Management of Acute Viral Upper Respiratory Infection with Cough and Rhinorrhea
For a patient with cough and rhinorrhea consistent with a viral upper respiratory infection, reassure them that antibiotics are not indicated, recommend supportive care with honey and lemon or dextromethorphan-containing cough suppressants, acetaminophen for discomfort, and menthol lozenges, while emphasizing that most symptoms resolve without medical intervention. 1
Initial Assessment and Red Flags
Most short-term coughs with rhinorrhea are due to viral infections and do not require physician evaluation. 1 However, immediately refer or escalate care if the patient presents with:
- Hemoptysis (coughing up blood) 1
- Breathlessness or respiratory distress 1
- Prolonged fever with systemic illness 1
- Pre-existing conditions (COPD, heart disease, diabetes, asthma) 1
- Recent hospitalization 1
- Symptoms persisting beyond 3 weeks 1
First-Line Treatment Approach
Symptomatic Management
Antibiotics are not indicated even if the patient is producing colored phlegm, as this is a viral illness. 1
Recommended over-the-counter therapies:
Cough suppressants containing dextromethorphan are the most effective pharmacologic option for symptomatic relief in adults. 1, 2 Note that dextromethorphan's effectiveness has not been demonstrated in children and adolescents. 3
Acetaminophen (paracetamol) for fever, malaise, and body aches. 1
Menthol lozenges or vapor may provide symptomatic relief. 1
Home remedies such as honey and lemon are recommended as first-line non-pharmacologic options. 1
Important Caveats About Antitussives
- Codeine has not been shown to effectively treat cough caused by the common cold. 3
- Central-acting antitussives like codeine and dextromethorphan should only be considered when other measures fail in chronic cough scenarios, not for acute viral illness. 1
Nasal Symptom Management
For significant rhinorrhea and nasal congestion:
Topical (intranasal) and oral nasal decongestants can relieve nasal symptoms in adolescents and adults but should be limited to 3 days maximum to avoid rebound congestion. 3
Antihistamines or combination antihistamine/decongestant therapies can modestly improve symptoms in adults, though benefits must be weighed against sedation and other side effects. 3
Newer nonsedating antihistamines are ineffective against cough. 3
Supportive Care Measures
Humidified air and adequate fluid intake may be useful without adverse side effects. 3
Smoking cessation counseling is critical, as continued smoking worsens symptoms. 1
Hand hygiene and respiratory etiquette to prevent transmission to others. 1
When to Consider Alternative Diagnoses
If symptoms persist beyond 2-3 weeks, consider:
Pertussis (whooping cough) if paroxysmal coughing, post-tussive vomiting, or inspiratory whooping sound is present. 1, 4 This requires nasopharyngeal culture and macrolide antibiotic therapy (azithromycin) if confirmed. 1, 4
Upper airway cough syndrome (post-nasal drip) may require a trial of intranasal corticosteroids for 1 month if prominent upper airway symptoms persist. 1, 5
Asthma, gastroesophageal reflux disease, or other chronic causes should be evaluated systematically if cough becomes chronic (>8 weeks). 1, 6
What NOT to Do
Do not prescribe antibiotics for uncomplicated viral upper respiratory infections with cough and rhinorrhea. 1
Do not use intranasal corticosteroids as first-line therapy for acute viral rhinorrhea—these are reserved for allergic rhinitis or chronic upper airway cough syndrome. 5, 7
Do not recommend vitamin C, zinc, or Echinacea for treatment, as these have not been shown to be effective. 3