What is the recommended management for a patient with viral upper respiratory infection, possibly with underlying conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Management of Viral Upper Respiratory Tract Infection

Antibiotics should not be prescribed for viral upper respiratory tract infections, as they will not prevent progression to lower respiratory tract infections and contribute to antimicrobial resistance. 1, 2

Primary Management Approach

Symptomatic Treatment for Uncomplicated Viral URI

• Honey and lemon is the recommended first-line treatment for benign viral cough, as it is as effective as pharmacological treatments 2
• Most viral URIs are self-limiting and improve within 7-10 days with symptomatic treatment alone 3
• If cough suppression is needed, use dextromethorphan 30-60 mg (not the standard subtherapeutic OTC dose) for short-term use only 2
• Avoid codeine or codeine-containing products, as they have no greater efficacy than dextromethorphan but significantly more adverse effects 2

Critical Reassessment Points

• Advise patients to return if cough persists beyond 3 weeks, worsens despite initial management, or new concerning symptoms develop 2
• Consider that what appears as "recurrent URI" may actually represent acute exacerbations of underlying chronic lung disease 2

Management in Patients with Underlying Asthma

When Asthma Exacerbation is Present

If the patient has an acute asthma exacerbation concurrent with viral URI, systemic corticosteroids are essential regardless of the viral infection. 4, 5

• Administer prednisone 40-60 mg orally or hydrocortisone 200 mg IV within the first hour of presentation 4, 5
• Provide albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 5
• Administer high-flow oxygen (40-60%) to maintain SaO₂ >90% 5
• Prescribe antibiotics only when there is strong evidence of bacterial infection (radiographic pneumonia, purulent sputum with fever, or clinical sinusitis), using aminopenicillin for 5-7 days as first-line 4, 5

When Only Viral URI Without Exacerbation

• Continue maintenance asthma medications as prescribed
• Use symptomatic treatment as outlined above
• Monitor closely for development of exacerbation features

Management in Patients with Underlying COPD

Determining Need for Antibiotics in COPD Patients

Antibiotics are indicated only for specific COPD exacerbation patterns, not for simple viral URI symptoms. 1

Prescribe antibiotics when:

• Type I Anthonisen exacerbation (all three symptoms present): increased dyspnea, increased sputum volume, AND increased sputum purulence 1
• Type II Anthonisen exacerbation with purulence: two of the three symptoms above, when increased purulence is one of the two 1
• Severe exacerbation requiring invasive or noninvasive mechanical ventilation 1

Do NOT prescribe antibiotics for:

• Type II exacerbations without purulence 1
• Type III exacerbations (one or none of the cardinal symptoms) 1
• Simple viral URI symptoms without meeting exacerbation criteria 1

Antibiotic Selection for COPD Exacerbations

For patients WITHOUT risk factors for Pseudomonas:

• Use amoxicillin or tetracycline as first-line options 1

For patients WITH risk factors for Pseudomonas (≥2 of: recent hospitalization, frequent antibiotics [>4 courses/year or within last 3 months], severe disease [FEV₁ <30%], previous Pseudomonas isolation):

• Use ciprofloxacin or β-lactam with anti-pseudomonal activity 1
• Obtain sputum cultures before starting antibiotics 1

Corticosteroids in COPD with Viral URI

• Prednisolone is indicated for COPD exacerbations meeting criteria above 4
• Inhaled steroids do NOT prevent lower respiratory tract infections and may actually increase LRTI/CAP risk 1, 4
• Monitor for hyperglycemia, which occurs in nearly twice as many steroid-treated patients (RR 1.49) 4

Special Circumstances and Red Flags

Influenza Considerations

• Zanamivir (RELENZA) is NOT recommended for patients with underlying airways disease (asthma or COPD) due to risk of serious bronchospasm, including fatalities 6
• Corticosteroids are absolutely contraindicated in influenza pneumonia due to increased mortality 4
• Antiviral prophylaxis is only recommended in unusual situations (outbreaks in closed communities) 1

When to Suspect Bacterial Infection

• Radiographic evidence of pneumonia 4, 5
• Purulent sputum with fever 4, 5
• Clinical sinusitis 4, 5
• Discolored sputum alone does NOT indicate bacterial infection—it reflects inflammation, not infection 4

Pertussis Consideration

• If pertussis is suspected, perform diagnostic testing and prescribe macrolide antibiotics with isolation for 5 days from treatment start 2

Preventive Measures

Vaccination Recommendations

Annual influenza vaccination is recommended for:

• All patients aged ≥65 years 1
• Patients with chronic cardiac or pulmonary diseases 1
• Patients with diabetes mellitus, chronic renal disease, or hemoglobinopathies 1
• Institutionalized patients 1

Pneumococcal vaccination (23-valent polysaccharide) is recommended for:

• All adults aged >65 years 1
• Patients with COPD, congestive heart failure, or history of previous pneumonia 1
• Patients with chronic liver disease, diabetes mellitus, or functional/anatomic asplenia 1

What Does NOT Prevent Lower Respiratory Tract Infections

• Prophylactic antibiotics in COPD or chronic bronchitis 1
• Regular inhaled steroids or long-acting β2-agonists 1
• Oral mucolytics 1
• Regular physiotherapy 1
• Homeopathic substances 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively for viral URI symptoms—this contributes to antimicrobial resistance without clinical benefit 1, 2
• Do not use subtherapeutic doses of dextromethorphan (standard OTC dose); maximum cough suppression requires 60 mg 2
• Do not assume recurrent cough episodes are simple viral URIs—perform chest radiography and spirometry to identify underlying chronic lung disease 2
• Do not prescribe steroids for uncomplicated LRTI based on discolored sputum alone 4
• Do not continue zanamivir in patients who develop bronchospasm or respiratory decline 6