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Common cold has predictable sequence of symptoms that appears 1 to 3 days of infection and persists for 7-14 days

  • 1st symptom: sore throat
  • nasal symptom dominate 2-3 days later.
    • 1st 2 days: clear, thin, or watery nasal secretions, or combination thereof
    • as cold progress: secretions are thicker, and the color change to yellow or green
    • when the cold begin to resolve: clear, thin, and/or watery
  • 4 or 5 days: Cough, although an infrequent symptom (<30%)
  • Children may have low-grade fever (<100.4F/38C)
  • Physical assessment: slightly red pharynx with postnasal drainage, nasal obstruction, and mid to moderate sinus tenderness on palpation

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Recommendation: Require medical referral

Rational: 

Look for other differential diagnosis

Recommendation: Look for respective symptom algorithm.

Recommendation: Require medical referral

Rational: 
  • Infant Physiology: Infants' bodies are different from older children and adults. Their organs are still developing, and they may not process medications in the same way. This can increase the risk of side effects.
  • Difficulty in Diagnosis: It can be harder to accurately diagnose the cause of respiratory symptoms in very young infants. Symptoms that seem like a common cold might be a sign of a more serious condition, like bronchiolitis or pneumonia, which require different treatment.
  • Risk of Overdose: Infants are much smaller, and giving them adult or even children's doses of medication can easily lead to an overdose, which can be very dangerous.
  • Ineffectiveness: Many cold medications only treat the symptoms and don't actually shorten the duration of the illness. In infants, the risks of medication often outweigh the limited benefits.
  • Alternative Methods: There are usually safer, non-medicinal ways to relieve cold symptoms in infants, such as nasal saline drops, gentle suctioning with a bulb syringe, and increased humidity.

Recommendation: Require medical referral

Rational:  Most colds resolve on their own within 7 to 10 days. If symptoms persist beyond 10 days, or if they worsen significantly at any point, it's generally recommended to seek medical advice.

Recommendation: Require medical referral

Rational:  A SpO2 of 94% in someone with cold symptoms should prompt careful consideration. It's a sign that the respiratory system might be more significantly affected than in a typical cold. The person's baseline: If their normal SpO2 is usually 98-100%, then 94% is a bigger drop than if their baseline is normally 95%. If the 94% is accompanied by shortness of breath, chest pain, confusion, or blue lips, it's a clear indication for medical help. Underlying conditions: People with pre-existing lung or heart conditions are at higher risk and should seek medical advice with a 94% reading.

Recommendation: Require medical referral

Rational:  T>100.4F or >100F for 3 days is a risk factor for community-acquired pneumonia.

Recommendation: Require medical referral

Rational:  Indicate a bacterial throat infection.

Recommendation: Require medical referral

Rational:  suspected Bacterial pharyngitis

Recommendation: Require medical referral

Rational: 

Reasons for self treatment

    • Masking a Serious Symptom: In conditions like TB, lung cancer, or even worsening heart failure, a cough is a significant indicator of the disease's activity or progression. Self-treating the cough can mask this crucial warning sign, delaying proper diagnosis and treatment.
    • Increased Risk of Complications: Respiratory Conditions (Asthma, COPD): A cough in these cases might signal a dangerous flare-up or infection that needs immediate medical management (e.g., steroids, antibiotics). Self-treatment can lead to severe breathing difficulties.
    • Heart Conditions (CHF): A cough can be a symptom of fluid buildup in the lungs due to heart failure. Self-treating with cough suppressants might hide this and worsen the heart condition.
    • Altered Immune Response:In conditions like HIV infection or cancer (especially during treatment), the immune system is compromised. A cough could indicate a secondary infection that requires prompt, targeted treatment, not just over-the-counter cough medicine.
    • Disease-Specific Interactions:Some cough medications can interact with drugs used to treat the underlying conditions (e.g., heart medications, HIV medications).

