As the colder months approach, the common cold and flu become prevalent, causing discomfort and concern for many. Understanding how to effectively manage these upper respiratory viral infections (URIs) is crucial for both patients and healthcare providers. This article delves into the nuances of diagnosing, treating, and counseling patients during cold and flu season, drawing upon expert advice to provide clarity and confidence in managing these common ailments.
Defining and Diagnosing the Common Cold
The common cold is essentially synonymous with a viral upper respiratory infection. While rhinoviruses and non-COVID coronaviruses are the most frequent culprits, a variety of viruses, including RSV, influenza, parainfluenza, enterovirus, and adenovirus, can cause cold symptoms. The hallmark of a cold is its typically benign and self-limited nature, meaning it is not a bacterial infection and will resolve on its own.
When a patient presents with typical URI symptoms—such as rhinorrhea, sore throat, congestion, cough, headache, and/or a low-grade fever—it’s important not to immediately anchor on the diagnosis of a common cold. Clinicians should remain vigilant for atypical features that might indicate a more serious condition. These include severe symptoms persisting for more than 5-7 days, predominantly constitutional symptoms, or a persistent fever. Lower respiratory symptoms like dyspnea or wheezing are also atypical for a common cold and may suggest more severe infection or lower airway involvement. Particular attention should be paid to high-risk patients, including the elderly, those with chronic lung disease (like COPD or bronchiectasis), cardiac disease (such as heart failure), pregnant individuals, the immunocompromised, or those with end-stage renal disease, as they may be at greater risk for severe symptoms or complications.
For patients seeking care asynchronously via message, Dr. Bird recommends that if more than two message exchanges are needed to clarify symptoms, a phone call or in-person visit should be considered. During a phone consultation, listening to the patient’s speech cadence and their ability to complete full sentences can provide clues about their respiratory status.
In-office, vital signs are paramount. If a patient presents with normal vital signs—including temperature, respiratory rate, and heart rate—the likelihood of a more concerning, severe infection is low. The sensitivity of all three being normal is approximately 89% for ruling out a more serious lower respiratory or bacterial infection. A thorough physical examination of the patient’s nose, throat, and lungs is also recommended.
Viral Respiratory Testing and Its Indications
The decision to perform viral respiratory testing depends on local availability and whether the results will influence management. Many facilities offer comprehensive respiratory viral panels, though these are more commonly used in inpatient settings. Seasonal panels typically test for influenza, COVID-19, and RSV.
Respiratory viral testing is advisable if it can guide treatment decisions. For instance, if influenza or COVID-19 is suspected, testing can determine if a patient is within the window for antiviral treatment or if specific isolation recommendations are necessary. Dr. Bird may consider extending testing beyond the standard window for high-risk patients for whom she might prescribe antivirals outside the typical FDA-approved timeline.
Symptomatic Treatment Options for the Common Cold
Dr. Bird emphasizes that many over-the-counter and prescription medications have limited data on efficacy, and their benefits can vary significantly among patients. The key is to focus on the patient’s most bothersome symptom and tailor the treatment accordingly.
For Congestion and Rhinorrhea
- Nasal Spray Decongestants: Short-term use of nasal spray decongestants, such as oxymetazoline, can be an appropriate option for patients who tolerate nasal sprays. It’s important to coach patients on correct usage to maximize effectiveness.
- Oral Decongestants: Pseudoephedrine, often combined with a non-sedating antihistamine like cetirizine, can provide symptom relief. The number needed to treat for symptom benefit is approximately four.
- Nasal Steroids, Saline Sprays, and Nasal Lavage: These interventions can offer some benefit in reducing rhinorrhea. While data is mixed, some studies indicate a reduction in symptoms by 1-1.5 days. It’s important to note that oral phenylephrine is generally not effective for congestion and rhinorrhea, although phenylephrine may have a role in nasal sprays.
For Cough
Cough can be a persistent and disruptive symptom of URIs, often lasting for weeks after other symptoms have resolved. It’s crucial to remind patients that cough is a protective mechanism and may not always need to be completely suppressed.
- Dextromethorphan: This centrally acting cough suppressant is Dr. Bird’s preferred choice for adults, despite limited data on its robust benefits.
- Guaifenesin: While marketed as an expectorant, the evidence supporting its significant beneficial effect is not strong. However, some research suggests that a combination of guaifenesin and benzonatate may be more effective at suppressing cough than either agent alone or placebo.
- Benzonatate: This topical anesthetic acts on respiratory stretch receptors. While data on its benefit is limited, it can offer a sense of empowerment for clinicians to prescribe. It is crucial to remember that benzonatate is not safe for children and can cause fatal overdose.
- Inhalers (Albuterol/Ipratropium): For patients without reactive airway disease (RAD), these inhalers are likely not helpful. However, it’s important to consider that a cold might be the first presentation of RAD or a lower lung infection like bronchitis, which could benefit from inhaler use.
For Sore Throat
- Analgesics: Nonsteroidal anti-inflammatory drugs (NSAIDs) are Dr. Bird’s first recommendation for sore throat relief. Additionally, lozenges and salt water gargles may offer some benefit for both prevention and treatment. [cite:12, cite:13]
Combination Drugs and Natural/Herbal Remedies
Dr. Bird advises against using over-the-counter combination medications, as they can increase the risk of side effects without necessarily providing added benefit. She recommends targeting specific, bothersome symptoms with individual medications. Evening-use medications often contain first-generation antihistamines, which are associated with side effects like urinary retention, cognitive impairment in the elderly, and drowsiness, making them generally best avoided.
- Honey: May help reduce cough and is considered safe. While more data exists for its use in children, it is also considered reasonable for adults.
