What treatment is recommended for a patient with congestion related to a respiratory infection?

Treatment for Congestion Related to Respiratory Infection

For symptomatic relief of nasal congestion from a respiratory infection, use a first-generation oral antihistamine combined with pseudoephedrine (not phenylephrine) as first-line therapy, or alternatively use a topical decongestant for no more than 3 days. 1

First-Line Oral Therapy

Combination antihistamine-decongestant therapy is the most evidence-based approach for post-viral nasal congestion:

• Dexbrompheniramine 6 mg twice daily plus pseudoephedrine 120 mg (sustained-release) twice daily is a recommended regimen 1
• Alternatively, azatadine 1 mg twice daily plus pseudoephedrine 120 mg twice daily 1
• The benefit comes from the anticholinergic properties of first-generation antihistamines, not their antihistamine action 1
• Improvement is expected within days to 2 weeks 1
• This combination has proven efficacy in randomized controlled trials specifically for post-viral nasal congestion 1

Pseudoephedrine is significantly superior to phenylephrine due to better oral bioavailability, as phenylephrine undergoes extensive first-pass metabolism in the gut 2, 1

Topical Decongestant Option

For rapid, superior relief, topical decongestants are more effective than oral agents but must be strictly time-limited:

• Oxymetazoline or xylometazoline nasal spray provides relief within minutes 2, 1
• Maximum duration is 3-5 days only to prevent rhinitis medicamentosa (rebound congestion) 3, 2, 4, 1
• Topical decongestants are superior to oral pseudoephedrine based on imaging studies showing reduced congestion of sinus and nasal mucosa 2
• Rebound congestion can develop as early as the third or fourth day of continuous use 2, 4

Adjunctive Symptomatic Measures

Additional supportive measures that provide symptomatic relief:

• Acetaminophen or ibuprofen for pain and fever 3
• Saline nasal irrigations to remove mucus and relieve symptoms 3
• Nasal steroid sprays may reduce symptoms after 15 days of use, but the benefit is small (14 people must use them to get 1 person better) 3

Safety Contraindications and Precautions

Screen carefully before prescribing oral decongestants:

• Use with extreme caution or avoid in patients with cardiac arrhythmias, angina pectoris, coronary artery disease, or cerebrovascular disease 2, 1
• Use with extreme caution or avoid in patients with uncontrolled hypertension, hyperthyroidism, glaucoma, or elevated intraocular pressure 2, 1
• Avoid during the first trimester of pregnancy due to reported fetal heart rate changes 2, 1
• Oral decongestants cause small increases in systolic blood pressure (0.99 mmHg) and heart rate (2.83 beats/min) 2

Ineffective Therapies to Avoid

Do not use the following for non-allergic post-viral congestion:

• Newer-generation antihistamines alone (loratadine, fexofenadine) are ineffective for non-allergic post-viral congestion 1
• Antihistamines without decongestants may worsen symptoms by drying nasal mucosa in non-allergic patients 3, 1
• Guaifenesin (expectorant) lacks evidence of clinical efficacy for nasal congestion 3, 1
• Oral steroid medicines should not be used routinely because they have side effects and do not relieve symptoms 3

Pediatric Considerations

Special precautions apply to children:

• Over-the-counter cough and cold medications should be avoided in children under 6 years of age due to lack of established efficacy and potential toxicity 1
• Oral decongestants are usually well-tolerated in children over 6 years when used at appropriate doses 1

Common Pitfalls

The most important caveat is avoiding prolonged topical decongestant use. Patients often continue using oxymetazoline or similar sprays beyond 3-5 days, leading to rhinitis medicamentosa—a cycle of worsening congestion requiring increasing doses 2, 4. If this occurs, the topical decongestant must be stopped completely and intranasal corticosteroids started to allow recovery 4.

Another common error is prescribing phenylephrine instead of pseudoephedrine. Phenylephrine has poor oral bioavailability and limited efficacy compared to pseudoephedrine 2, 1.