Upper Respiratory Tract Infection(Also Known as Catarrh ( URIs)Treatment & Management

• Author: Anne Meneghetti, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP

Symptomatic, Nonpharmacologic Self-Care.

The following home-care measures may help to provide relief of nasal and sinus symptoms:

• Warm, moist air
• Nasal saline
• Hydration
• Warm facial packs
• Bulb suction (for infants)
• Avoidance of nasal irritants (eg, cigarette smoke, indoor and outdoor air pollutants)

Nasal and paranasal sinus mucosae may become more irritated with dry air. The following strategies may maintain the moisture of membranes and loosen nasal secretions:

• Turn on hot shower water, close the bathroom door, sit down, and inhale the steam
• Take long, hot showers
• Use a vaporizer to increase humidity in rooms

If a vaporizer is used, the water must be changed daily to prevent microbial growth, especially with heated vaporizers. Heated systems may pose a risk for scalding injuries.

One way to provide moist, warm air is to pour boiled water into a shallow pan or bowl placed in a stable location (eg, middle of a kitchen counter) and have the patient drape a cloth over his/her head and lean over the bowl to inhale the steam. Exercise caution to avoid spilling boiling water, which may cause scalding injuries.

Sipping hot water or warm drinks may be more soothing to the nasal passages than ice cold drinks. Avoid extremely cool and dry air.

Nasal saline may provide temporary relief of congestion by removing nasal crusts and dried secretions. A systematic review of nasal saline irrigation as an adjunct in chronic rhinosinusitis symptom management concluded that the evidence shows symptom relief and that irrigation is well tolerated by most patients.  Patients with sinusitis experienced symptomatic benefit from use of a neti pot method of nasal irrigation. 

Saline drops or sprays are commercially available. A homemade normal saline solution can be prepared by placing a quarter of a teaspoon of table salt in 8 oz of water. A bulb syringe, dropper, clean pump spray bottle, or squeeze bottle can be used to instill the saline into each nostril while the person inhales and then expels the saline. Saline is safe to use as needed.

Drinking 8 or more 8-oz glasses of water, juice, or noncaffeinated beverages daily may help to thin mucous secretions and replace fluid losses. Patients with congestive heart failure or renal or liver disease may need to moderate their fluid intake to avoid volume excess.

Warm facial packs may provide comfort, relieve congestion, and promote drainage in cases of rhinosinusitis. A warm, folded washcloth or hot-water bottle (filled with hot water from a tap) may be applied directly to the face and cheek for 5-10 minutes. Facial packs may be repeated 3-4 times a day as needed.

For infants, a bulb syringe can be used to gently suction the nostrils before feeding to ease nasal breathing. Parents should clean the bulb after each use with hot soapy water followed by a rinse. Drain the bulb and allow it to dry before reuse.

Home-care measures to relieve throat symptoms include warm saline gargles, which may reduce associated edema; lozenges; popsicles; and cold and slushy beverages. Avoid choking hazards in small children.

Home-care measures to relieve cough include reducing irritating stimuli (eg, cold, dry air; indoor or outdoor air pollutants) that may provoke coughing. An upright or semiupright posture, such as sleeping with the head and shoulders raised, may decrease cough related to pharyngeal secretions. A 2007 study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI. 

Home-care measures to improve sleep include sleeping with the head and shoulders slightly elevated, which may promote sinus and nasal drainage. Many symptoms worsen at night, because airway clearance mechanics are relatively ineffective in the prone position. In addition, distractions from the experience of symptoms are fewer than during the day.

Under normal circumstances, the 2 nares alternate between being open or closed throughout the day. Cycles last approximately 45-90 minutes per naris. When the person is lying recumbent on one side, the naris closest to the pillow or surface tends to become congested, while the higher nostril is decongested. During nasal congestion associated with URI, alternating positions or lying with the shoulders and head propped up may increase comfort.

Symptomatic, Pharmacologic Therapy

Treatment of an uncomplicated URI is focused on specific measures to reduce symptoms, including use of the following:

• Oral or topical decongestants
• Ipratropium bromide
• Antihistamines
• Topical and systemic steroids
• Saline nasal drops
• Guaifenesin
• Topical phenol or lidocaine
• Cromolyn

Oral and topical decongestants

Oral decongestants may provide symptom relief for patients with persistent rhinorrhea or sneezing associated with URI. However, despite common usage, evidence regarding the effectiveness of oral decongestants in acute sinusitis is scarce.

Adverse effects of oral decongestants include the following:

• Anxiousness
• Insomnia
• Tachycardia and dysrhythmias
• Elevated blood pressure
• Palpitations
• Tremor
• Urinary retention

Exercise caution in patients with heart disease, hypertension, prostate enlargement, glaucoma, anxiety, hyperthyroidism, or other medical conditions and in pregnant or lactating women. Unlike topical nasal decongestants, oral decongestants do not appear to cause rebound phenomena after cessation of use.