- Green Tea: Some evidence suggests that green tea consumption may decrease the duration and severity of illness.
- Vitamin C: The strongest data for Vitamin C supports its role in preventing infection in individuals experiencing physiological stress, rather than treating an active cold. While the quality of data is not consistently high, the likelihood of harm is low. Dosing can range widely, typically from 1-6 grams per day.
- Zinc: Data on zinc is mixed, but it may shorten the duration of common cold symptoms by approximately 1.5 days. [cite:17, cite:18] Dr. Bird notes that the quality of zinc lozenges can vary, and while the maximum benefit may be seen with 100 mg per day, as little as 20 mg might be effective.
- Eucalyptus or Menthol Rubs and Lozenges: These are generally safe but have limited data supporting their benefit in adults.
Dr. Bird reminds us that the perceived efficacy of these treatments can be subjective. She encourages patients to try safe options that work best for them, given that many treatments lack strong evidence of overwhelming benefit.
Targeted Antivirals: Oseltamivir for Influenza
Dr. Bird engages in shared decision-making with patients when considering the use of oseltamivir. If a patient is interested in a medication that might reduce symptom duration by 1-1.5 days, she is comfortable prescribing it within the first 48 hours of symptoms consistent with influenza. She may also recommend it to reduce the risk of transmission, particularly for patients who are primary caregivers for high-risk family members (elderly, immunocompromised) or for healthcare workers. Oseltamivir is also recommended for high-risk populations, including pregnant women, the elderly, and individuals with underlying health conditions. For patients with severe medical conditions, such as advanced lung disease or significant immunosuppression, she might prescribe it beyond the 48-hour window, a practice that, while not FDA-approved, has some limited evidence of potential benefit. Monitoring local influenza rates through public health departments can aid in assessing influenza risk in the community.
Antibiotics and Counseling Patients
It is essential to avoid unnecessary antibiotic prescriptions for viral illnesses. However, it is equally important not to dismiss patients seeking antibiotics. Dr. Bird dedicates a significant portion of her visits to explaining why she believes an infection is viral, why antibiotics would not be helpful, and how they might even be harmful.
Anticipatory counseling is key. Dr. Bird explains to patients, “Right now, I don’t think you need antibiotics, but if your symptoms were to change—where you start to notice fevers, or you’re initially getting better and then after a few days, you’re worsening again, or you’re noticing severe pain on just one side of your face, or new shortness of breath, or a fever that you didn’t have when your symptoms started—I want you to reach back out.” These new or worsening symptoms might suggest a bacterial infection or a need for a different treatment approach. Empowering patients to reach out if their condition changes is crucial. Providing an explicit timeline can also be helpful. Dr. Bird might say, “Today is day three. I expect that you’re going to have these symptoms for at least this week. And, at the end of the week, they should be getting a little bit better. So if at the end of the week, they’re not getting better and they’re actually worsening each day, I need to hear from you.” Patients with a cold should be informed that a cough could persist for weeks. For a deeper dive into bacterial upper respiratory infections and antibiotics, refer to Curbsiders Episode #54.
Counseling Around URIs: Contagion and Isolation
Providing clear guidelines on the duration of contagiousness for the common cold can be challenging. Dr. Bird notes that the most contagious period typically begins 1-2 days before symptom onset and continues through the first few days of symptomatic illness, usually at the beginning of the infection. However, individuals can remain contagious for upwards of weeks, depending on their immune status and the specific infection.
Dr. Bird suggests that for the first two to three days, patients should practice rigorous hand hygiene, cover their coughs, and avoid sneezing on others. If a patient is around someone who is severely immunocompromised, they might consider isolating from them during this initial period. After the first few days, as long as symptoms are improving and there are no persistent fevers, it is generally considered safe to be around others while continuing to practice good hand hygiene. The CDC recommends returning to normal activities when symptoms are improving and there has been no fever for 24 hours, with the caveat to take extra precautions (like masking and hygiene) for an additional five days. The contagiousness of a virus also impacts its transmission likelihood; COVID-19 is significantly more contagious than influenza.
How Many Colds Per Year is Normal?
For the average adult, experiencing 2 to 3 colds per year is considered normal. Infants can have up to 11 colds annually, and preschool-aged children can have up to eight colds per year. For new parents with infants in daycare, where exposure to numerous viruses is common, up to 11 colds per year might be within the normal range. As individuals are exposed to viruses over time, their immune systems typically build immunity. Dr. Bird becomes concerned about frequent colds if a patient, without new risk factors like young children or new exposures, experiences numerous colds annually. In such cases, she considers underlying immunosuppressive conditions or immunodeficiency, particularly if frequent colds are accompanied by post-viral bacterial sinusitis or pneumonias.
Vaccines
Dr. Bird reassures that vaccinations can be safely administered to individuals with mild upper respiratory illnesses. Visits for mild URIs present an ideal opportunity to offer protective vaccinations against influenza or COVID-19.
Key Takeaways and Conclusion
The common cold encompasses a range of viral upper respiratory infections that are typically benign and self-limited. Management should focus on conservative, symptom-driven strategies, often involving non-prescription options. While many over-the-counter remedies and traditional approaches have limited evidence of benefit, they generally carry little risk of harm, allowing patients to try options that provide them with some relief. It is crucial to avoid the inappropriate prescription of antibiotics. Investing time in counseling patients against antibiotic use for URIs is invaluable in minimizing unnecessary antibiotic exposure and combating future antibiotic resistance.
This comprehensive approach, focusing on accurate diagnosis, targeted symptomatic relief, and thorough patient counseling, equips both healthcare providers and individuals with the knowledge to effectively navigate the challenges of cold and flu season.