Recommendation: Require medical referral

 
Rational:  Dyspnea (shortness of breath): A cold primarily affects the upper respiratory tract. Dyspnea indicates the lower respiratory tract (lungs) may be involved, suggesting conditions like pneumonia, bronchitis, asthma exacerbation, or even heart failure.
Rational:  Chest pain: Chest pain is rarely a symptom of a simple cold. It can indicate cardiac issues (angina), pneumonia, pleurisy (inflammation of the lung lining), or other serious conditions.
Rational:  Cold, pale, clammy skin: This suggests poor perfusion and the body's attempt to shunt blood to vital organs. It can be a sign of shock, severe infection, or a cardiac event.
Rational:  Altered sensorium: Confusion, disorientation, or decreased alertness indicates that the brain isn't getting enough oxygen or there's a systemic issue (severe infection, etc.) affecting brain function.
Rational:  Unable to swallow: While a sore throat is common with a cold, being unable to swallow suggests a severe infection (tonsillitis, abscess), epiglottitis (inflammation of the epiglottis), or another condition obstructing the throat.
Rational:  Cyanosis: Bluish discoloration of the skin or lips signifies severe hypoxemia (low blood oxygen levels). This is a critical sign of impaired respiratory function. It can be seen in severe asthma, COPD, or heart failure.
Rational:  Hemoptysis (coughing up blood): This is never a symptom of a simple cold. It suggests a serious underlying condition such as tuberculosis, lung cancer, pulmonary embolism, or severe bronchitis.
Rational:  Weight loss: Significant, unintentional weight loss is not typical of a cold. It can be a sign of chronic conditions like cancer, tuberculosis, or other chronic infections.
Rational:  Night sweats: While fever and chills can occur with a cold, true night sweats (drenching sweating requiring a change of clothes/linens) are more indicative of tuberculosis, other infections, or even malignancy.
Rational:  Peripheral edema (swelling in extremities): This is not a cold symptom. It often points to heart failure, kidney disease, or other systemic issues.
Rational:  Enlarged lymph nodes: While some mild lymph node swelling can occur with a cold, significantly enlarged or persistently enlarged nodes suggest a more widespread infection or even malignancy.

Recommendation: Pharmacological and non-pharmacological therapy

 

Non pharmacological

  • Colds are self limiting
  • Rest and adequate hydration is necessary
  • Upright positioning and use of nasal bulb syringes or irrigation of the nose with saline drops will clear mucus accumulated in the airway
  • Increased humidity of the inspired air soothes the airway
  • Prevent direct or indirect transmission to the family and friends through hygiene and use of sanitizers
  • Avoiding smoking can help
  • Steam inhalation, Increased humidification with cool mist vaporizers or steamy showers has been found to beneficial and hence can be done
  • Aromatic oil (camphor, menthol, and eucalyptus) products such as Vicks VapoRub (age>2 years) ease nasal congestion and improve sleep by producing soothing sensation
  • Sucking on hard candy, gargling with salt water (half to 1 teaspoon of salt per 1 glass of warm water), or honey, ginger and dinking fruit juices or hot tea with lemon may ease sore throat
  • Oral zinc (lozenges and syrup: effective in reducing symptoms and duration if started within 24 hours of symptom onset and administered every two hours while awake
  • Routine Vitamin C (>2gm/day): Mildly reduce the duration in preventively taken; taken after onset of cold is not effective in reducing symptoms, duration and severity. Avoid > 4 gm/day
  Pharmacological therapy  
  • Oxymetazoline may be used
    • 2-3 drops in each nostril no more than twice daily.
    • therapy should be limited to 3-5 days to avoid rebound congestion
    • Use cautiously with patient on glaucoma and HTN

