Coughs, Colds and Sore Throats

Coughs, Colds and Sore Throats

• Onset - 1-3 days

• Peak incidence - anytime of year

• Duration - 1-2 weeks

• Symptoms - sneeze, cough, congestion, discharge, sore throat

• Person presenting - patient

• Vaccination - no

• Onset - matter of hours

• Peak incidence - Winter (Dec - March)

• Duration - 1-2 weeks

• Symptoms - myalgia, chills, shivering, malaise, non-productive cough, loss of appetite

• Person presenting - third party

• Vaccination - yes

• Colds and flu are both caused by viruses
  • Colds - mild, self-limiting viral infection of the upper respiratory tract
  • Flu - acute respiratory illness caused by influenza virus (A, B or C)
• Cannot vaccinate against colds because:
  • caused by many different strains
  • immunity against one strain does not impart immunity against another
  • mind and self-limiting so no clinical need 

Flu vaccine prepared annually for strain advised by WHO, recommended for:

• Over 65s
• Over 6 months in clinical risk category
• Chronic respiratory or heart disease
• Renal or liver disease
• Chronic neurological disease
• Diabetes
• Immunocompromised
• Health care workers
• Pregnant women
• Children aged 2-3 years old and children in reception, year 1-4 (new nasal spray 2013)

• Sore throat, sneezing

• Runny or blocked nose

• Cough, hoarse voice

• Mild fever

• Pressure in ears/sinuses

• Headache

• Myalgia

• Severe malaise - up to 1-2 weeks

• Sudden onset

• Temperature of 38 degrees or higher

• Chills

• Muscular aches and pains

• Severe headache

• Loss of appetite

• Dry cough, sore throat, nasal discharge/obstruction, sneezing

• Flu symptoms/suspected flu
• Ear ache not responding to analgesia
• Sinus pain not responding to decongestants
• No improvement after 10-14 days of self medication

• Be careful of complications in very young/old and at risk patients, i.e. cardiac, diabetics, renal and respiratory patient, e.g. shortness of breath, chest pain

• In most cases OTC treatment will be appropriate

Differential diagnoses?

• Influenza
• Hayfever
• Sinusitis (can accompany cold)

Complications?

• Bacterial infections
• Young children - acute otitis media

• Respiratory tract illness

• Co-morbidities

• Self-limiting
• Focus on symptomatic relief
• Can use combination therapy
• Antibiotics are generally no good

Non-pharmacological interventions

• Reassurance and rest

• Educate for the future
• Complementary therapy, e.g. zinc/vitamin C are not proven but not harmful

• Steam inhalants
• Voltatile ingredients
• Analgesics
• Oral decongestants: sympathomimetics (supply restrictions due to abuse - crystal meth - and contraindicated with hypertensive medication)
• Topical decongestants
• Sedating antihistamines

• Hot drinks, liquids, tablets, capsules, steam inhalations, powders, nasal spray/drops - patient preference

• Steam inhalants - not for children, hydrate upper respiratory tract tissue to loosen mucus and reduce congestion
• Analgesics - paracetamol, ibuprofen, aspirin for over 16s, anti-pyretic, headache relief
• Topical decongestants - less systemic side effects, vasoconstricting effect, rapid and potent, maximum 7 days use
• Volatile ingredients - menthol and eucalyptus, can be used by all
• Sedating antihistamines - drowsy making, dry up secretions, antimuscarinic side effects
• Oral decongestants - decrease mucus production, maximum 7 days use, stimulant effect, many contrindications, liable to abuse - restricted

• Infection of one or more of the paranasal sinuses --> inflammation
• Fluid builds up in the usually air spaced sinuses --> bacterially infected
• Pain - maxillary sinuses most commonly
• Headache worse when lying down or bending

Treatment

•  Oral analgesics

• Topical/system decongestants

• Antibiotics for severe cases

• Cough is a protective/defensive reflex when the airway is irritated or obstructed --> clears the airway

• Cough is a symptom not a disease

• Most coughs are self-limiting and will resolve spontaneously

• More people consult in general practice for cough and upper respiratory tract infections than anything else

• Irritants, e.g. smoking, pollution, scented products

• Allergens, e.g. dust, mould, animal dander, pollen, grass

• Medication, e.g. ACE inhibitors

• Medical conditions, e.g. asthma, COPD, bronchitis, emphysema, congestive heart failure (lying down), GORD, tuberculosis, laryngitis, bacterial infection (e.g. sinusistis), viral infection (e.g. influenza), upper airways cough syndrome - post nasal drip (lying down)

