What primary care approach is recommended for a patient with an Upper Respiratory Infection (URI) and a burning chest?

Primary Care Management of URI with Burning Chest

For a patient with URI and burning chest symptoms, you should first rule out pneumonia by assessing for new focal chest signs, dyspnea, tachypnea, or fever lasting more than 4 days—if any are present, obtain a chest X-ray to confirm or exclude pneumonia. 1

Initial Assessment: Distinguish URI from Lower Respiratory Tract Infection

The burning chest sensation requires immediate evaluation to differentiate between simple tracheobronchitis (part of URI) and pneumonia, which carries higher morbidity risk. 1

Key clinical indicators that suggest pneumonia rather than simple URI:

• New focal chest signs on auscultation 1
• Dyspnea or tachypnea 1
• Pulse rate >100 bpm 1
• Fever persisting >4 days 1

If pneumonia is suspected based on these criteria, obtain a chest X-ray for confirmation. 1

Use of C-Reactive Protein (CRP) Testing

If clinical suspicion for pneumonia exists but is uncertain, CRP testing can help stratify risk: 1

• **CRP <20 mg/L** (with symptoms >24 hours) makes pneumonia highly unlikely 1
• CRP >100 mg/L makes pneumonia likely 1
• If doubt persists after CRP testing, proceed with chest X-ray 1

Management if Pneumonia is Ruled Out

If the patient has URI with tracheobronchitis (burning chest from airway inflammation) but no pneumonia:

For Symptomatic Relief of Burning Chest/Cough:

First-line treatment: Inhaled ipratropium bromide for persistent cough, which is the only recommended inhaled agent for URI-related cough suppression. 2, 3 This works through anticholinergic activity in the airways with minimal systemic absorption (only 7%). 2

Do NOT prescribe: 1, 2, 3

• Cough suppressants (codeine, dextromethorphan) - limited efficacy 2, 3
• Expectorants, mucolytics 1
• Antihistamines 1
• Inhaled corticosteroids 1
• Bronchodilators 1

Additional Symptomatic Management:

• Analgesics (acetaminophen or ibuprofen) for chest discomfort and general malaise 3, 4
• Pseudoephedrine for nasal congestion if present 3
• Throat lozenges if sore throat accompanies the burning sensation 3
• Adequate hydration and rest 3

Red Flags Requiring Re-evaluation or Referral

Monitor carefully and consider referral if the patient has: 1

• Age >65 years with comorbidities (COPD, diabetes, heart failure) 1
• Previous hospitalization in past year 1
• Current use of oral glucocorticoids 1
• Recent antibiotic use (previous month) 1
• Confusion or diminished consciousness 1
• Respiratory rate >30 1
• Blood pressure <90/60 1

Return immediately if: 3

• Symptoms persist beyond 10 days without improvement 3
• Symptoms worsen after initial improvement 3
• High fever develops with purulent discharge 3

Expected Clinical Course

Most uncomplicated viral URIs with tracheobronchitis resolve within 5-7 days. 3 Respiratory symptoms typically peak by days 3-6 before improving. 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics for uncomplicated URI with burning chest unless pneumonia is confirmed—this is viral tracheobronchitis. 1, 3
• Do not order routine microbiological testing in primary care for URI. 1
• Avoid the temptation to prescribe combination cold medications or traditional cough suppressants, as they lack proven efficacy and increase unnecessary medication exposure. 2, 3