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Friday, February 25, 2011

Managing Colds & Their Complications


      On a fairly regular basis, I will comment on what we are seeing in the office this week in order to try to help our patients know when they need physician services. This week visits to our offices have been dominated by colds, flu, and the common complications of cold--bronchitis, ear infections, pneumonia, sinusitis, and sore throat. Here is a quick and simple guide how to assess whether you need to see a doctor for your symptoms.

It's winter in the mountains, and that means cold & flu season is here. The following tips are presented to help folks decide when they need to see a doctor.

1. PREVENTION: Flu, the most serious of all the common viral infections is preventable. Get your flu shot each year in the Fall.
    Many colds could be prevented by measures as simple as covering your nose and mouth when you sneeze, disposing of tissues properly, and, most important, washing your hands often.

2. THE SIMPLE COLD: Colds are due to viruses. Usually it is a mild, mostly just annoying illness, characterized by runny nose, stuffiness, light cough, and sometimes a low-grade fever. There are no medications that cure viruses involved in colds, so specific treatment is not available. typically symptoms last 3-5 days. Managing the cold just means managing the symptoms. You actually don't need any doctor expertise to do this. If your nose is runny, get a decongestant (e.g., Claritin, Sudafed, Benadryl, etc.) or a nasal spray like Afrin. (Caution: Do not use for more than 3 days consecutively.) If you're coughing, get one of the over-the-counter cough products (e.g., Robitussin, Robitussin-DM, etc.) or an expectorant like guaifenesin. If you're throat is just mildly sore, use tylenol, motrin, or lozenges (like Cepacol). That is all there is too it. You do not need an antibiotic because it will not work against a virus.
    During flu season, if you experience the abrupt onset of fever with shaking chills, mild cough, runny nose, headache, upset stomach, and severe muscle aches all over, then you probably have flu (influenza). This is a viral condition that makes you much sicker than a simple cold. Flu makes you feel terrible and usually puts you right to bed for 3 to 5 days. There is treatment now that can shorten the duration of influenza (Tamiflu), but it has to be started within the first 3 days to offer any benefit--the sooner the better. This is a really nasty disease, so it is best to try to prevent it with an annual flu shot. Antibiotics have no role in the treatment of influenza.

3. COMPLICATIONS OF A COLD:  The problem with colds, particularly if they hang on for a while, is that they weaken your immune system and set you up for secondary bacterial infections. The common bacterial complications of a cold are:
    a. an ear infection (otitis media): Treatment with antibiotics reduce the duration of pain and fever by about 1 day. It is really a parent's decision whether to use antibiotics in this situation because the benefit, while significant, is small and you can get side-effects (like diarrhea, rashes, upset stomach) from the medication. In some locations in the US and in many other countries, ear infections are treated initially only with medication for the pain of the earache, and antibiotics are not prescribed unless the child is still having symptoms in 3 days. Another option, you should ask you doctor about, is to request a "delayed prescription" whereby the doctor gives you a prescription for an antibiotic at the time of the visit with the understanding that you will not fill it immediately, but only after a day or two if symptoms are still really bothering the child.

    b. a sinus infection (sinusitis): Colds frequently lead to nasal congestion and stuffiness. If they hang on long enough they tend to block your sinuses from draining and fluid and bacteria can collect in the sinuses in your forehead and on either side of your nose. Sinus pressure from infection can cause significant discomfort for such small air pockets in the bone. Typically the presenting symptom is pain over the forehead, worse when you bend down, or face pain on either side of your nose. Sometimes a sinus infection can feel like a tooth ache since the roots of the teeth reach all the way up to the lining of the lower (maxillary) sinuses. There may be low-grade fever, and frequently there is a severe "washed out" feeling. Antibiotics are indicated for sinus symptoms.

    c. sore throat (strep): Most sore throats are mild and are due to viruses (viral pharyngitis) for which antibiotics are of no use. But on a regular basis during the winter time there will be community outbreaks of strep throat starting in the schools, and in a small town everyone ends up getting exposed eventually. A strep throat is much sorer than the usual viral sore throat.
     You can pretty well diagnose your own sore throat by using the 4 "Centor criteria":
             A. Fever > 102 o.
             B. Enlarged tender glands in the neck
             C. Pus on the tonsils or severe enlargement and redness of the tonsils
             D. Absence of cough. Strept throat does not tend to cause any cough.

