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

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

Symptoms: the common cold*

Day 2 to 3

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

Symptoms: the common

cold*
Day 4 to 5

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

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

QUIZ: the common cold

What is the most common culprit?
a. rotavirus
b. coronavirus

c. rhinovirus
d. echovirus
e. influenza virus

Virology *4,5

5%

5%

10%

Rhinovirus
Coronavirus
Influenza
50%

15%

RSV
Parainfluenza
Adeno, Entero

15%

* 4 Lancet 2003 Jan 4;361(9351):51-9.

* 5 Lancet Infect Dis. 2005 Nov;5(11):718-25.

Seasonal Patterns
Fall, late spring :

Rhinovirus
Parainfluenza

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 its just a cold?

Fever
Headache
Myalgia
Malaise
Extreme fatigue
Nasal congestion
Sneezing
Sore throat
Chest discomfort/
cough

COLD
Rare
Rare
Mild
Mild
Unusual
Common
Common
Common
Mild

INFLUENZA
39-40o
Usual
Severe
May last 3 wks
Usual
Common
Sometimes
Common
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

But how do I know its just a cold?

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

But how do I know its just a cold?

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 exacerbations
Up 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.

QUIZ: the common cold

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

QUIZ: the common cold

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

QUIZ: the common cold

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

QUIZ: the common cold

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 WONT 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 WONT 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.

Treatment: the common cold

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.

Treatment: the common cold

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