Common Cold

Liliana Rios, M.D. – PGY-1

July 24 - 2008

CASE: Mr. Sniffle, 35 y.o. male

• complaining of feeling tired and achy for few days

• today: congested, thick yellow nasal discharge

• non-productive cough started this morning

• no fever

• requesting an antibiotic

• wants to know what OTC products will work for his symptoms

QUIZ

What is the most likely diagnosis?

a. influenza

b. acute bacterial sinusitis

c. the common cold

d. pneumonia

e. asthma

Definition: the common cold

benign self-limited syndrome

caused by members of several families

of viruses

Mild upper respiratory viral

illness

Symptoms: the common cold

Day 1: sore or “scratchy” throat, +/- low grade fever

Day 2-3: nasal obstruction, rhinorrhea, sneezing

• thick purulent nasal discharge does NOT mean bacterial sinusitis!

Day 4-5: cough becomes bothersome, nasal symptoms less severe

• Average duration: 3-7 days

• Virus-induced changes in airway reactivity can persist for up to 4 weeks

Symptoms: the common cold*

Day 1

* Epidemiol Infect 1993 Aug;111(1):143-56


Day 2 to 3


http://images.google.com/imgres?imgurl=http://img2.travelblog.org/Photos/10392/85921/t/584653-Jen-s-ingenious-solution-to-my-runny-nose-P-Jen-s-photo-1.jpg&imgrefurl=http://www.travelblog.org/Asia/Thailand/South/Ko-Tao/blog-85921.html&h=225&w=300&sz=8&hl=en&start=8&tbnid=_NDHTvhm2FQarM:&tbnh=87&tbnw=116&prev=/images%3Fq%3Drunny%2Bnose%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DX


Day 4 to 5


• thick purulent nasal discharge does NOT mean bacterial sinusitis!

QUIZ: the common cold

What is the most common culprit?

a. rotavirus

b. coronavirus

c. rhinovirus

d. echovirus

e. influenza virus

50%

15%

15%

5%5% 10% Rhinovirus

Coronavirus

Influenza

RSV

Parainfluenza

Adeno, Entero

Virology *4,5

* 4 Lancet 2003 Jan 4;361(9351):51-9. * 5 Lancet Infect Dis. 2005 Nov;5(11):718-25.

Seasonal Patterns

Fall, late spring : RhinovirusParainfluenza

Winter, spring: RSV, coronavirus

Summer: Enterovirus (year)

Adenovirus: Outbreaks in Military facilities daycare centers, hospital

Facts: the common cold

• Incubation period 24 to 72 hours• Average duration 3 – 7 days•Virus-induced changes in airway reactivity can persist for up to 4 weeks(Rhinovirus )• 2 to 3 episodes /per year*

*Ann Allergy Asthma Immunol 1997 Jun;78(6):531-9;

Diferential diagnosis: the common cold

•Allergic or seasonal rhinitis •Bacterial pharyngitis or tonsillitis (Centor criteria) •Sinusitis •Influenza

But how do I know it’s just a cold?

COLD INFLUENZA

Fever Rare 39-40o

Headache Rare Usual

Myalgia Mild Severe

Malaise Mild May last 3 wks

Extreme fatigue Unusual Usual

Nasal congestion Common Common

Sneezing Common Sometimes

Sore throat Common Common

Chest discomfort/ cough

Mild Mod-Severe

Facts: Influenza

•Patients with illnesses which involve the cardiovascular or pulmonary systems •Patients with diabetes mellitus, renal disease, hemoglobinopathy, or immunosuppression

•Residents of nursing homes or chronic care facilities

•Otherwise healthy individuals over age 50

Facts: Influenza Vaccine

All of the mentionated before

Plus

Health care workers

Pregnant women in second or third trimestrer


• Acute Bacterial Sinusitis

• complicate 0.5-2% of colds

• Diagnosis = persistent URTI with no improvement >10-14 days OR worsening after 5 days +

• nasal congestion/ purulent nasal discharge

AND

• facial pain


• Pneumonia =

1. 2 of: fever, new cough, pleuritic chest pain, SOB +

2. Auscultatory findings +

3. New opacity on CXR

•Asthma

Airway reactivity*1

Vs

Acute asthma attacks exacerbationsUp to 40% of viral upper resp infection*2

*1 Am J Respir Crit Care Med 1995 May;151(5):1666-73; discussion 1673-4. *2 Chest 1997 Sep;112(3):591-6.

