> Table of Contents > Upper Respiratory Infection (URI)
Upper Respiratory Infection (URI)
Lisa M. Schroeder, MD
Vu D. Tran, MD
image BASICS
Upper respiratory infections (URIs) are one of the most common medical diagnoses, contributing to ˜30 million office visits annually and resulting in significant lost productivity through missed days from work/school.
DESCRIPTION
  • Inflammation of nasal passages resulting from infection with multiple respiratory viruses
  • Most cases are mild to moderate in severity, selflimited, and amenable to self-treat.
  • System(s) affected: ENT; pulmonary
EPIDEMIOLOGY
  • Each virus has different seasonal peaks (e.g., rhinovirus: late spring, fall); most infections occur during the winter months.
  • Symptoms usually peak in 1 to 3 days and can last up to 2 weeks.
  • Transmission:
    • Contact with contaminated skin/surface followed by contact with mucous membranes (hand-to-face contact)
    • Aerosolized particles from sneezing and coughing
  • Viruses may last up to 2 hours on skin and even longer on environmental surfaces.
Incidence
  • Predominant age: children > adults
    • Preschool children: 5 to 7 URI/year
    • Kindergarten: 12 URI/year
    • Schoolchildren: 7 URI/year
    • Adolescents/adults: 2 to 3 URI/year
  • Predominant sex: male = female
ETIOLOGY AND PATHOPHYSIOLOGY
Rhinoviruses infect the ciliated epithelial mucosa of the upper airway, resulting in edema, hyperemia, and mucous production.
  • Histology: edema of subepithelial connective tissue and a scanty cellular infiltrate containing neutrophils, plasma cells, lymphocytes, and eosinophils with exudation of serous and mucinous fluid
  • Rhinovirus causes a “nondestructive” inflammation of the mucous membranes.
  • Influenza and parainfluenza viruses denude respiratory epithelium to the basement membrane.
  • Several hundred viral strains from different families; spread within geographic region and groups with close contact
    • Rhinovirus (>100 serotypes): 30-50%; incubation period 1 to 5 days
    • Influenza virus types A, B, C: 10-15%; incubation period 1 to 4 days
    • Coronaviruses: 10-15%
    • Parainfluenza, respiratory syncytial virus (RSV): 5%; more common in children; incubation period 1 week
    • Enteroviruses, adenoviruses: <10%
  • In many cases, no specific pathogen is identified.
RISK FACTORS
  • Exposure to infected people
  • Touching one's face with contaminated fingers
  • Allergic disorders
  • Smoking
  • Immunosuppression
  • Stress
GENERAL PREVENTION
  • Frequent hand washing, especially in children (1,2)[A]
  • Limiting exposure to infected persons/children
  • Probiotic milk (with live culture lactobacillus) may reduce respiratory infections in children age <7 (3)[A].
COMMONLY ASSOCIATED CONDITIONS
  • Pharyngitis
  • Sinusitis
  • Otitis media
  • Bronchitis
  • Bronchiolitis
  • Pneumonia
  • Croup
  • Asthma
image DIAGNOSIS
PHYSICAL EXAM
  • Low-grade temperature; mild tachycardia common with fever; tachypnea if significant respiratory involvement
  • Rhinorrhea (clear, yellow, or green)
  • Mucosal edema and/or inflammation
  • Postnasal drainage
  • Pharyngeal erythema
  • Dull tympanic membranes
DIFFERENTIAL DIAGNOSIS
  • Allergic rhinitis
  • Acute sinusitis
  • Strep pharyngitis
  • Epiglottitis
  • Infectious mononucleosis
  • Pneumonia
  • Influenza
  • Pertussis
  • Otitis media
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • No routine lab testing is typically needed, as diagnosis is based on clinical findings.
  • In cases of pharyngitis, rapid streptococcal antigen testing with reflex culture can be used to rule out group A streptococcal infection if clinically suspected.
  • Rapid influenza antigen testing if influenza is suspected.
  • Heterophile antibody testing if infectious mononucleosis is suspected.
  • Imaging not routinely indicated
Follow-Up Tests & Special Considerations
Patients should consider contacting a physician's office for fever >101°F associated with systemic symptoms, difficulty breathing, or purulent drainage >2 days.
image TREATMENT
GENERAL MEASURES
  • Smoking cessation
  • Vaporizer/humidifier: no consistent benefit proven
  • Cold preparations do not change course
  • Antibiotics not indicated
  • Avoid cough and cold preparations under age of 2 years.
MEDICATION
Most cases of URI resolve spontaneously without specific intervention. Treatment is symptom-driven and for patient comfort.
First Line
  • Saline nasal irrigation is safe for adults and children.
  • Antibiotics are not recommended. They produce minimal to no reduction in symptoms or duration, with greater risk of side effects from usage (4)[A].
  • Analgesics: acetaminophen, and NSAIDs for relieving aches and pains associated with URI (5,6)[A]
Second Line
  • Many mouthwashes, gargles, and lozenges are promoted to relieve the pain of sore throat. The demulcent effects of hard candy, gargling with warm saline, and products with anesthetics (benzocaine/phenol) may provide pain relief.
  • Aromatic oils (menthol, camphor, eucalyptus), produce a sensation of increased airflow without a significant change in airflow resistance.
  • Topical decongestants (sympathomimetics) reduce nasal mucosa swelling and airflow resistance and promote drainage. Sprays preferred over drops in patients >6 years of age:
    • Limit use to 3 days, as rebound congestion may occur after 72 hours of use with resultant rhinitis medicamentosa.
