What is the management approach for viral upper respiratory tract infections (URTI) with symptoms like wet cough and runny nose?

Management of Viral URTI with Wet Cough and Runny Nose

Viral upper respiratory tract infections with wet cough and runny nose should be managed with symptomatic relief only—antibiotics are not indicated as they are ineffective for viral illness and do not reduce symptom severity or duration. 1

Symptomatic Treatment Approach

First-Line Interventions

Analgesics and antipyretics should be offered for pain, fever, and inflammation:

• Acetaminophen or ibuprofen (NSAIDs) are recommended 2, 1
• These address constitutional symptoms and discomfort 2

Nasal saline irrigation provides modest symptomatic benefit:

• Can be used liberally with low risk of adverse effects 2, 1
• Provides cleansing action and minor improvements in nasal symptoms 2

Decongestant Options

Oral decongestants (e.g., pseudoephedrine) may provide symptomatic relief if no contraindications exist:

• Avoid in patients with hypertension or anxiety 2, 1
• Can be combined with first-generation antihistamines for enhanced effect on cough and postnasal drip 2

Topical decongestants can be used short-term:

• Limit use to 3-5 days maximum to prevent rhinitis medicamentosa 2, 1
• Effective for immediate congestion relief but rebound congestion is a significant risk 2

Cough Management

For wet/productive cough, expectorants may be considered:

• Guaifenesin can be used though clinical efficacy evidence is limited 2, 1
• Decision to use is largely based on patient preference 2

First-generation antihistamines (e.g., brompheniramine, diphenhydramine) combined with decongestants:

• More effective than newer non-sedating antihistamines for URTI-related cough 2
• Help reduce excessive secretions and postnasal drip that trigger cough 2
• Diphenhydramine can relieve runny nose, sneezing, and itchy/watery eyes 3

Additional Considerations

Intranasal corticosteroids may provide modest benefit:

• Not FDA-approved for viral URTI but can relieve facial pain and nasal congestion 2, 1
• Effect is small: 73% improvement with steroids vs 66% with placebo at 14-21 days 2
• Adverse events are rare, so use is based on patient preference and cost considerations 2

Hydration and rest are supportive measures that should be recommended 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics for viral URTI:

• Antibiotics are ineffective for viral illness and contribute to antibiotic resistance 2, 1
• Discolored nasal discharge does NOT indicate bacterial infection—it reflects neutrophil presence from inflammation, not bacteria 2, 1

Avoid newer non-sedating antihistamines:

• These are relatively ineffective for common cold symptoms compared to first-generation antihistamines 2

Educate patients on expected duration:

• Symptoms typically peak within 3 days and resolve within 10-14 days 2
• Pharmacists and clinicians should explain this natural course 2

When to Reassess or Escalate

Patients should return if:

• Symptoms persist beyond 3 weeks 1
• Fever exceeds 4 days 1
• Dyspnea worsens 1
• Patient stops drinking or consciousness decreases 1
• Symptoms worsen after initial improvement (suggests possible bacterial superinfection) 2