Recommendation: Pharmacological and non-pharmacological therapy

Non-pharmacological treatment

  • Colds are self limiting
  • Rest and adequate hydration is necessary
  • Upright positioning and use of nasal bulb syringes or irrigation of the nose with saline drops will clear mucus accumulated in the airway
  • Increased humidity of the inspired air soothes the airway
  • Prevent direct or indirect transmission to the family and friends through hygiene and use of sanitizers
  • Avoiding smoking can help
  • Steam inhalation, Increased humidification with cool mist vaporizers or steamy showers has been found to beneficial and hence can be done
  • Aromatic oil (camphor, menthol, and eucalyptus) products such as Vicks VapoRub (age>2 years) ease nasal congestion and improve sleep by producing soothing sensation
  • Sucking on hard candy, gargling with salt water (half to 1 teaspoon of salt per 1 glass of warm water), or honey, ginger and dinking fruit juices or hot tea with lemon may ease sore throat
  • Oral zinc (lozenges and syrup: effective in reducing symptoms and duration if started within 24 hours of symptom onset and administered every two hours while awake
  • Routine Vitamin C (>2gm/day): Mildly reduce the duration in preventively taken; taken after onset of cold is not effective in reducing symptoms, duration and severity. Avoid > 4 gm/day

For: Headache/ Fever

Pharmacological treatment

Recommend salicylates, acetaminophen, ibuprofen, naproxen or ketoprofen as appropriate (<=3 times/week)

  • Acetaminophen.
    • Dosing: 10-15 mg/kg every 4-6 hours, not to exceed 4000 mg/day.
    • Time to effect: 30-60 min to reduce 1-2F with maximum reduction with 2 hours
    • Caution:
      • Liver toxicity with high doses or in patients with liver disease.
        • Overdose symptoms (>4gm per day)- N/V, rashes (rare) and eventually hepatic failure (may appear only after 4-6 days)
        • A/E: Nausea, hepatotoxicity, rash (rare)
      • Safe in
        • Pregnancy (safe if used <8 days. Emerging evidence in ADHD in child when used >29 days)
        • breastfeeding: crosses breast milk but safe. A rare occurrence of maculopapular rash in infants but will subside with discontinuation
        • aspirin hypersensitive patients,
        • GI ulceration,
        • Patient on anticoagulants, methotrexates or thiazides,
        • pt with renal, cardiac impairment in
        • conjunction of diuretics or ACE inhibitors;
        • elderly and
        • babies over 3 months.
      • A/E monitoring:  If signs of liver toxicity occur (jaundice, right upper quadrant pain)- Refer
 
  • Does the patient have NSAID contraindication like GI ulcers, renal diseases? If no use NSAID (Ibuprofen/Naproxen) otherwise use acetaminophen or NSAID with PPI.
    • Dosing:
      • Ibuprofen: 5-10 mg/kg every 4 to 6 hours as needed, not to exceed 1200 mg/day (OTC)
        • It takes 30-60 min to reduce 1-2F with maximum reduction with 2 hours
      • Naproxen: 220 mg every 8-12 hours as needed, not to exceed 660 mg/day (OTC).
        • preferred among NSAIDs for those patients having cardiovascular risks (use minimum dose for shortest duration)
    • Onset: Naproxen/ibuprofen: 30 minutes
    • CI: naproxen: <12 years age; salicylates: <18 years; ketoprofen: < 16 years
    • Special consideration
      • COX-2 selective preferred for patients having GI issues
      • Pregnancy: avoid (esp third semested) due to risk of bleeding potential, pregnancy prolongation and teratogenic effect.
      • Breastfeeding: Naproxen avoid in lactating mothers. Ibuprofen is considered safe.
      • Elderly: Cautiously use in elderly above 65 years (short term use is likely less problematic)
      • Children: Ibuprofen can be used for patients above 6 months age; Naproxen can be used for children above 12 years
    • Caution:
      • Causes GI irritation, bleeding risk, renal effects. Avoid in patients with a history of Asthma with nasal polyps, chronic/recurrent GI ulcers, gout, coagulation disorders or anticoagulant therapy, high blood pressure, CHF, kidney disease, or aspirin allergy.
    • A/E monitoring:
      • GI: Heartburn, nausea, abdominal pain, black stools (melena), vomiting blood.
        • Action: Take with food.
        • Referral: If signs of GI bleeding occur.
      • Renal: Decreased urine output, swelling in legs/ankles.
        • Referral: In patients with pre-existing renal disease.
  • Patient may report a better response to one NSAIDs than to another for unknown reason. if one NSAIDs fail to provide relief, another may be tried.

