Definition
A.The common cold is a self-limiting acute respiratory tract infection (ARTI) resulting from viral infection of the upper respiratory tract. It is also called acute nasopharyngitis. ARTI is characterized by mild coryzal symptoms, rhinorrhea, nasal obstruction, and sneezing.
Incidence
A.Upper respiratory tract infections are among the most frequent reasons for office visits. However, the true incidence is not known because patients treat themselves with over-the-counter (OTC) and home remedies and there is seasonal and geographic variability. Most adults have two to three colds a year.
B.ARTIs cause 40% of lost work days.
Pathogenesis
A.Over 25% to 80% of ARTIs are caused by a rhino-virus (>100 antigenic serotypes). Other viral agents include coronavirus (10%–20%), respiratory syncytial virus (RSV), adenoviruses (5%), influenza viruses (10%–15%), and parainfluenza viruses. Incubation period is 1 to 5 days with viral shedding lasting up to 2 weeks.
B.Rhinoviral infections are chiefly limited to the upper respiratory tract but may cause otitis media and sinusitis.
Predisposing Factors
A.Exposure to airborne droplets.
B.Direct contact with virus by touching hands or skin of infected people, or by touching surfaces they touched and then touching eyes or nose.
C.Very young or old ages.
D.Smoking, which increases risk by 50%.
E.Crowded conditions such as long-term care facilities and college dormitories.
Common Complaints
A.Low-grade fever.
B.Generalized malaise.
C.Nasal congestion and discharge (initially clear, then yellow and thick).
D.Sneezing.
E.Sore throat or hoarseness.
F.Watery and/or inflamed eyes.
Other Signs and Symptoms
A.Headache.
B.Cough.
Subjective Data
A.Elicit the onset, course, and duration of symptoms.
B.Inquire about color and other characteristics of nasal discharge and sputum. Purulent nasal discharge after 14 days signals bacterial sinusitis.
C.Inquire about other discomforts and exposure to people with similar symptoms.
D.Review allergens, seasonal problems, and exposure to irritants and smoke.
E.Review history for other respiratory problems, such as asthma, chronic bronchitis, and emphysema.
F.Determine the frequency of similar symptoms, including the last ARTI.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure (BP). Check pulse oximetry as needed:
B.Inspect:
1.Observe general appearance.
2.Inspect eyes. Note allergic shiners,
tearing, and eyelid swelling.
3.Observe ears, throat, and mouth. Otitis media is indicated by redness and bulging of tympanic membrane, or by membrane perforation with drainage.
4.Inspect nose for nasal redness, swelling, polyps, enlarged turbinates, septal deviation, and foreign bodies.
5.Transilluminate sinuses:
a.Group A streptococci: Tonsillar enlargement, exudates, palatine petechiae.
b.Allergies: Cobblestoned
pharyngeal mucosa.
c.Mononucleosis: About half of patients with mononucleosis develop tonsillar exudates, and about one-third develop petechiae at the junction of the hard and soft palate, which is highly suggestive of the disease or co-infection with Group A beta-hemolytic strep.
C.Auscultate:
1.Auscultate all lung fields.
2.Auscultate heart.
D.Percuss:
1.Percuss sinus cavities and mastoid process of temporal bone to rule out otitis media.
2.Percuss chest for consolidation.
3.Percuss the abdomen for organomegaly.
E.Palpate:
1.Palpate face for sinus tenderness.
2.Examine head and neck for enlarged, tender lymph nodes.
Diagnostic Tests
A.Diagnosis may be made from history and physical. Because common cold manifestations are so prevalent, an aggressive workup is rarely necessary.
B.Consider rapid strep test if the patient has symptoms, positive exam findings, or recent exposure.
C.Consider throat culture if the patient has negative rapid strep and is symptomatic or has positive exam findings.
D.Consider testing for influenzas A and B.
Differential Diagnoses
A.Upper respiratory infection (URI).
B.Allergic rhinitis.
C.Foreign body.
D.Sinusitis.
E.Influenza.
F.Group A strep pharyngitis.
G.Otitis media.
H.Pneumonia.
I.Acute bronchitis.
J.Immunocompromise if history of excessive ARTIs.
Plan
A.General interventions: Supportive care with rest and fluids.
B.Controlled trials reveal minimal therapeutic benefits of vitamin C for the treatment and prevention of colds. Zinc has no proven benefit. Echinacea has not shown any differences in rates of infection or severity of symptoms when compared with placebo. Validation and standardization of herbal products have not been completed.
C. 
See Section III: Patient Teaching Guide Common Cold.
D.Pharmaceutical therapy:
1.The American College of Chest Physicians released clinical practice guidelines in 2006 for the
management of cough.
2.Antibiotics are ineffective in treating viral infection.
3.Corticosteroids may actually increase viral replication and have no impact on cold symptoms.
4.Topical decongestants for rhinorrhea and nasal congestion:
a.Intranasal ipratropium bromide 0.06% two sprays, each nostril, three to four times daily.
b.Intranasal cromolyn sodium one spray, each nostril, three to four times daily.
c.Pseudoephedrine (Afrin) nasal spray 0.05% two to three sprays per nostril twice daily, or phenylephrine (Neo-Synephrine) nasal spray 0.25% to 1% two to three sprays per nostril every 4 hours as needed. Limit use to 2 to 3 days maximum to avoid rebound rhinitis.
5.Oral decongestants such as pseudoephedrine (Sudafed) have no proven benefits, and the side effects can be problematic in the elderly.
6.Analgesics, such as acetaminophen (Tylenol) and ibuprofen (Advil), may be used for headache relief.
7.Cough suppressants are not recommended, as side effects outweigh benefits. Dextromethorphan can be used for cough suppression to improve sleep as needed.
8.Colds have no allergic mechanism, so antihistamines are ineffective. The atropine-like drying effect from antihistamines may exacerbate congestion and obstruct the upper airway by impairing mucus flow.
Follow-Up
A.None is recommended unless symptoms persist longer than 7 days from onset or the patient develops symptoms of lower respiratory infection.
Consultation/Referral
A.Consult a physician if the patient has been reevaluated and given a new treatment plan but still has symptoms.
B.Make a same-day referral to an otolaryngologist if tonsillar abscess is suspected.
Individual Considerations
A.Adolescents: May use dextromethorphan as a recreational drug with potential for abuse.
B.Geriatrics: Potential benefits from cold preparations do not outweigh the risks including sedation and urinary retention.