• Stress

• Excessive mucus

Productive (chesty)

• Chesty or loose
• With sputum/phlegm
• Excess secretions produced
• Helpful - clears the phlegm

Non-productive (dry)

• Dry/irritating/tickle in throat
• Upper airways get inflamed
• No sputum/phlegm
• Stimulation of cough centre with no excess secretions
• Serves no beneficial purpose

• Cough lasting over 3 weeks
• Recurrent night time cough in children
• Suspected bacterial infection
• Coughing blood

Sputum colour:

• Non-coloured (clear or whitish) - uninfected
• Green/yellow or rusty - infection - refer

• Blood - haemoptysis - refer
• Pink and frothy - heart failure - refer

Differential Diagnoses

• Whooping cough
• Asthma
• Croup

Complications

• Shortness of breath/wheezing
• Chest pain

• Whooping cough or croup
• Pain on inspiration

• Croup - viral infection, most common between 6 months and 3 years of age, harsh and barking cough, hoarse voice, noisy breathing on inspiration (stridor), often worse at night

• Whooping cough (pertussis) - bacterial infection, very infectious, pattern - mild, dry cough and mild fever - cough gets worse - bouts of intense coughing - face often is red - breathing in gives whooping sound, immunisation

• Asthma - recurrent night time cough - first sign, allergies, family history

• Expectorants - loosen muscus, useful for productive chesty coughs
• Demulcents - no active ingredients, suitable for all, high sugar content
• Cough suppressants - codeins unsuitable <18, useful for non-productive dru coughs, not for chesty coughs
• Sedating antihistamines - drowsy making, dry up secretions, antimuscarinic side effects

Other things to consider:

• Sugar content - diabetics, children, sugar free alternatives
• Non-pharmacological advice - steam inhalations (productive coughs), high fluid intake

Depends on type of cough

Dry cough:

• Demulcents

• Suppressants (antitussives)
• Sedating antihistamines)

Chesty

• Demulcents

• Decongestants

• Pharyngitis and Tonsilitis = sore throat
• Laryngitis = soreness lower down and hoarse voice

Causes:

• Most sore throats are vital, can be bacterial - streptococcal
• Bacterial more common in school children
• Tonsils and pharynx are red, yellow exudate and swollen glands
• Fungal, e.g. Candida
• Clinically difficult to differentiate between viral and bacterial
• Associated with upper respiratory tract infection (viral) - often 1st sign
• Self limiting ~7 days

• Smoking

• Glandular fever most common in young adults and teenagers

• Rheumatic fever, quinsy, immunosuppressed patients

• Early sign of chickenpox, mumps, measles

• Obstruction, e.g. due to a tumour

• Medication, e.g. Carbimazole - refer immediately - indicative or bone marrow suppression, steroid patients, steroid inhalers, e.g. budensonide or beclometasone - check inhalation technique

• Duration of longer than 2 weeks
• Suspected bacterial infection
• Painful in absence of cold/flu symptoms and no improvement after 48 hours
• Hoarseness for longer than 3 weeks
• Dysphagia (difficulty swallowing)
• Associated skin rash
• Failed medication
• Repeated bouts of infection
• Side effect of medication - Captopril, Carbimazole, Cytotoxics, Neuroleptics, Sulfasalazine

Aim to:

• Relieve symptoms

• Shorten illness duration

• Prevent complications

• Simple analgesics, e.g. paracetamol/ibuprofen

• Gargling with aspirin/salt water - little evidence

• Careful with doses and age ranges

• Pastilles and lozenges - antibacterial (e.g. Benzalkonium Cetylpyridinium), local anaesthetic can cause sensitisation (e.g. Benzocaine), anti-inflammatory effect (e.g. Flurbiprofen, Strefen), good contact time, glycerin honey and lemon pastilles, volatile ingredients (e.g. menthol or eucalyptus), high sugar content, sugar free versions are available

• Mouthwashes and sprays - limited contact time, good antiseptic and numbing properties, mechanical effect of gargles assist removal of microbes from the pharynx, anti-inflammatory (e.g. Benzydamine, Difflam), local anaesthetic (e.g. benzocaine, lidocaine)

• Restricted to paracetamol/ibuprofen, non-pharmacological treatment, e.g. honey and lemon, vapour rubs/inhalants (not steam), sodium chloride nasal drops in infants
• OTC products containing antihistamines, antitussives, expectorants and decongestants (oral or topical) should not be used
• Careful with doses for older children and only use one product at a time

• Symptoms in young children and babies: fever, cough, nasal congestion, restlessness/irritability
• Earache common complicator