Non-pharmacological treatment

  • Relaxation Techniques: Headaches are often triggered or exacerbated by stress, anxiety, and muscle tension.
    • Deep Breathing Exercises: Slow, deep breaths can help to relax muscles and reduce stress.
    • Progressive Muscle Relaxation: Tensing and then relaxing different muscle groups in the body, to identify and release tension.
    • Meditation/Mindfulness: Focusing on the present moment can help to quiet the mind and reduce stress.
    • Yoga/Tai Chi: These practices combine physical postures, breathing exercises, and meditation
  • Physical Therapy: Headaches are frequently associated with tight muscles in the neck, shoulders, and upper back.
    • Stretching: Specific stretches can help to lengthen and relax tight muscles in the neck and shoulders.
    • Strengthening Exercises: Strengthening weak muscles can improve posture and reduce muscle strain.
    • Manual Therapy: A physical therapist may use hands-on techniques such as massage, joint mobilization, or manipulation to release muscle tension and improve joint function.
    • Postural Correction: Improving posture can reduce strain on the muscles of the head, neck, and shoulders.
    • Trigger Point Therapy: Trigger points are tight knots in muscles that can refer pain to other areas. Physical therapists can use various techniques to release trigger points.
  • Stress Management: Identify stressors, develop coping mechanisms (Time management, Regular exercise, Hobbies, Adequate sleep)
  • Sleep Hygiene:
    • Regular sleep schedule: Aim for consistent sleep and wake times.
    • Adequate sleep duration: Most adults need 7-9 hours of sleep per night.
    • Relaxing bedtime routine: Create a calming routine before bed to promote sleep.
  • Ergonomics:
    • Proper workstation setup: Ensure your chair, desk, and computer monitor are positioned correctly to minimize strain.
    • Regular breaks: Take breaks from prolonged sitting or computer work to stretch and move around.
  • Heat or Cold Therapy: Applying a heating pad or ice pack to the neck or shoulders can help to relieve muscle tension and pain.
  Drug interaction
  • Acetaminophen
    • With alcohol
      • Potential effect: Increased hepatotoxicity risk
        • Management and preventive measure: avoid concurrent use, minimize alcohol intake when acetaminophen use
    • With warfarin
      • Potential effect: Increase bleeding risk (elevate INR)
        • Management and preventive measure: limit acetaminophen to occasional use; monitor INR for several weeks when acetaminophen 2-4 gm is added or discontinued in patients on warfarin. Acetaminophen < 2gm may not alter INR
  • Aspirin
    • With NSAIDS including COX-2 inhibitors
      • Potential effect: increased risk of GI bleeding and ulcers
        • Management and preventive measure: avoid
  • Ibuprofen
    • With Aspirin (CV prophylaxis)
      • Potential effect: decreased antiplatelet effect of aspirin
        • Management and preventive measure: take aspirin 30 minutes before or 8 hours after ibuprofen. Use acetaminophen or other analgesic instead
  • NSAIDs
    • With Bisphosphonates
      • Potential effect: increased GI ulceration
        • Management and preventive measure: use with caution and monitor
    • With Digoxin
      • Potential effect: decreased digoxin renal clearance
        • Management and preventive measure: monitor digoxin, adjust dose
    • With agents with antiplatelet properties (SSRIs, NSAIDs, P2Y12 inhibitors)
      • Potential effect: increased bleeding risk
        • Management and preventive measure: monitor therapy
    • With antihypertensive agents (e.g., beta blockers, ACEIs, vasodilators, diuretics)
      • Potential effect: antihypertensive effect inhibited; possible hyperkalemia with potassium-sparing diuretics and ACEIs
        • Management and preventive measure: monitor BP, cardiac function and potassium level
    • With Anticoagulants
      • Potential effect: increased bleeding risk (esp. GI)
        • Management and preventive measure: avoid
    • With Alcohol
      • Potential effect: increased bleeding risk
        • Management and preventive measure: avoid concurrent use, minimize alcohol intake when NSAIDs use
    • With Methotrexate
      • Potential effect: decreased methotrexate clearance
        • Management and preventive measure: avoid NSAIDs with high-dose methotrexate therapy, monitor levels
    • With Sulfonylureas
      • Potential effect: increased hypoglycemia risk
        • Management and preventive measure: avoid concurrent use, if possible monitor blood glucose level when changing dose
    • With Caffeine
      • Potential effect: have additive effect
        • Management and preventive measure: monitor for side effect such as nausea, headache, insomnia

