What are the symptoms and treatment options for a patient with a common cold, considering potential underlying conditions such as asthma or other respiratory diseases?

Common Cold Symptoms and Management

Core Symptoms

The common cold presents with a predictable constellation of symptoms that evolve over 7-14 days, with sore throat appearing first, followed by nasal congestion becoming most bothersome on days 2-5, and cough dominating later in the illness. 1, 2

Primary Symptoms (Days 1-4)

• Sore throat - typically the harbinger symptom, most prominent on day 1 2, 1
• Nasal congestion - becomes the most bothersome symptom on days 2-5 2, 1
• Rhinorrhea (runny nose) - present throughout, may become mucopurulent after a few days (this does NOT indicate bacterial infection) 3
• Sneezing - frequent in early phase 4, 2
• Headache - common accompaniment 2, 1
• Postnasal drip - contributes to throat clearing and cough 4, 3

Secondary Symptoms

• Cough - less prominent initially but becomes most bothersome on days 6-7 and may persist up to 14 days 2, 1
• Facial pressure/pain - common but not severe 3, 4
• Ear fullness - due to Eustachian tube involvement 3, 1
• Hyposmia/anosmia (reduced smell) - from nasal inflammation 3, 4
• Low-grade fever and myalgia - typically resolve within 3-5 days 3, 5
• General malaise - throughout illness 3, 5

Expected Duration

• Typical duration: 7-10 days in adults 1, 5
• Up to 25% of patients experience symptoms (particularly cough and nasal discharge) for 14 days - this is entirely normal and does NOT indicate bacterial infection 1, 6, 3
• Children's colds last 10-14 days on average, longer than adults 7

Critical Red Flags Requiring Immediate Evaluation

These symptoms indicate potential complications and require medical assessment:

• Hemoptysis (any amount) - warrants chest radiograph 1
• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement 1, 6
• Severe unilateral facial pain - suggests bacterial sinusitis 1, 6
• "Double sickening" pattern - initial improvement followed by worsening 1, 6
• Acute breathlessness - assess for asthma exacerbation 1
• At least 3 of 5 bacterial criteria: discolored discharge + severe local pain + fever >38°C + double sickening + elevated inflammatory markers 1, 6

Common Pitfall to Avoid

Do NOT diagnose bacterial sinusitis in the first 10 days - 87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics 1. Only 0.5-2% of viral URIs develop bacterial complications 1, 6.

Evidence-Based Treatment Algorithm

First-Line Treatment: Combination Products

Use combination antihistamine-decongestant-analgesic products as they provide superior symptom relief compared to single agents, with 1 in 4 patients experiencing significant improvement (NNT 5.6). 1, 3

• Specific effective combination: First-generation antihistamine (brompheniramine) + sustained-release pseudoephedrine + analgesic 1, 3
• These combinations work in adults and older children but have no evidence of effectiveness in young children 3
• Benefits must be weighed against side effects (drowsiness, dry mouth) 3

Individual Symptom-Targeted Therapies

For nasal congestion:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 1, 3
• Topical nasal decongestants are effective BUT limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1

For rhinorrhea:

• Ipratropium bromide nasal spray effectively reduces runny nose but does NOT improve congestion 1, 3
• Side effects are well-tolerated and self-limiting 3

For pain, headache, and malaise:

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are most effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 1, 3
• Acetaminophen/paracetamol may help nasal obstruction and rhinorrhea but does NOT improve sore throat, malaise, sneezing, or cough 1, 3

For cough:

• Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard OTC doses are likely subtherapeutic 1
• Menthol inhalation provides short-lived relief 1
• Honey and lemon is recommended as simple, inexpensive home remedy with patient-reported benefit (honey only for children ≥1 year old) 1, 5
• Avoid opiate antitussives due to significant adverse effects without clear superiority 1

Adjunctive Therapies with Evidence

Zinc lozenges (≥75 mg/day):

• CRITICAL TIMING: Must start within 24 hours of symptom onset to be effective 1, 3
• Use zinc acetate or zinc gluconate formulations 1, 3
• No benefit if symptoms already established beyond 24 hours 1
• Side effects: bad taste and nausea 3, 1

Nasal saline irrigation:

• Provides modest symptom relief, particularly beneficial in children 1, 3
• Helps dilute secretions and facilitate elimination 1

Vitamin C:

• May reduce duration and severity in some individuals when taken regularly 3
• Low cost and safe, worth individual trial 3

Pediatric-Specific Management

• Acetaminophen/paracetamol for fever and pain 1
• Honey (for children ≥1 year old) for cough 1, 5
• Nasal saline irrigation 1, 5
• Topical ointment containing camphor, menthol, and eucalyptus oils 5
• DO NOT use over-the-counter cold medications in children <4 years - potential for harm without benefit 5, 8

What Does NOT Work (Avoid These)

Antibiotics:

• No benefit for uncomplicated common cold and contribute to antimicrobial resistance 1, 3
• Even when symptoms persist beyond 7-10 days, antibiotics are NOT indicated unless bacterial criteria are met 1, 6

Intranasal corticosteroids:

• Not effective for acute cold symptoms 1, 3
• May be beneficial only if symptoms suggest post-viral rhinosinusitis (>10 days) 6

Non-sedating antihistamines:

• Newer generation antihistamines are ineffective 1
• Only first-generation (sedating) antihistamines in combination products show benefit 3, 1

Steam/heated humidified air:

• No proven benefits or harms 3

Echinacea:

• Not shown to provide benefits for treating colds, though weak benefit from some products possible 3

Special Considerations for Underlying Conditions

Asthma Patients

• Monitor for acute breathlessness indicating asthma exacerbation 1
• Viral URIs are common asthma triggers requiring increased bronchodilator use
• Maintain regular controller medications throughout cold

Chronic Respiratory Disease

• Higher risk of bacterial superinfection if symptoms worsen after initial improvement 1, 6
• Lower threshold for medical evaluation if fever develops or dyspnea worsens

Pregnant Women

• Acetaminophen/paracetamol is first-line for pain and fever 1
• Avoid NSAIDs, especially in third trimester
• Nasal saline irrigation is safe and effective 1

Management of Prolonged Symptoms (>10 Days)

Approximately 25% of patients continue with cough and nasal discharge up to 14 days - this is normal and does NOT indicate bacterial infection. 1, 6, 3

Approach to Persistent Symptoms:

• Continue symptomatic treatment with combination products 6
• Consider intranasal corticosteroids for post-viral rhinosinusitis 6
• Only suspect bacterial infection if ≥3 of 5 criteria present: discolored discharge + severe local pain + fever >38°C + double sickening + elevated inflammatory markers 1, 6

Key Teaching Point:

Mucopurulent (colored) nasal discharge is NOT a specific sign of bacterial infection - it occurs due to neutrophil influx during normal viral infection resolution 3. Do not prescribe antibiotics based on discharge color alone.