The risk-to-benefit ratio for using cough and cold medicines in children younger than 2 years requires careful consideration because serious adverse events, including fatalities, have been reported with the use of over-the-counter preparations.  Numerous over-the-counter cough and cold preparations are labeled “do not use” in children younger than 4 years. 

Topical decongestants such as phenylephrine and oxymetazoline may provide rapid temporary relief of nasal obstruction. However, rebound congestion may occur after cessation of use. To avoid this rebound congestion, limit topical agents to 3-4 days of use. In addition, these decongestants may cause throat irritation in some individuals.

One study, in which oxymetazoline was administered to patients with a nasal bellows, suggested that oxymetazoline did not accelerate the rate of healing of acute maxillary sinusitis, as judged by sinus radiographs and subjective symptom scores. The researchers concluded that decongestion of the sinus ostia may not be of primary importance in the healing of acute sinusitis. 

Ipratropium bromide

This agent, which is an anticholinergic, has been evaluated in adults and young adults with rhinorrhea of moderate or greater severity. In one study, ipratropium reduced the severity of sneezing and rhinorrhea, but it did not appear to reduce nasal congestion. Rates of blood-tinged mucus and nasal dryness were higher in the treated group than in the control group. 

Antihistamines

Histamines are not thought to play a role in generating URI symptoms; therefore, newer, nonsedating antihistamines are not useful in reducing URI symptoms. However, first-generation oral antihistamines (eg, diphenhydramine, chlorpheniramine, clemastine) have some anticholinergic effects, which, in theory, could reduce sneezing and rhinorrhea. (Such effects have been reported for clemastine fumarate in patients with the common cold.) 

Steroids

Topical and systemic steroids are often prescribed with the intention of reducing mucosal swelling in patients with acute viral or bacterial rhinosinusitis. However, little evidence supports their use for this indication

Saline nasal drops

Saline nasal drops may provide relief from thick secretions and mobilize nasal crusting. Nasal saline irrigation is effective and well tolerated as an adjunct to persistent rhinosinusitis symptoms. 

Guaifenesin

The use of guaifenesin, a mucolytic, is commonly suggested with the intention of thinning secretions. However, data regarding its effectiveness in reducing secretions and promoting drainage in persons with nasopharyngitis or rhinosinusitis are limited.

Topical phenol and lidocaine

Lozenges, gargles, or sprays that contain phenol may provide temporary relief of sore throat. In young children, however, lozenges may pose a choking hazard.

Cromolyn

Intranasal cromolyn sodium is typically used for relief of allergic rhinitis. Data are insufficient, however, to permit evidence-based recommendations regarding its use to treat URI-related nasal symptoms in nonallergic patients

Cough relief

Cough suppression may increase comfort when cough is severe or when it prevents sleep.  As stated earlier, the risk-to-benefit ratio for using cough and cold medicines in children younger than 2 years requires careful consideration because serious adverse events, including fatalities, have been reported with the use of over-the-counter preparations in young children. Since 2008, many nonprescription cough and cold product labels state “do not use” in children younger than 4 years. 

Cough associated with the common cold may be treated with a first-generation antihistamine combined with a decongestant (eg, brompheniramine with pseudoephedrine). Older-generation histamines have anticholinergic effects, which may account for cough reduction. Newer-generation (nonsedating) antihistamines are ineffective for cough.

Inhaled ipratropium, an anticholinergic, may be useful in postinfectious cough (3-8 wk after the onset of the URI) in adults. Inhaled steroids may be considered in postinfectious cough (3-8 wk after URI onset) if ipratropium fails to control it. If postinfectious cough remains severe and if other causes (eg, rhinosinusitis, cough asthma, gastroesophageal reflux disease) have been excluded, a short, time-limited course of oral steroids may be considered.

Several agents (eg, codeine, guaifenesin, dextromethorphan) are intended for the symptomatic relief of cough. However, evidence is mixed regarding effectiveness of these agents. While codeine may inhibit cough under various circumstances, data are limited regarding its effectiveness in reducing acute cough from URI. As an expectorant, guaifenesin is intended to mobilize secretions. However, consistent data regarding its effectiveness in reducing discomfort from cough associated with URIs are scarce.

Dextromethorphan, a centrally acting cough suppressant, may be considered for the treatment of postinfectious cough in adults if other medications fail. However, this agent may have limited efficacy in treating cough related to acute URI. One study showed that honey was superior to dextromethorphan in reducing cough symptoms and improving sleep in children with URI. 

Over-the-counter cough suppressants may cause notable adverse effects in young children. Additional data are required to permit evidence-based recommendations for the use of central-acting antitussives in URI-related cough in children

Codeine is an effective, centrally acting cough suppressant in adults. As with other centrally acting antitussives, additional evidence is required to create evidence-based recommendations for the use of codeine in URI-related cough in children.  Clinically significant respiratory and nonrespiratory adverse events have been reported. Sedatives should be avoided in patients with chronic obstructive pulmonary disease and in others at risk of respiratory depression.