For: Pharyngitis

 
  • Saline gargles and
  • local anesthetic sprays or lozenges
    • Avoid in children <2 years (associated with methemoglobinemia)
    • Seek medical care if any of the following occur: pale, gray or blue-colored skin, lips, and nail beds; headache; lightheadedness; shortness of breath; fatigue; and rapid heart rate
    • lozenges or sprays containing benzocaine or dyclonine HCL may be used every 2-4 hours
    • Menthol and camphor may be effective
    • They will numb your mouth and tongue, do not eat until they go away
    • Use
      • Lozenges: Allow to dissolve slowly in the mouth.
      • Sprays: Spray directly onto the back of the throat.

For: Additional symptoms of sleeplessness

 
  • Switch to nasal decongestant sprays and nighttime use of AHs or alcohol-containing products
  • Antihistamines

    • Dose

      • Diphenhydramine : Adults: 25-50 mg every 4-6 hours (maximum daily dose: 300 mg).
      • Chlorpheniramine: Adults: 4 mg every 4-6 hours or 8-12 mg sustained-release every 12 hours (maximum daily dose: 24 mg).
          • slightly lower incidence of sedation than diphenhydramine.
      • Doxylamine: Adults: 7.5 - 12.5 mg every 6-8 hours (or as directed for sleep).
          • Potent sedative effects.
      • Brompheniramine : Adults: 4mg every 4-6 hours (maximum 24mg/day)

    • Caution

      • CI: new borns and premature infants, children (paradoxical excitation rather than sedation and also have safety issues), frail elderly, Narrow angle glaucoma, acute asthma exacerbation, stenosing peptic ulcer, BPH, bladder neck and pyloroduodenal obstruction, hyperthyroidism, CV disease
      • 1st Gen A/E: CNS depression (e.g., sedation, impaired performance) and anticholinergic effects (e.g., dry eyes, mouth, nose, vagina; blurred vision; urinary hesitancy and retention; constipation; and reflex tachycardia), respiratory depression
      • Some 1st gen are photosensitizing and require use of sunscreen or protective clothing
      • Avoid in lactating mothers (pass to breast milk)- short acting chloramphenicol, fexofenadine or loratadine are the best option if oral antihistamines is needed. Take the antihistamine ar bedtime after last feeding of the day
      • 1st gen avoid in children (paradoxical excitation as well as safety issues)
      • 1st generation are the choice of drug. 2nd generation are ineffective for treatment of colds.
      • May cause sedation. avoid daytime use
  • Nasal decongestants
    • Dose:
      • Oxymetazoline: Adults: 2-3 sprays in each nostril no more than twice daily.
      • Xylometazoline : Adults: 2-3 drops or sprays in each nostril every 8-10 hours as needed.
      • Naphazoline: Adults: 1-2 drops or sprays in each nostril every 6 hours as needed.
      • Phenylephrine: Adults: 2-3 sprays of 0.25% solution in each nostril every 4 hours as needed.
    • A/E and caution
      • Use cautiously in patients with hypertension
    • Remarks
      • low systemic absorption makes it ideal for special populations and patients with comorbidities
      • therapy should be limited to 3-5 days to avoid rebound congestion
      • may be used during pregnancy owing to low systemic absorption.

