, making the nasal passages drier and more vulnerable to infection. Young children have an average of six-nine URIs per year, but 10-15% of children have at least 12 infections per year. The incidence decreases with age, with two-four illnesses per year by adolescence.

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 daycare attendance are risk factors associated with a higher incidence of AOM.

Sinusitis is also a complication of URIs. Differentiating the common cold from bacterial sinusitis can be difficult, but generally distinguished based on duration of symptoms. 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 develop.

Other complications of URI include pneumonia, bronchiolitis, croup, and asthma or reactive airway exacerbations. When evaluating a child with potential URI, many historical and exam features can help point to alternative diagnoses.

Differential Diagnosis

The differential diagnosis of URIs and their unique features include:

Sinusitis: 14 days nasal discharge, cough, fevers, facial pain.
Pneumonia: Worsening cough, fevers over 101F, upper abdominal pain.
Allergic Rhinitis: Itching, sneezing.
Rhinitis Medicamentosa: History of nasal decongestant use.
Pertussis: Paroxysmal coughing fits, vomiting with cough.
Foreign Body: Unilateral foul-smelling discharge/secretions.
Epiglottitis: Dysphagia, drooling, stridor, high fever (especially in a previously unimmunized child).

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, although these studies are generally not indicated nor recommended in most patients.

If streptococcal pharyngitis and Bordetella pertussis is suspected clinically, especially if there is a history of exposure, bacterial cultures or antigen detection is indicated with appropriate antibiotics for positive results.

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.
In children over one year of age, honey (5-10 mL) can be a useful treatment for symptomatic cough. Honey should be avoided in children younger than one year of age because of the risk for botulism. The use of a cool mist humidifier is also recommended for nocturnal cough. Antipyretics can be used as indicated for associated discomfort and fevers.
Inhaled corticosteroids and oral steroids are ineffective when given to children without asthma or reactive airway disease. Cough in patients with URI can also be due to postnasal drip. Some providers will use a first-generation antihistamine (anticholinergic properties) but should be used with caution in the very young child. It should be noted that second-generation “nonsedating” antihistamines have no effect on an URI. Codeine, dextromethorphan, and expectorants such as guaifenesin are not effective antitussive agents. Along with being ineffective, these antitussives can lead to respiratory depression in young children and are associated with misuse and addiction in adolescents.
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, as 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 three consecutive days.
Zinc, given as oral lozenges to previously healthy patients, reduces the duration but not the severity of symptoms of URIs 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 URIs.

Pearls and Pitfalls

Case Study Resolution

References

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