It usually starts with a tickle in the throat and perhaps mild fatigue. Just plain tired when you don't expect to be tired. Congestion and runny nose, sore throat and sometimes a fever and body aches follow. Next may come a cough that keeps you awake at night. With these symptoms comes the recognition and dismay that you have a "cold." This constellation of symptoms adds up to general inconvenience and misery.

The Upper Respiratory Tract Infection (URI) is one of the most common complaints in all primary care and emergency care practices. Even though it is considered a "self-limited" disease and relatively benign in terms of some critical illnesses that are seen in any medical practice it has a tremendous impact on the health care system and society.

The URI is estimated to cost $3.5 BILLION a year in the US alone, and accounts for 40 percent of the time lost from jobs and as many as 23 million lost school days. It is an easily acquired illness that sweeps through communities and families causing mild to moderate misery and sending many to their doctor for care and advice.

I hope that this article can present a clear picture of what the URI is, how to treat it if you are infected and how best to protect yourself.

• What We Know About the URI
• Treatments of a Viral Respiratory Tract Infection
• When to Seek Medical Help
• How to Prevent a Cold

What We Know About the URI

We know that greater than 90 percent of upper respiratory tract infections are viral. Viruses are sophisticated infectious agents that are self limited -- meaning they resolve on their own. There are over 100 different types of viruses that infect the upper respiratory tract.

Each virus is different in strength (or virulence) and affects each person differently.

If your immune system has been exposed to a similar virus in the past your experience of the URI may be short and mild compared to someone who has never been infected with that strain of virus. This explains the often confusing experience of your friend being sick for five days while you are ill for ten.

Your general health also affects your response to a viral illness. A twenty year-old healthy college student will experience the URI differently than a fifty year-old with immune compromise from cancer and smoking, or a twenty year-old with allergies and asthma.
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Treatments of a Viral Respiratory Tract Infection

First and foremost, antibiotics DON'T work.

In the past it was common knowledge that if you were blowing out or coughing up discolored (green) mucous that you had a bacterial infection and needed antibiotics. More recent research indicates that the color of mucous is not necessarily related to bacterial infection.

In the past, about day 5-7, when most patients just wanted the whole thing to be over they came into the doctor's office and got antibiotics - just about the time the viral illness had run its course and they would have gotten better naturally. Of course, everyone associated the antibiotic with the resolution of the illness. This misuse of antibiotics is one part of the growing problem of antibiotic-resistant bacteria and makes it more difficult to treat bacterial infections.

At the Palo Alto Medical Foundation we are striving to use antibiotics only when clearly necessary.

Basic Treatment

Rest and fluid intake are critical to recovering from a viral upper respiratory illness.

Illness, like health, takes time. In our busy and very hectic life with commitments to our children, marriage or relationship and work no one has the time to be sick. There are play-dates, work presentations, family gatherings, holidays, marriages, vacations and just life in general that simply preclude any illness. Unfortunately, illness does not respect your social or work schedule. Rest allows the immune system to deal with the virus. Fluids keep you well hydrated and thin your mucous to keep your lungs and sinuses from becoming over-congested with thick mucous. If you don't get enough consistent rest and plenty of fluids every other treatment will be less effective.

Over-The-Counter Medication

Over-the-counter medication is for symptom relief. It is not a cure but can allow you to rest more easily and to control the more irritating symptoms. Unfortunately, if you walk into a pharmacy you will confront shelves with literally thirty to forty different preparations to relieve your symptoms. This can be very confusing, especially when you are feeling tired and ill.

In general, the advice is to avoid medication you don't need. I think it is appropriate to take medication tailored to your specific symptoms and any health care problems you might have. It is always important to check for interactions with the medication prescribed by your doctor.

There are only a few ingredients used in cough and cold preparations. Most multi-symptom preparations usually use some combination of medications. Take as directed on the packaging. Generics are just as effective as the brand name medications.

A reasonable medication routine that I often recommend for healthy adults depending on their symptoms is:

1. Tylenol® (acetaminophen) 325 mg two tablets every four hours for pain, fever, and discomfort.

2. Sudafed® 12 Hour (Pseudoephedrine 120 mg extended release) once in the morning for nasal congestion. Don't take this at night as it may keep you awake. If you have high blood pressure, please check with your doctor.

3. Afrin® 12 Hour nasal spray (oxymetazoline) and/or Benadryl® 25 mg (diphenhydramine) before bed for nasal congestion. These medications usually don't stimulate you and will allow you to sleep.

4. Robitussin DM® for cough. This is a combination of an expectorant and cough suppressant.

5. Cepacol® lozenges for temporary sore throat relief.

Of course, drink lots of fluids and rest as much as possible.

Each person is unique and will discover a combination of treatments that will work best for him.
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When to Seek Medical Help

It is always difficult to give generic written advice when each experience of illness is so individual. If you are worried or feel worse than you expect, it is important to call for advice or to see your doctor. The following are the clinical symptoms that often warrant evaluation.

Fever

In general, a fever of 100º - 102º is expected during the initial 2 days of a viral illness. Seek advice or care if:

• The fever is exceptionally high - 103o and above.
  
• The fever is prolonged or not controlled by acetaminophen.
  
• The fever returns during the course of the illness, especially with new symptoms.

Prolonged Course

Most viral illnesses follow a pretty predictable course and last between 7-14 days. If your symptoms are not improving over time, or a cough is prominent and keeping you awake at night, or the course of the illness simply continues, it is important to seek medical advice.

Underlying Illness

If you have an underlying illness like asthma, diabetes or cancer it is important to seek medical assistance or advice.

Change of Symptoms

Sometimes a viral infection will lead to a secondary bacterial infection. If your symptoms change or become suddenly more severe, it is important to seek evaluation.

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How to Prevent a Cold

The best way to prevent an upper respiratory infection is to avoid the virus and support your immune system.

1. WASH YOUR HANDS. Wash often, especially after touching another person. Carry an alcohol-based non-water hand wash (Purell is one brand) and use while traveling or shopping. I know it seems straight-forward and simple, but research indicates that only 35 percent of people wash their hands after using the restroom! I am sure this indicates that most people are not taking the time to wash their hands 8-10 times a day.

2. DON'T TOUCH YOUR FACE. The virus transfers from your hands to your eyes and nose, and then invades your mucous membranes to start the actual infection.

3. IMMUNE SUPPORT. Stress management, regular exercise, a diet with five or more servings of fruits and vegetables, fluids and appropriate rest are the best investment in your overall immune system.

The experience of any illness is often humbling, reminding us of our human frailty. Illness demands that we slow down and mind what is important in life. As unique and personal as each experience of illness is, it always affects our community of family and friends. My best advice is to seek out the support of family and friends, let your community support you as you would support them. A little support goes a long way towards healing.
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