For: congestion and rhinorrhea

  Decongestant (oral/topical) or 1st generation antihistamines or combination
  • Antihistamines

    • Dose

      • Diphenhydramine : Adults: 25-50 mg every 4-6 hours (maximum daily dose: 300 mg).
      • Chlorpheniramine: Adults: 4 mg every 4-6 hours or 8-12 mg sustained-release every 12 hours (maximum daily dose: 24 mg).
          • slightly lower incidence of sedation than diphenhydramine.
      • Doxylamine: Adults: 7.5 - 12.5 mg every 6-8 hours (or as directed for sleep).
          • Potent sedative effects.
      • Brompheniramine : Adults: 4mg every 4-6 hours (maximum 24mg/day)

    • Caution

      • CI: new borns and premature infants, children (paradoxical excitation rather than sedation and also have safety issues), frail elderly, Narrow angle glaucoma, acute asthma exacerbation, stenosing peptic ulcer, BPH, bladder neck and pyloroduodenal obstruction, hyperthyroidism, CV disease
      • 1st Gen A/E: CNS depression (e.g., sedation, impaired performance) and anticholinergic effects (e.g., dry eyes, mouth, nose, vagina; blurred vision; urinary hesitancy and retention; constipation; and reflex tachycardia), respiratory depression
      • Some 1st gen are photosensitizing and require use of sunscreen or protective clothing
      • Avoid in lactating mothers (pass to breast milk)- short acting chloramphenicol, fexofenadine or loratadine are the best option if oral antihistamines is needed. Take the antihistamine ar bedtime after last feeding of the day
      • 1st gen avoid in children (paradoxical excitation as well as safety issues)
      • 1st generation are the choice of drug. 2nd generation are ineffective for treatment of colds.
      • May cause sedation. avoid daytime use
  • Nasal decongestants
    • Dose:
      • Oxymetazoline: Adults: 2-3 sprays in each nostril no more than twice daily.
      • Xylometazoline : Adults: 2-3 drops or sprays in each nostril every 8-10 hours as needed.
      • Naphazoline: Adults: 1-2 drops or sprays in each nostril every 6 hours as needed.
      • Phenylephrine: Adults: 2-3 sprays of 0.25% solution in each nostril every 4 hours as needed.
    • A/E and caution
      • Use cautiously in patients with hypertension
    • Remarks
      • low systemic absorption makes it ideal for special populations and patients with comorbidities
      • therapy should be limited to 3-5 days to avoid rebound congestion
      • may be used during pregnancy owing to low systemic absorption.
  • Oral decongestants (phenylephrine, pseudoephedrine (oral decongestant of choice)
    • Dose:
      • Phenylephrine:
        • Adults/Children ≥12 years: 10 mg every 4 hours (maximum daily dosage: 60 mg)
        • Children 6-12 years: 5 mg every 4 hours (maximum daily dosage: 30 mg)
        • Children 2-6 years: 2.5 mg every 4 hours (maximum daily dosage: 15 mg)
      • Pseudoephedrine:
        • Adults/Children ≥12 years: 60 mg every 4-6 hours (maximum daily dosage: 240 mg)
        • Children 6-12 years: 30 mg every 4-6 hours (maximum daily dosage: 120 mg)
        • Children 2-6 years: 15 mg every 4-6 hours (maximum daily dosage: 60 mg)
    • A/E or caution
      • cardiovascular stimulation (e.g., elevated BP, tachycardia, palpitation, or arrhythmias) and CNS stimulation (restlessness, insomnia, anxiety, tremors, fear, or hallucinations)
      • Refer to physicians if patient has diabetes, hypertensives, BPH, hyperthyroidism, ischemic heart disease, increased intraocular pressure
      • Avoid in pregnancy
      • Decongestants should not be given to children under six years and treatment for children aged six to 12 years should be restricted to five days or less.
    • Remarks:
      • Pseudoephedrine compatible with breast feeding
      • Avoid taking at bedtime, because of potential to cause insomnia and restlessness
      • pseudoephedrine max dose: 240 mg/day
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