Coughs, Colds and Sore Throats

Coughs, Colds and Sore Throats

Coughs, Colds and Sore Throats

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Cold

  • 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
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Flu

  • 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
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Colds vs. Flu: Key Points

  • 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 
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Flu Vaccinations

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)
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Cold Symptoms

  • Sore throat, sneezing
  • Runny or blocked nose
  • Cough, hoarse voice
  • Mild fever
  • Pressure in ears/sinuses
  • Headache
  • Myalgia
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Flu Symptoms

  • 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
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When to Refer

  • 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
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Differential Diagnoses and Complications

Differential diagnoses?

  • Influenza
  • Hayfever
  • Sinusitis (can accompany cold)

Complications?

  • Bacterial infections
  • Young children - acute otitis media
  • Respiratory tract illness
  • Co-morbidities
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Managing Colds

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

Non-pharmacological interventions

  • Adequate fluid intake
  • Reassurance and rest
  • Educate for the future
  • Complementary therapy, e.g. zinc/vitamin C are not proven but not harmful
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Treatment Options: Colds

  • 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
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Treatment Options: Colds

  • 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
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Sinusitis

  • 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
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Coughs

  • 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
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Causes of Coughs

  • 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
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Types of Cough

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
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When to Refer

  • 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
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Differential Diagnoses and Complications

Differential Diagnoses

  • Whooping cough
  • Asthma
  • Croup

Complications

  • Shortness of breath/wheezing
  • Chest pain
  • Whooping cough or croup
  • Pain on inspiration
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Differential Diagnosis

  • 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
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Treatment Options: Coughs

  • 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
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Treatment Options: Coughs

Depends on type of cough

Dry cough:

  • Demulcents
  • Suppressants (antitussives)
  • Sedating antihistamines)

Chesty

  • Expectorants
  • Demulcents
  • Decongestants
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Sore Throat

  • 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
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Other Causes of Sore Throat

  • 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
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When to Refer

  • 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
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Treatment Options: Sore Throat

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
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Treatment Options: Sore Throat

  • 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)
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Treatment in Children Under 6

  • 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
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