What is the initial management for a patient presenting with Upper Respiratory Infection (URI) symptoms, possibly with underlying conditions such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Initial Management of Upper Respiratory Infection Symptoms

For a patient presenting with URI symptoms, begin with symptomatic treatment using acetaminophen or ibuprofen, provide hydration and rest recommendations, and withhold antibiotics unless specific criteria for bacterial infection or COPD exacerbation are met. 1

Immediate Assessment Priorities

Rule out pneumonia and serious illness first before assuming simple viral URI. Look specifically for: 2

• New focal chest signs on auscultation (crackles, bronchial breathing)
• Dyspnea or respiratory rate ≥30 breaths/min
• Pulse rate >100 bpm
• Fever persisting >4 days
• Dull percussion note or pleural rub 2

If any of these are present, obtain chest X-ray to confirm or exclude pneumonia. 2 Consider C-reactive protein testing: CRP <20 mg/L makes pneumonia highly unlikely, while CRP >100 mg/L indicates pneumonia is likely. 2

Distinguishing URI from Lower Respiratory Tract Involvement

Viral URI characteristics: predominantly nasal symptoms (congestion, rhinorrhea), sore throat, absence of dyspnea, normal respiratory rate, and fever typically <4 days. 3, 2

Acute bronchitis indicators: cough as the predominant symptom, absence of focal chest signs, no dyspnea or tachypnea. 2 Note that purulent sputum alone does NOT indicate bacterial infection—it reflects inflammation, not bacterial involvement. 1

Special Consideration: Underlying Asthma or COPD

Consider lung function testing when ≥2 of the following are present: 3

• Wheezing on examination
• Prolonged expiration
• Smoking history
• History of allergy
• Previous consultations for wheezing or cough 3

Up to 45% of patients presenting with acute cough >2 weeks actually have underlying asthma or COPD rather than simple infection. 3 This distinction matters because β-agonists and steroids benefit these exacerbations. 3

COPD Exacerbation Criteria

Antibiotics are indicated for COPD exacerbation ONLY when ≥2 of the following Anthonisen criteria are present: 4

1. Increased breathlessness beyond baseline
2. Increased sputum volume
3. Development of purulent sputum 4

If these criteria are met, first-line antibiotic choice is amoxicillin-clavulanate 875mg twice daily for 5-7 days. 4

Symptomatic Management

Provide the following treatments for viral URI: 1

• Acetaminophen or ibuprofen for pain, fever, and inflammation 1
• Adequate hydration and rest 1
• Saline nasal irrigation for minor improvement in nasal symptoms 1
• Oral decongestants if no contraindications exist (hypertension, cardiac disease) 1

When Antibiotics Are NOT Indicated

Do NOT prescribe antibiotics for: 1

• Viral URIs (ineffective and contributes to resistance) 1
• Purulent nasal discharge alone 1
• Symptoms <10-14 days duration in otherwise healthy adults 4
• Acute bronchitis without COPD exacerbation criteria 4

When to Reassess or Escalate Care

Instruct patients to return if: 1

• Symptoms persist beyond 3 weeks
• Fever exceeds 4 days total duration
• Dyspnea worsens
• Patient stops drinking fluids
• Consciousness decreases 1

Consider hospital referral for: 3

• Age >65 years with comorbidities (COPD, cardiovascular disease, diabetes, chronic liver or renal failure) 3
• Temperature <35°C or ≥40°C 3
• Respiratory rate ≥30 breaths/min 3
• Blood pressure <90/60 mmHg 3
• Confusion or altered mental status 3
• Suspected pleural effusion or cavitation 3

Common Pitfalls to Avoid

Do not: 1

• Prescribe antibiotics for viral URIs based on patient pressure (most patients actually seek examination and explanation, not antibiotics) 1, 5
• Assume purulent discharge indicates bacterial infection 1
• Order imaging studies for uncomplicated acute sinusitis 1
• Delay appropriate antibiotic therapy when bacterial infection criteria are truly met 1

Do: 1

• Provide clear safety-netting advice about when to return 1
• Explain that most URIs are viral and self-limiting within 1-2 weeks 1
• Reassure patients while providing thorough examination 5