The combination of nasal congestion, rhinorrhea, sore throat, cough, and malaise is the symptomatic profile that constitutes an uncomplicated upper respiratory tract infection (URI), also known as the common cold. Because no known cure exists for a URI, numerous products are available, each marketed with the promise of alleviating the associated symptoms and/or shortening the duration of illness. The evidence supporting these claims is variable and is the focus of this article, with an emphasis on complementary and integrative therapies.
Key points
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The current theory regarding upper respiratory tract infections (URIs) holds the inflammatory response to viral infection, rather than the virus itself, responsible for the symptoms.
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Treatment of URI remains focused on symptom management and the tincture of time.
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Antibiotics and surgery have no role in the treatment of an uncomplicated URI.
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Nasal decongestants offer modest but significant relief of nasal congestion, with a low incidence of adverse effects.
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Insufficient evidence supports the use of vitamin and herbal remedies in the prevention and/or treatment of URIs, although some studies have shown significant benefits in symptom reduction.
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Evidence supporting the use of acupuncture for URIs is too limited to offer a recommendation regarding this treatment.
Overview
The combination of nasal congestion, rhinorrhea, sore throat, cough, and malaise is the symptomatic profile that constitutes an uncomplicated upper respiratory tract infection (URI), also known as the common cold. It is a pervasive illness; approximately 25 million people in the United States visit their doctor every year seeking treatment for a URI. Nationally, the economic burden of URI is estimated to be approximately $40 billion per year, including $22 billion from nearly 200 million lost work days every year. Because no known cure exists for the common URI, numerous products are available for treatment, each marketed with the promise of alleviating the associated symptoms and/or shortening the duration of illness. The evidence supporting these claims is variable and is the focus of this article, with an emphasis on complementary and integrative therapies because these are being used with increasing frequency in the United States.
Overview
The combination of nasal congestion, rhinorrhea, sore throat, cough, and malaise is the symptomatic profile that constitutes an uncomplicated upper respiratory tract infection (URI), also known as the common cold. It is a pervasive illness; approximately 25 million people in the United States visit their doctor every year seeking treatment for a URI. Nationally, the economic burden of URI is estimated to be approximately $40 billion per year, including $22 billion from nearly 200 million lost work days every year. Because no known cure exists for the common URI, numerous products are available for treatment, each marketed with the promise of alleviating the associated symptoms and/or shortening the duration of illness. The evidence supporting these claims is variable and is the focus of this article, with an emphasis on complementary and integrative therapies because these are being used with increasing frequency in the United States.
Pathophysiology and anatomy
URIs are caused by a plethora of viruses, with rhinovirus being the most common causative agent. Other responsible viruses include coronavirus, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus. It is even likely that a portion of URIs are caused by viruses that have not yet been identified.
The pathophysiology of a URI begins with transmission of the offending agent, which may occur via 3 routes: touching one’s nose or eyes after contacting either an infected person or a contaminated object, inhalation of small particle aerosols that were produced by the cough of an infected person, or the sneeze of an infected person resulting in large particle aerosols landing on the nasal mucosa or conjunctiva. The viral agent travels from the eye to the nasal mucosa via the nasolacrimal duct. Once the virus infects the nasal mucosa, it is propelled to the nasopharynx through mucociliary action of the respiratory epithelium lining the nasal cavities. The virus then binds to epithelial cell receptors, which allow it to gain entrance into these cells. Within the epithelial cells rapid viral replication occurs.
The current theory regarding URIs holds the inflammatory response to viral infection, rather than the virus itself, responsible for the symptoms. In response to viral infection of the nasal epithelial cells, an upregulation of inflammatory mediators occurs, including cytokines such as interleukins 6 and 8, which drive the host’s inflammatory response. As a result, there is an influx of neutrophils, vasodilation, and an increase in vascular permeability that results in the leakage of plasma proteins into the nasal cavity. Additionally, parasympathetic stimulation occurs, which causes production of excess mucous. This process translates into nasal congestion, rhinorrhea, and sneezing.
One reason people are susceptible to recurrent URIs year after year is challenges to immunity. Some virus types, including respiratory syncytial virus, parainfluenza, and coronavirus, do not produce lasting immunity. Other viruses, including rhinovirus, adenovirus, and enterovirus, do produce lasting immunity but so many serotypes exist that one is still susceptible to recurrent infection. These challenges are also the reason that no antiviral medications are available that are effective in treating URIs. Thus, treatment of URIs remains focused on symptom management and the tincture of time.
Symptoms
The symptoms of the common URI include nasal congestion, sneezing, rhinorrhea, sore throat, headache, myalgia, and malaise. Fever may be present but is more common in children than adults. Symptom duration is usually 7 to 10 days but can be as long as 3 weeks. Drainage from rhinorrhea often begins clear but then may become thicker and discolored. Yellow or green nasal discharge is not an indication of a bacterial infection but rather of neutrophil infiltration, which is the hallmark of the immune system response.
Medical treatment approaches and outcomes
Antibiotics
Antibiotics have no role in the treatment of an uncomplicated URI with or without purulent rhinorrhea. Specifically, antibiotics do not decrease severity or duration of symptoms and commonly are associated with adverse effects, most commonly gastrointestinal issues, such as diarrhea. In the United States, unnecessary prescription of antibiotics results in an economic burden of nearly $800 million per year and puts the patient and society at risk for developing antibiotic-resistant strains of bacteria.