If you have 0 or 1 of these findings, then you are unlikely to have strep throat. If you have 3 or 4 of these findings, then strep is very probable and I would recommend antibiotics (penicillin) without any testing (throat swab for culture or rapid strep test).
    If you have exactly 2 of these findings, then it is unclear what kind of sore throat you have. It is in this case that testing with either a throat culture or the rapid strep test is most helpful.

    d. persistent purulent drainage just from the nose (purulent rhinitis): After a viral cold has hung around for a while, it is common for the ordinary bacteria in your nose and mouth to overgrow and sometimes cause a thick, nasty discharge from your nose that is either yellow, gray, or green in color. This is an unpleasant, but not serious symptom. There is usually no fever or other systemic symptoms, but sometimes there can be a related sensation of ear pressure as the Eustachian tube that goes from your throat to your ears also gets congested. There have been several studies of this condition, and almost all of them conclude that antibiotics are of minimal benefit for this, and that the condition is most likely to resolve on its own. In my practice, I usually give it up to 5 days to resolve on its own; if it doesn't resolve by then I prescribe an antibiotic.

     e. bronchitis: When cold symptoms have persisted for a week or more, it is common to develop a deep, harsh, chest cough that is usually associated with thick green, gray, or yellow sputum. Usually there is no fever, and you don't feel very sick except for the cough. There have been over a dozen studies of the treatment of acute bronchitis, and they split right down the middle as to whether antibiotics really help or not. So this is really a patient's choice. Many physicians do not routinely prescribe antibiotics for bronchitis in the early phase. My practice is to prescribe an antibiotic if the purulent sputum has not cleared in 5 days.

      f. pneumonia: Pneumonia is often the result of a progression of a simple bronchitis as described above. The longer a cold lasts the more likely that bacterial germs will travel down your airways (bronchi and bronchioles). If this bronchitis stage persists, then the germs can actually reach all the way down to the lung tissue itself and cause a pneumonia. Pneumonia is a severe disease, and you usually know that your really sick. It is associated with high fever (> 102 o), rapid breathing, perhaps a sensation of shortness of breath, purulent sputum, shaking chills, severe fatigue and malaise. Antibiotics are definitely necessary for this condition, and the sooner the better. If you have a cough and fever and are not sure whether you just have bronchitis or pneumonia, it is best to be checked. Sometimes your doctor will need an xray to be sure which condition you have.

    g. meningitis:  The most severe complication of a simple cold is meningitis, in which ordinary respiratory germs causes so much inflammation around blood vessels that they actually get into the blood stream and travel up to head and the lining of the brain (meninges). The symptoms are abrupt onset of high fever, intense headache, progressing to lethargy or somnolence, nausea and vomiting, and neck pain or stiffness. This condition is a medical emergency requiring immediate hospitalization and intravenous antibiotics. Fortunately, it is relatively rare and becoming rarer as our childhood vaccines now prevent many of the germs that used to be common causes of this condition.

Bottom LineThis is all you really need to know about colds and flu. A simple cold needs no specific treatment and does not require a doctor's visit. The thing to watch for after a cold are signs of the secondary infections that can occur that will be indicated by new symptoms like earache, face pain, headache, cough with purulent sputum, severe sore throat, and high fever. The symptom pattern that is most concerning is having a cold that last for a week or two, and you think it is getting better, then suddenly, wham!, it is back again worse--with fever, chills, sweats, severe cough or pain. In this situation the new problem is highly likely to be a secondary bacterial complication. It is in this situation that a visit to the doctor is most helpful.