Discussion

Upper respiratory tract infection is a non-specific term that involves inflammation of the
respiratory mucosa from the nose, paranasal sinuses, pharynx, larnynx and bronchi, not
including the alveoli. It causes localized symptoms that constitute several overlapping
syndromes: sore throat (pharyngitis), rhinorrhea (common cold), facial fullness and pain
(sinusitis), and cough (bronchitis). The prototype URTI illness is known as the common cold,
which will be focused upon, in addition to pharyngitis, sinusitis, and tracheobronchitis.
Etiology
Viruses cause most upper respiratory tract infections with rhinovirus, parainfluenza virus,
coronavirus, adenovirus, respiratory syncytial virus, Coxsackie virus, human metapneumovirus,
and influenza virus accounting for most cases. For bacterial pharyngitis, group A beta-hemolytic
streptococcus (GABHS) is most commonly associated. Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis. are the most common organisms that cause
the bacterial superinfection of viral acute rhinosinusitis.
Pathogenesis
Viruses that cause upper respiratory tract infection are spread by small-particle aerosols, largeparticle-aerosols and direct contact (hand-to-hand contact with subsequent passage to the
nostrils or eyes). Direct invasion of the respiratory epithelium results in symptoms corresponding
to the areas involved. The respiratory viruses have evolved different mechanisms to avoid host
defenses. Infections with rhinoviruses and adenoviruses result in development of serotypespecific protective immunity. However, recurrence of illness with these pathogens occurs
because of the large number of distinct serotypes of each virus. Influenza virus have the ability
to change the antigens presented to the surface of the virus, thus behaving like multiple viral
serotypes.
Viral infection of the nasal epithelium can be associated with destruction of the epithelial lining,
as with influenza viruses and
adenoviruses, or there can be no apparent histologic damage, as with rhinoviruses and RSV.
Infection of the nasal epithelium is associated with an acute inflammatory response
characterized by release of a variety of inflammatory cytokines and infiltration of the mucosa by
inflammatory cells. This acute inflammatory response appears to be responsible, at least in part,
for many of the symptoms associated with the common cold such as rhinorrhea, nasal
congestion, and fever. Inflammation can obstruct the sinus ostium or eustachian tube and
predispose to bacterial sinusitis or otitis media. If the tracheobronchial epithelium is invaded by
the infectious agent, it leads to activation of inflammatory cells and release of cytokines,
resulting in inflammation of the airway, causing sputum production and cough symptoms.
Diagnostic Plan
Diagnosis is primarily done clinically with a good history and physical examination. Onset of
common colds occurs 1-3 days after a viral infection. 1st symptom noted is often sore or
scratchy throat, followed by nasal obstruction and rhinorrhea. The sore throat usually resolves
quickly and, by the 2nd and 3rd day of illness, nasal symptoms predominate. 3 to 4 days later,
with persistence of rhinitis, a frequent, dry, hacking cough develops which may or may not be

productive. After several days, the sputum can become purulent, indicating leukocyte migration
but not necessarily bacterial infection. Mucus gradually thins,
usually within 5-10 days, and then the cough gradually subsides. For a usual cold, it persists for
about a week. However if with acute bronchitis, the entire episode usually lasts about 2 weeks
and seldom >3 weeks.
Physical examination will reveal swollen, erythematous nasal turbinates, with or without nasal
discharge. There could be sinus tenderness indicating sinus involvement. On inspection of the
oral mucosa, the posterior pharyngeal wall may be inflamed. Auscultation of the chest may be
unremarkable at the early phase. As the syndrome progresses and cough worsens, breath
sounds may present with rhonchi, scattered high-pitched wheezing, fine and coarse crackles.
Laboratory studies are not routine in the diagnosis and management of upper respiratory tract
infection. However, a complete blood count can be done to check for a viral or a bacterial type
of etiology. Predominance of neutrophils may point to a bacterial in etiology, while lymphocytosis
may indicate a viral disease. Chest X-rays can be done to check for increase bronchial
markings, and lung infiltrates which suggests pneumonia or a lower tract infection.
It is important to note that the principal objective of the clinician is to exclude pneumonia, which
is more likely caused by bacterial agents requiring antibiotic therapy.
Therapeutic Plan
A viral upper respiratory tract infection is a self-limiting disease. Management of common colds
is primarily supportive and symptomatic relief.
Possible symptomatic therapies:
1. Increase oral fluid intake to thin respiratory secretions and maintain hydration status since
children often have a reduced appetite during a cold, and may eat less than usual.
2. Normal saline solution nasal spray to thin the mucus, and use of bulb suction to temporarily
remove nasal secretions.
3. Topical -adrenergic agonists such as oxymetazoline, xylometazoline, and phenylephrine for
nasal decongestion. It is important to note that prolonged use may result in a rebound
phenomenon-rhinitis medicamentosa-after discontinuation.
4. First-generation anti-histamines can decrease rhinorrhea symptoms by 25-30%. An
alternative for treatment of rhinorrhea is use ipratropium bromide, a topical anticholinergic
agent.
5. Paracetamol as anti-pyretic; however generally not indicated.
6. Role of antitussives and expectorants remains controversial. Codeine or dextromethorphan
hydrobromide has no effect on cough from colds. Expectorants such as guaifenesin are not
effective antitussive agents. Based on pathophysiology, cough in some patients is associated
with postnasal drip. Cough may also be a result of virus-induced reactive airway disease.
Therefore, cough that persists for days to weeks after the acute illness and might benefit from
bronchodilator therapy. Use of cough suppressants might even worsen it by increasing the risk
of suppuration and inspissated secretions.

In summary, the use of cold medications is not recommended for use in infants and children
because of the lack of proven efficacy and the potential risk of dangerous side effects. Drinking
adequate amount of fluids is still the simplest but effective way in reducing the duration of
illness.
Prognosis
Upper respiratory tract infections are usually self-limiting. Symptoms peak within one to three
days and generally clear by one week, although cough often persists a little longer. In other
cases, upper respiratory infections may serve as a gateway to infection of adjacent structures,
resulting in the infections such as acute otitis media, bacterial sinusitis, pneumonia, meningitis,
sepsis.
Patient Education/Public Health Issues
1. Frequent hand washing with proper techniques.
2. Covering the mouth and nose while sneezing or coughing with tissue napkin, and not with
ones hand.
3. Limiting contact with others who are ill.
4. Annual immunization against influenza.