Common Cold Ppt 9r2v

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 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 it’s 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 it’s 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 it’s 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 • 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 WON’T 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 WON’T 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