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Thursday, May 26, 2011

The Cold That Won't Quit

A VIEW FROM THE OFFICE




THE COLD THAT WON'T QUIT

     
     We all get colds once in a while. Usually we suffer a couple of days of runny nose, sneezing, the feeling of congestion, and the feeling of being a little run down. Most (but not all) colds are done in 72 hours, and we're used to dealing with them. Colds are caused by viruses and do not require antibiotics. The problem is that many colds lead to secondary complications, what we call a bacterial superinfection. Examples of such superinfection include ear infections (otitis media), strep throat, sinus infection (sinusitis), goopy eyes (conjunctivitis), chest cough (bronchitis), or even pneumonia. These infections happen because the preceding viral infection reduced our immunity and gave these germs a better chance to set up shop in one of our cranial cavities or airway passages. These infections are the reason most patients come to see a doctor after a cold. Most of these will respond to an antibiotic. The usual practice is for a doctor to prescribe an antibiotic for 7 days--usually something like amoxicillin, sulfa, or azithromycin. We are now increasingly realizing that most of these infections do not even require a full 7-days of antibiotics. For most symptoms will resolve in 2-3 days. 


     The problem I want to talk about today are the exceptional cases--the ones where symptoms have not resolved even after a full 7-days. What do you do then? 


     There are 3 main patterns to these exceptional cases:

  1. An ear infection that does not resolve. Most often this is caused by retained fluid in the ear. Occasionally, it is a problem because the initial antibiotic used does not cover whatever particular germ was in the ear fluid. The standard approach to this problem is to undertake another round of antibiotics with a different, stronger antibiotic. Occasionally, if the problem is clearly due to fluid in the ear, we will prescribe some form of cortisone, either as a nasal spray like Flonase, or as cortisone pills (prednisone) for 7 to 14 days. Ultimately, failure of symptoms to resolve with this treatment will lead to a referral to an Ear-Nose-Throat (ENT) specialist. Usually, they will repeat this same kind of therapy for another round, and, if that doesn't work, they will offer a surgical option like placing tubes in the ears. It is quite rare that an adult would need this kind of surgery, but occasionally, especially among persons with severe allergies, it is appropriate.
  2. Sinus infections that do not resolve. Sinuses can be notoriously difficult to clear up. In fact, many patients, especially those with allergies, will have repeated bouts of sinus infections during a year. Each episode of infection tends to make it more difficult to clear up the next one. In recent years, the experts have generally recommended delaying antibiotic therapy for at least a week to give it a chance to resolve on its own. If symptoms of face pressure or pain or severe congestion persist for over a week, then amoxicillin is the most often prescribed antibiotic. The exception is when you have previously been treated with amoxicillin for some other infection within the last 2-3 months. In this case, the high-strength form of amoxicillin is used--i.e., Augmentin, which is significantly more potent, but also more likely to cause intestinal upset and diarrhea. For persons with chronic, frequently recurring sinusitis, treatment needs to be for longer periods of time--for 14-21 days. Failure of symptoms of sinusitis to resolve is the most common good reason for using one course of antibiotics right after another and perhaps even for a third time. Failure to resolve with a third course of antibiotics will result in a referral to an Ear Nose Throat specialist and x-rays of the sinuses or a CT scan.
  3. Chest infections that do not resolve. Here the primary symptom is cough, often associated with a sensation of chest tightness, and occasionally even by frank wheezing.  One practical tip to remember is that there are basically two kinds of cough: (1) the cough due to a tickle in the throat or drainage in the back of your throat from your nose or sinuses. This usually feels like a scratchy throat and is accompanied by a constant upper airway cough to clear the throat; (2) the second type of cough is the deep in the chest cough. It will be very obvious that the cough is coming from deep in the chest, often with production of yellow-greenish phlegm. This combination of symptoms (cough and yellow-green sputum) is indicative of the common diagnosis of acute bronchitis     The experts are still arguing about what is the best treatment for acute bronchitis, and the majority trend is to believe that antibiotics are usually not necessary for simple, acute sinusitis where symptoms have only been present for 1-7 days. Experts differ on whether you should wait for 7 or 14 days to start antibiotic treatment. I have reviewed all the major bronchitis studies myself and I reach a slightly different conclusion. Basically there are about a dozen major studies (and several studies studying these studies), and the truth is that they split right down the middle on whether antibiotics help the resolution of acute bronchitis symptoms or not. So it's a toss up. It is perfectly reasonable to treat these symptoms with antibiotics, and it is also perfectly reasonable not to treat them. I usually let patients make this decision. My personal rule of thumb is to consider antibiotics if symptoms have persisted for more than 3 days, and definitely to recommend them if they last for 5 days or more. I usually prescribe either amoxicillin or azithromycin for these infections. Usually 5 days of antibiotics is enough.
               When cough is associated with more symptoms than just purulent sputum and chest tightness, the other diagnosis that must be consider is pneumonia. Pneumonia is basically just an extension of bronchitis as the germs move all the way down the airways and actually begin to enter into the lung tissue (alveoli) itself. Pneumonia is accompanied by much more severe symptoms--usually including high fever, shaking chills, and shortness of breath, often severe fatigue of just a feeling of being really sick. In fact, just the combination of acute cough, high fever, and shortness of breath (rapid breathing) is enough to make a diagnosis of pneumonia; you don't even need a chest x-ray. There is a variation of pneumonia, however, that is more subtle; in these cases it can present with just a cough, but no fever, and usually with a sense of malaise. This kind of pneumonia is often referred to as "walking pneumonia" or an atypical pneumonia. Pneumonia, of all types, is treated with amoxicillin, azithromycin, or Levaquin (or their equivalents) for at least 7 days. Symptoms usually improve dramatically after 48 hours.