Beta agonists are not thought to be helpful in URI-related cough, including that due to pertussis. However, beta-agonists are recommended in the setting of asthma or chronic obstructive pulmonary disease exacerbated by URI.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to reduce discomfort due to cough. Avoid aspirin in children with viral illness because aspirin is associated with Reye syndrome.

Fever and discomfort relief

Fever may be physiologically helpful in eliminating pathogens from the body. In some individuals, however, fever poses a risk of provoking underlying illness. In a fragile cardiac patient, for example, increased metabolic demands associated with fever may increase the work of the heart. In children with a history of febrile seizures, avoiding high fevers may reduce the risk of seizure.

Acetaminophen, rather than aspirin, is recommended for the relief of fever, sore throat, myalgias, facial pain, and other uncomfortable sensations in pediatric patients because aspirin is associated with Reye syndrome. Avoid the use of respiratory depressants in patients with serious airway congestion or compromise

Complementary and alternative therapies

Alternative therapies and traditional folk remedies are widely used to treat URIs. While some may provide symptomatic relief, current studies are insufficient to permit evidence-based conclusions regarding effectiveness.

Zinc

Studies of oral zinc have yielded mixed results, and data on children are limited. Unpleasant taste and nausea have been reported. Zinc nasal gel has been studied for the common cold.  However, the US Food and Drug Administration (FDA) has issued a public health advisory against the use of intranasal zinc because of reports of long-lasting or permanent loss of smell associated with its use. In some cases, anosmia occurred with the first dose; in others, it occurred after multiple uses of intranasal zinc. 

Echinacea

Echinacea preparations are widely used for common colds. A meta-analysis noted that echinacea preparations tested in clinical trials differ greatly, but found some evidence that Echinacea purpura preparations may be effective in the early treatment of colds in adults.  In a randomized study of common cold symptom severity in older children and adults, standardized echinacea tablets started within the first 24 hours of symptoms were not superior to placebo. 

Vitamin C

High-dose oral vitamin C supplementation for the attenuation of URI symptoms has been studied. Results have been inconsistent.

Deterrence/Prevention

Several measures can reduce susceptibility to URIs. In newborns, the practice of breastfeeding transfers protective antibodies through the mother’s milk, providing passive immunization against numerous pathogens.

In older children, adolescents, and adults, an adequate diet is necessary for overall health and optimal immune function. Eating 5 servings of fruits and vegetables each day is commonly recommended. Various vitamins and minerals are necessary for immunity. Obtaining these from food may have more nutritional benefit than taking individual supplements.

Lifestyle measures such as smoking cessation and reduction of exposure to secondhand smoke may reduce the incidence of URIs. Regular, moderate exercise may reduce susceptibility to URIs, whereas intensive training in high-performance endurance athletes may increase susceptibility.

Preventing the spread of infection

Hygiene

Handwashing is the mainstay for reducing the risk of contracting a URI. Wash the hands for 20 seconds with ordinary soap and water; include all surfaces of the hands, such as in between the fingers and around the nail bed where debris may accumulate. People should wash their hands before eating and preparing meals, after toileting, after changing diapers or handling other waste, and after coughing or sneezing. Especially during cold season, people should wash their hands frequently and avoid touching unwashed hands to their nose and mouth. Discourage sharing of items passed from hand to mouth.

Use of alcohol-based hand sanitizers is acceptable when soap and water are not available. Avoid contact with secretions of infected persons. Cover coughs and sneezes with a tissue or upper sleeve.

Rhinoviruses can survive for as long as 3 hours on skin and fomites, such as telephones, door handles, and stair railings. Regular cleaning of environmental surfaces with a disinfectant may reduce the spread of infection; however, optimal cleaning approaches have not been established.

Avoidance and treatment of the patient’s contacts.

People with URI should reduce contact with others to avoid the spread of infection. Adults may be infectious from the day before symptoms begin through approximately 5 days after the onset of illness. Children may shed virus for several days before their illness begins, and they may remain infectious for up to 10 days after symptom onset.

Patients with pertussis may be contagious for weeks during the coughing phase. Severely immunocompromised persons may shed virus for weeks or even months. Patients with diphtheria should be isolated.

Immunization and immunoprophylaxis

Vaccination against Haemophilus influenzae type b has dramatically reduced rates of epiglottitis. Immunization against diphtheria and pertussis is recommended for nonimmunized patients.

To address the increased rate of pertussis cases in adolescents whose immunity has waned, the American Academy of Pediatrics recommends that adolescents receive a single dose of the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap).  Updated CDC recommendations are available, including guidance for children, pregnant patients, and adults (including those who may come into contact with young children). 

Prevention with complementary and alternative therapies

Complementary and alternative therapies and folk remedies are used by some to prevent URIs. Common choices include zinc, echinacea preparations, and vitamin C. However, conclusive evidence that these strategies reduce URI infection is inconsistent. Lactobacillus GG is being studied for a possible connection in reducing the incidence of respiratory infections.