Oral and Intranasal Decongestants
Nasal congestion is one of the most common and bothersome symptoms of a URI, and therefore many over-the-counter cold remedies are geared toward relieving this symptom. Common oral decongestants include pseudoephedrine and phenylephrine. Phenylpropanolamine was previously used in over-the-counter preparations but has been removed from the market because of an associated risk of intracranial hemorrhage. Pseudoephedrine, a popular over-the-counter remedy for nasal congestion, has come under scrutiny recently because of its use in the illicit manufacturing of methamphetamines. Although still available over-the-counter, it is now only accessible behind pharmacy counters and its purchase is monitored.
A review of the current literature was completed in 2009 by Taverner and Latte to assess the efficacy of topical and oral decongestants in relieving nasal congestion. Only randomized, placebo-controlled trials were included in their review. Their analysis indicated that nasal decongestants offer modest but significant relief of nasal congestion with a low incidence of adverse effects. Symptomatic relief was supported by a physiologic response of a significant reduction in nasal airway resistance. The evidence supports recommending a single dose trial of decongestants for patients with a URI. Those who experience improvement in symptoms of nasal congestion should be encouraged to continue treatment for 3 to 5 days. It is important to inform patients to discontinue use of topical decongestants after this period because of the risk of a rebound increase in congestion, as is seen with rhinitis medicamentosa. Patients with hypertension and/or benign prostatic hypertrophy should be closely monitored if using oral decongestants because the α-adrenergic properties may exacerbate these conditions.
Intranasal Steroids
Topical steroid sprays used intranasally have been shown to have significant benefit in treatment of nasal inflammation that is characterized by a dominantly eosinophilic infiltration, such as allergic rhinitis and nasal polyposis. They have not, however, proven beneficial in the treatment of infectious nasal inflammation, such as the common cold/URI.
Intranasal Ipratropium Bromide
Ipratropium bromide is an anticholinergic agent that when used intranasally can decrease rhinorrhea associated with the common cold. It has not been shown to have an effect on nasal congestion. It is generally well tolerated, with nasal dryness, blood tinged mucous, and epistaxis being the most commonly reported adverse effects. For patients with a URI whose chief complaint is rhinorrhea, use of intranasal ipratropium bromide could be of benefit.
Antihistamines
Although antihistamines have a proven role in the treatment of allergy-associated nasal symptoms, they do not offer benefit in relief of sneezing, rhinorrhea, or nasal congestion associated with a URI. The main adverse affect is sedation, which is seen more commonly with first-generation antihistamines. The use of antihistamines is not recommended for the treatment of nasal symptoms associated with URI.
Nonsteroidal Anti-Inflammatory Agents
Nonsteroidal anti-inflammatory agents are known for their analgesic, antipyretic, and anti-inflammatory properties and have widespread use for a variety of ailments. For the common cold they have proven effective for reducing pain-related symptoms, including myalgias, headache, and otalgia. Despite their anti-inflammatory properties, a literature review completed by Kim and colleagues did not support the theory that they might be helpful in reducing respiratory symptoms associated with URI, such as cough, sneezing, or rhinorrhea.
Guaifenesin
Limited evidence is available on the utility of the expectorant guaifenesin in treating URI symptoms. In a review of 2 studies, Smith and colleagues identified conflicting data. In one study, patients reported no difference in cough but did report a decrease in the thickness of mucous; in the second study patients did experience a decrease in cough frequency. Because side effects are minimal, it is reasonable for patients to trial guaifenesin to determine if they experience benefit. Further study is needed to determine the overall effectiveness of guaifenesin in the treatment of URIs.
Patient self-treatments
Nasal Saline Irrigation
Nasal saline irrigation is often used as an adjunctive treatment for URIs. It can be used in the form of an atomized spray or lavage irrigation. The utility of nasal saline lies in its ability to clear excess mucous from the nasal cavities, improve mucociliary clearance, and reduce cough associated with postnasal drip. In general, studies on the use of nasal saline are limited because of the difficulty using an adequate control and thus inability to perform a blinded study. Additionally, numerous formulations and delivery methods are available for nasal saline, making comparisons between studies more difficult. Finally, outcomes are often based on patients subjectively reporting symptoms, allowing the introduction of bias.
In 2010, Kassel and colleagues performed an exhaustive literature review to assess the efficacy of nasal saline irrigation in the treatment of symptoms associated with URIs, the duration and severity of these symptoms, and the incidence of adverse effects associated with nasal saline use. Although evidence was limited, they found no statistically significant improvement in symptom severity or duration associated with the use of nasal saline. However, a reduction in time off of work and a trend toward decreased antibiotic use were seen. Adverse effects were minor, with approximately one-third of subjects reporting a dry or irritated nose. In the adult population, none of these effects was significant enough to cease treatment with nasal saline. Overall, the authors concluded that nasal saline may offer some benefit to adults with a URI. However, the current evidence is not sufficiently convincing to make it a routine intervention.
Heated Humidified Air
Inhalation of heated, humidified air has long been used as home remedy for the common cold. It is thought to provide symptomatic relief of nasal congestion through improving mucous drainage, and the rise in temperature may impede viral replication. The current literature shows conflicting data evaluating its efficacy, with some studies finding improvement of nasal symptoms after inhalation of warm humidified air, and other studies not. A review by Singh and Singh in 2011 pooled the results of randomized controlled trials on the topic and did not find that steam inhalation offered any consistent benefit to sufferers of the common cold. A large-scale, double-blinded study producing evidence of benefit is needed before heated, humidified air can be recommended as standard intervention.
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