    So the real issue for today's article is what do you do if your cold is still causing severe chest cough, tightness, and/or wheezing one to two weeks after onset? I am assuming that you have already made one visit to the doctor and that appropriate treatment with antibiotics was undertaken if there were any signs of bacterial infection. There are basically two courses to follow here:
  1. If the doctor told you that initially all you had was a viral infection and did not prescribe antibiotics, then you may in the mean time have acquired a secondary bacterial infection (otitis media, sinusitis, or bronchitis). The appropriate plan for this is antibiotic treatment for 5 to 7 days with a common antibiotic like amoxicillin and treatment for the most severe symptoms--like a decongestant for severe runny nose or nasal obstruction, a cough syrup for severe cough, and/or asthma medications (an inhaler usually) for wheezing or tightness. In this scenario, symptoms usually resolve quickly and you're done.
  2. The other scenario is the classic prototype of the cold that just won't quit. After your previous treatments, your cough is improving some, you're no longer coughing up as much yellow or green phlegm, you don't have any fever or chills, but you still feel tight in your chest, may have occasionally whistling or wheezing sounds in your chest, and tend to have bad spasms of coughing that make you really breathless and leave you feeling weak with aching ribs. The first thing to do in this scenario is to take a chest x-ray to make sure than no atypical lung infection (pneumonia) has been overlooked, and to make sure there is nothing else there that could cause such symptoms (like a lung mass in smokers). If the chest x-ray is negative, then the most common cause of this scenario is asthma. In many cases there may be a past history of asthma in childhood. For many, there is no history of asthma, but severe viral infections (and bacterial infections) can trigger new asthma (usually short-lived) even in a patient who has never had it before. In others there is a history of smoking. Smokers are the one group of patients who should expect to have recurrent episodes of the "cold that won't quit" since smoking so damages the airways. The treatments for asthma are an inhaler (albuterol, 2 puffs every 4 to 6 hours for coughing spells, chest tightness, and/or wheezing). If this is tried and does not bring enough relief, the next step is cortisone, usually by pills, usually in a dose of 40 mg of prednisone (or equivalent) for 7 to 14 days. This should take care of the asthmatic part of any infection that won't quit. For the rare patient, who is not better even after this, I will prescribe Advair; this is a dry-powder inhaler that combines a long-acting form of albuterol with a long-acting cortisone. It is probably the most effective medication on the market right now for persistent symptoms due to bronchospasm and asthma. Note that once you have had one course of antibiotics for a chest cough and the x-ray is negative, there is no real point in taking any more antibiotics.
     Sometimes there is still a nagging cough and a general feeling of fatigue and just not feeling well. This is very distressing to patients, and they generally want the doctor to do something and to do it quickly. If we have already run through the steps described above, there is not much else to do. For some infections, and certainly at this stage of the cold that won't quit, you just have to wait it out. It will go away. About once in every 5 years most adults will get a severe infection like this that seemed to start as an ordinary cold, but it keeps them feeling sick and miserable for as long as one to two months. If you have run through the protocol above, there is nothing else to do. You just wait. After a while, simple time will cure most everything. While you're waiting to feel better, just ask yourself if you've had any other cold this bad in recent years. If you haven't had one like this in the last 5 years, then you can tell yourself that everything is normal, and you've paid your dues for another 5 years.

2 comments:

  1. Might I suggest that if the cold does not go away that a simple CBC be done? If those results come back fine then waiting it out would be ok. Sometimes a cold that does not go away can be indicative of something that can be treated following the results of a CBC.

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