      • Oxymetazoline
        • Adults and children aged 6 to 12 years: 0.05% solution, 2 to 3 sprays in each nostril BID
  • P.1081

  • Oral decongestants (sympathomimetic) have some advantages over topical decongestants: longer duration of action, lack of local irritation, and no risk of rebound congestion (7)[B].
    • Pseudoephedrine: potential for abuse/misuse or diversion for methamphetamine production
    • Use with caution for patients with cardiovascular disease, HTN, and BPH:
      • Adults: 60 mg q4-6h (120 mg sustainedrelease q12h) superior to placebo in short-term use (7)
      • Children aged 6 to 12 years: 30 mg q4 to 6h; 2 to 5 years: 15 mg q4 to 6h
  • Acute cough, postnasal drip, and throat clearing associated with the common cold can be treated with a first-generation antihistamine/decongestant preparation (brompheniramine and sustainedrelease pseudoephedrine) (8)[A].
  • Antihistamines: minimal benefit when used as monotherapy. Only first-generation (sedating) antihistamines show any symptomatic relief, but sedation may be worse than relief (9)[B]:
    • Chlorpheniramine
      • Adults: 4 mg QID, 8 mg TID, 12 mg BID
      • Children age 6 to 12 years: 2 mg q4-6h
    • Diphenhydramine
      • Adults: 25 to 50 mg q4-6h PRN
      • Children age 6 to 12 years 12.5 to 25 mg q4-6h PRN
Pediatric Considerations
In 2007, the FDA issued a warning to limit the use of all cough and cold preparations for children age ≤2 years due to risk of overdose (10,11)[A].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Zinc prevents viral replication in vitro:
    • Avoid intranasal preparations of zinc: risk of potential permanent loss of smell (12)[C]
    • Has shown moderate benefit in reducing symptoms and duration, but proper dosing has not been determined
  • Echinacea has not proven consistently effective for treatment of common cold symptoms (12)[C].
  • Probiotics may decrease severity and duration of URIs and possibly reduce episodes (3,13)[B].
  • Vitamin C (ascorbic acid) (14)[C]
    • Regular supplementation trials have shown that vitamin C may reduce the duration of colds.
    • Vitamin C prophylaxis not recommended for general use but may be beneficial in those exposed to severe physical exertion and cold environments.
Geriatric Considerations
Cold medications, especially decongestants and antihistamines, commonly produce adverse effects in older patients and should not be used routinely.
Pregnancy Considerations
  • Decongestants: Most are Category B or C.
  • Antihistamines: Most are Category B or C.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Contact a physician's office for prolonged fever, difficulty breathing, or concern for secondary complications.
DIET
Encourage fluids and adequate hydration.
PATIENT EDUCATION
  • Discuss the difference between viral and bacterial infections; instruct about appropriate antibiotic use.
  • Good hand hygiene
  • Symptomatic treatment; no cure
  • Reinfection is possible with reexposure.
  • Patient information: www.niaid.nih.gov/factsheets/cold.htm
PROGNOSIS
  • Excellent; expect full recovery. Usual duration 5 to 7 days but may last up to 2 weeks. For smokers, 3 to 4 additional days
  • Cough may persist after other symptoms have resolved.
REFERENCES
1. Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/community/materials-references/index.html.
2. Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev. 2011;(7):CD006207.
3. Hatakka K, Savilahti E, Pönkä A, et al. Effect of long term consumption of probiotc milk on infections in children attending day care centres: double blind, randomised trial. BMJ. 2001;322(7298):1327.
4. Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2013;(6):CD000247.
5. Li S, Yue J, Dong BR, et al. Acetaminophen (paracetamol) for the common cold in adults. Cochrane Database Syst Rev. 2013;(7):CD008800.
6. Kim SY, Chang YJ, Cho HM, et al. Nonsteroidal anti-inflammatory drugs for the common cold. Cochrane Database Syst Rev. 2013;(6):CD006362.
7. Horak F, Zieglmayer P, Zieglmayer R, et al. A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber. Ann Allergy Asthma Immunol. 2009;102(2):116-120.
8. Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1)(Suppl):72S-74S.
9. Sutter AI, Lemiengre M, Campbell H, et al. Antihistamines for the common cold. Cochrane Database Syst Rev. 2003;(3):CD001267.
10. Centers for Disease Control and Prevention. Infant deaths associated with cough and cold medications—two states, 2005. MMWR Morb Mortal Wkly Rep. 2007;56(1):1-4.
11. Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev. 2013;(6):CD001364.
12. Linde K, Barrett B, Wölkart K, et al. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev. 2006;(1):CD000530.
13. Hao Q, Lu Z, Dong BR, et al. Probiotics for preventing acute upper respiratory tract infections. Cochrane Database Syst Rev. 2011;(9):CD006895.
14. Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2013;(1):CD000980.
Additional Reading
&NA;
Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
See Also
&NA;
Bronchitis, Acute; Pharyngitis; Rhinitis, Allergic
Codes
&NA;
ICD10
  • J06.9 Acute upper respiratory infection, unspecified
  • J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations
  • B97.4 Respiratory syncytial virus causing diseases classd elswhr
Clinical Pearls
&NA;
  • Supportive therapy is mainstay for most upper respiratory tract infections.
  • Point of care testing can rule out group A Streptococcus infection in the appropriate clinical setting
  • Limit unnecessary use of antibiotics.
  • URI symptoms last 3 to 4 more days in smokers.