How to approach a patient with a cold, considering their demographic information, past medical history, and symptom severity?

Approach to a Patient with a Cold

For a patient presenting with cold symptoms, immediately assess for red flags requiring urgent intervention, then provide symptomatic relief with combination antihistamine-decongestant products while educating that antibiotics are never indicated for uncomplicated viral upper respiratory infections. 1, 2

Initial Assessment and Red Flag Identification

Begin by ruling out life-threatening conditions and complications that require immediate intervention:

• Assess respiratory status for signs of distress including increased respiratory rate, intercostal retractions, breathlessness with chest findings, cyanosis, or altered consciousness 1
• Check for hemoptysis (any amount warrants chest radiograph) 2
• Measure temperature—fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement suggests bacterial complication 2, 3
• Evaluate for severe unilateral facial pain indicating possible bacterial sinusitis 2, 3
• Identify "double sickening" pattern (initial improvement followed by worsening), which suggests bacterial superinfection 2, 3
• Perform pulse oximetry if respiratory symptoms are prominent 1
• Obtain chest radiograph if pneumonia is suspected based on tachypnea, tachycardia, dyspnea, or abnormal lung findings 1

Implement infection control immediately: provide tissues for respiratory secretions, ensure hand hygiene, consider masking the patient if tolerated, and maintain 3-foot separation in waiting areas 1

Classify Cough Duration to Guide Management

Duration determines your diagnostic and therapeutic approach:

• Acute (<3 weeks): Most likely viral common cold requiring only symptomatic management 1, 2
• Subacute (3-8 weeks): Determine if postinfectious versus other causes 1
• Chronic (>8 weeks): Requires systematic evaluation for upper airway cough syndrome, asthma, non-asthmatic eosinophilic bronchitis, and GERD 4

Critical Diagnostic Pitfall to Avoid

Do NOT diagnose bacterial sinusitis during the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics. 4, 2 Bacterial rhinosinusitis should only be suspected if at least 3 of 5 criteria are present: purulent nasal discharge, severe local pain, fever >38°C, "double sickening" pattern, or elevated inflammatory markers 2, 3

Symptomatic Treatment Algorithm for Uncomplicated Cold

First-line therapy (most effective):

• Combination antihistamine-decongestant-analgesic products provide superior relief with 1 in 4 patients experiencing significant improvement (NNT 5.6). 2 Specifically, first-generation antihistamine (brompheniramine) plus sustained-release pseudoephedrine effectively reduces congestion, rhinorrhea, postnasal drip, and throat clearing 4, 2
• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) for headache, ear pain, muscle/joint pain, malaise, and sneezing 2

Additional symptomatic options:

• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit 2
• Topical nasal decongestants are effective but limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 2
• Ipratropium bromide nasal spray for rhinorrhea (does not improve congestion) 2
• Dextromethorphan 60 mg for cough suppression (standard OTC doses likely subtherapeutic) 2
• Honey for cough in patients >1 year old 1, 2
• Nasal saline irrigation for modest symptom relief 2

Zinc supplementation—timing is critical:

• Zinc lozenges (≥75 mg/day using acetate or gluconate formulations) significantly reduce cold duration ONLY if started within 24 hours of symptom onset 2, 3
• No benefit if symptoms already established beyond 24 hours 2, 3

What Does NOT Work (Avoid These)

• Antibiotics have no benefit for uncomplicated common cold and contribute to antimicrobial resistance 2, 5
• Non-sedating antihistamines (newer generation) are ineffective 4, 2
• Intranasal corticosteroids for acute cold symptoms 2

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. 4, 2, 3

Continue symptomatic treatment with combination products and consider:

• Intranasal corticosteroids for post-viral rhinosinusitis (symptoms >10 days without improvement) 3
• First-generation antihistamine/decongestant for persistent postnasal drip 1
• Inhaled bronchodilators if bronchial hyperresponsiveness is suspected 1

Only 0.5-2% of viral URIs develop bacterial complications. 2, 3 Antibiotics are not justified even when symptoms are prolonged beyond 7 days unless bacterial infection criteria are met 2, 3

Patient Education and Expectations

• Cold symptoms typically last 7-10 days, with up to 25% lasting 14 days 2, 3
• The illness is self-limiting and viral—antibiotics will not help 2
• Adequate fluid intake to avoid dehydration 1
• Hand hygiene is the best prevention method 1, 6

Special Population Considerations

Pediatric patients:

• Acetaminophen/paracetamol for fever and pain 2
• Do NOT use over-the-counter cough and cold medications in children <4 years due to potential harm without benefit 5, 6
• Honey for cough (only in children ≥1 year) 1, 6
• Nasal saline irrigation 6

Pregnant women:

• Acetaminophen/paracetamol is first-line for pain and fever 2

High-risk patients (elderly, comorbidities, immunocompromised):

• Follow same initial algorithm but maintain lower threshold for complications 1
• Consider expanded differential diagnosis in immunocompromised patients 1