Complications Sinusitis:

Acute bacterial sinusitis develops in 0.5 to 2.5 percent of adult patients after viral *1

Lower respiratory tract disease :

RSV, elderly (CHF) and immunocompromised

Acute otitis media: Eustachian tube dysfunction;

*1 J Allergy Clin Immunol 1998 Sep;102(3):403-8.


Mr. Sniffles wants to know if his girlfriend will catch this if he kisses her. You tell him the virus is:

a. Likely to transmit by kissing

b. Unlikely to transmit by kissing


Mr. Sniffles wants to know if his girlfriend will catch this if he kisses her. You tell him the virus is:

a. Likely to transmit by kissing

b. Unlikely to transmit by kissing*

* Prim Care 1996 Dec;23(4):657-75

FACTS: transmission*

• Hand –to- hand

• most efficient = direct contact

• virus can survive for 2 hours on human skin

• also aerosol

• NOT via saliva – kissing is OK!

(in 90% of people with colds, no detectable virus in saliva) *Epidemiol Rev 1988;10:243-58.

FACTS: the common cold

• you can be re-infected by the same virus, but subsequent illness will be milder and shorter *1

• NO evidence that cold climate increases susceptibility to respiratory illness *2

*1 Am J Epidemiol 1989 Feb;129(2):319-40.

*2 Prim Care 1996 Dec;23(4):657-75.

FACTS: the common cold

• huge economic burden

• annual work absence in the US = 23 million lost days/ year*1

* Arch Intern Med. 2003 Feb 24;163(4):487-94.

Therefore …

• huge potential for drug companies to make big money!!

• 1 in 4 US adults had taken a cough or cold medication in the last 7 days

• in Canada, >700 OTC cough and cold medications


Mr. Sniffles only wants to spend his money on treatments that he can be sure will help his symptoms. What do you suggest?

a. Antibiotics

b. Antihistamine

c. Codeine

d. Dextromethorphan

e. Pseudoephedrine

f. D. or E.

g. None of the above – just rest and fluids

Treatment: the common cold

• the ONLY “A” recommendation is NOT to use antibiotics to treat the common cold.*1

• everything else is “B” (inconsistent or limited quality evidence)

*1 Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000247.

Treatment: what might work

COUGH:

• dextromethorphan (DM) – cough suppressant

• Cochrane review: 2 studies: benefit, 1 study: no benefit *1

• guaifenesin (Benylin E, Robitussin) – expectorant

•1 study: benefit, 1 study: no benefit

Treatment: what might work

NASAL CONGESTION:

• topical or oral decongestant (pseudoephedrine = Sudafed) *1

• small benefit of single dose, NO benefit of repeated use over several days

• topical intranasal Atrovent (0.06% spray) *2

• 2x 42ug sprays per nostril TID-QID x 4 days

• decreased nasal discharge by 26% : only 1 study, expensive

• humidified air and fluid intake *3

• inconsistent results, but no harm!

*1 Cochrane Database Syst Rev 2004;(3):CD001953*2 Cochrane Database Syst Rev 2004;(3):CD001953*3 Arch Fam Med. 1998 Jan-Feb;7(1):39-43.

Treatment: what WON’T work

COUGH:

• codeine – works for chronic cough, NOT for acute cough*1

• antihistamines – no benefit*2

*1 Chest. 2006 Jan;129(1 Suppl):72S-74S*2 Chest. 2006 Jan;129(1 Suppl):72S-74S

Treatment: what WON’T work

NASAL CONGESTION:

• Antihistamines *1

• no benefit, significant adverse effects

• Saline nasal spray

• no benefit

*1 J Gen Intern Med 1996 Apr;11(4):240-4.


COMPLEMENTARY/ ALTERNATIVE:

• Vitamin C *1

• no effect if started after onset of symptoms

• inconsistent results if started before: may slightly decrease cold duration if 200mg daily

• Exercise *2

• decreased incidence in overweight postmenopausal women who exercised 5x/week

*1 Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000980. *2 Am J Med. 2006 Nov;119(11):937-42.


COMPLEMENTARY/ ALTERNATIVE:

• Echinacea *1

• no evidence in well-designed studies

• Zinc *2

• inhibits viral growth in vitro

• inconsistent study results

*1 Cochrane Database Syst Rev. 2006 Jan 25;(1):CD000530. *2 Laryngoscope. 2006 Feb;116(2):217-20.

Case Conclusion: Mr. Sniffle

• you reassure Mr. Sniffle that he has just a common cold

• you educate him about why antibiotics are not a good idea

• after you expound upon the evidence (or lack of) for various remedies, he chooses to try intranasal atrovent

• you also suggest hydration, rest, and not to waste his money on OTC products

Common Cold

Education

Transcript of Common Cold