Upper Respiratory Tract Infection Treatment & Management

  • Author: Anne Meneghetti, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Sep 21, 2011
 

Medical Care

Most URIs are self-diagnosed and self-treated at home. Patients who present with infections often benefit from reassurance, education, and instructions for symptomatic home treatment. Antimicrobial therapy is appropriate in selected patients (see Medication). Several URIs warrant special attention. These are described below.

Epiglottitis

The risk for airway compromise is notable, especially in children. Immediately transfer the patient to the nearest hospital. Adults with epiglottitis typically have a relatively gradual course. However, some older children and adults may have respiratory compromise, especially those with congenital or acquired subglottic stenosis. The treatment of epiglottitis in adults requires individual tailoring of therapy on the basis of the severity of disease at presentation and the course of the disease as it unfolds under observation.

  • Instrumentation: Avoid instrumentation. In suspected epiglottitis, limit the examination to observation and an assessment of the vital signs. Tongue depressors or other instruments may provoke airway spasm and precipitate respiratory compromise. Keep the patient comfortable, and avoid unnecessary examinations.
  • Specialist consult: An anesthesiologist or otorhinolaryngologist should be involved early in the management of epiglottitis.
  • Monitoring: Patients must be monitored for respiratory fatigue visually and with continuous pulse oximetry. Accessibility to equipment and expertise for immediate intubation is required in the event of respiratory failure. If endotracheal intubation is not possible, cricothyroidotomy may be required.
  • Oxygen: Oxygen is administered according to pulse oximetry results. Dry air may worsen inflammation. Use of humidified oxygen or a room humidifier is recommended.
  • Antibiotics: Presumptive intravenous antibiotics are indicated, tailored to results from blood cultures.
  • Glucocorticoids: Either intravenous or inhaled glucocorticoids are sometimes given to reduce inflammation. However, controlled trials of the effectiveness of this approach in epiglottitis are limited.
  • Volume deficits: Correct volume deficits with intravenous fluids.
  • Sedatives: Avoid sedatives that may suppress the respiratory drive.
  • Other medications: In patients with croup, aerosolized racemic epinephrine is sometimes used to reduce mucosal edema; however, the role of this drug in persons with epiglottitis is not defined. Adverse events have been reported in patients with epiglottitis.[30] Beta-2 agonists are not typically used in patients who do not have asthma.

Laryngotracheitis

Patients may require hospitalization, especially infants and young children who have hypoxemia, volume depletion, a risk for airway compromise, or respiratory fatigue. Mild cases of croup (ie, laryngotracheobronchitis) may be managed at home with moist air inhalation. Patients with diphtheria may require isolation and hospitalization for airway management. The following measures apply to hospitalized patients:

  • Monitoring: Patients are monitored for respiratory fatigue visually and with continuous pulse oximetry. Expertise for immediate intubation and access to the necessary equipment are required if respiratory failure is a possibility. If endotracheal intubation is not possible, cricothyroidotomy is indicated for respiratory failure. Keep the patient comfortable, and avoid unnecessary procedures and examinations.
  • Oxygen therapy: Administer humidified oxygen to all hypoxemic patients. In patients who do not require oxygen therapy, a cool-mist humidifier may be used. Dry air may worsen inflammation. Heliox, a mixture of helium and oxygen, compared favorably with inhaled racemic epinephrine in a small study of pediatric patients with moderate-to-severe croup.[31]
  • Glucocorticoids: Intravenous or oral glucocorticoids are commonly used to reduce symptoms and shorten hospitalization in patients with moderate-to-severe croup. Inhaled steroids may be considered in cases that are not severe; however, evidence from large controlled trials regarding the use of inhaled steroids in croup is lacking.
  • Antibiotic therapy: Antibiotics are appropriate for whooping cough (pertussis); however, croup is typically a viral condition. Blood cultures are ordered.
  • Volume deficit: Correct volume deficits with intravenous fluids.
  • Sedatives: Avoid sedatives that may suppress the patient's respiratory drive.
  • Other medications: Inhaled racemic epinephrine may temporarily dilate the airways by relaxing bronchial smooth muscle and causing vasoconstriction that may reduce mucosal inflammation. Epinephrine may be considered in patients with persistent stridor. Because rebound edema may occur when inhaled epinephrine is stopped, monitoring and observation is required for several hours afterward. The use of steroids may reduce the need for epinephrine to manage croup. In persons with whooping cough, evidence is insufficient to justify the use of long-acting beta-agonists, antihistamines, or pertussis immunoglobulin.[32]

Deep tissue infections

Retropharyngeal abscess, intracranial abscess, or other deep tissue infection may compromise the airway, vision, or neurologic function. Patients with evidence of intraorbital or intracranial extension of suppurative infection warrant hospitalization, imaging, and surgical consultation. Antibacterial therapy is often warranted.

Patients with immunocompromise

Special attention is warranted in patients with suboptimal immune defenses. This includes patients without a spleen, those with HIV infection, patients with cancer or those undergoing cancer therapy, patients receiving dialysis, those undergoing stem cell or organ transplantation, or those with congenital immunodeficiency. Splenectomy lowers a patient's ability to fight infections with encapsulated organisms. Appropriate antimicrobial therapy and close follow-up may be appropriate because a simple URI may quickly progress to a systemic illness in immunocompromised patients. Although the threshold for hospitalization is lowered for these patients, their risks of nosocomial infections must be weighed against the benefits of close monitoring in the inpatient setting.

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Surgical Care

Deep tissue infections of adjacent structures, such as a peritonsillar, oropharyngeal, or intracranial abscess, warrant immediate consultation with a surgeon.

Repeated streptococcal infection may be an indication for surgical intervention. In patients with 4-5 confirmed group A streptococcal infections in a single year or in those with chronic sore throat with adenopathy that is not responsive to treatment over 6 months, tonsillectomy may be considered.

In a study of children aged 1-6 years with recurrent URI in the Netherlands, where adenoidectomy rates are several times that of the United States, adenoidectomy did not reduce URI episodes compared with initial watchful waiting.[33]

Complicated sinus disease may warrant surgical intervention, but surgery is rarely warranted in acute rhinosinusitis. Surgery may be considered when the condition has not responded to months of medical therapy, when a mucopyocele is present, when a fungal sinus infection occurs, or when infection extends to the bone. If possible, the sinus mucosa should be left intact. Functional endoscopic sinus surgery is designed to promote drainage of the sinuses by altering the ostiomeatal complex. For surgical management of chronic sinusitis, see the eMedicine article Sinusitis, Chronic.

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Consultations

  • Surgeon: Airway obstruction from epiglottitis, tonsillar hypertrophy, peritonsillar abscess, retropharyngeal abscess, or other mass requires emergency consultation by a surgeon. Sleep apnea associated with tonsillar hypertrophy may also prompt surgical consultation.
  • Neurosurgeon: Neurologic findings or mental status changes in the setting of suspected intracranial suppurative complications warrant emergency consultation with a neurosurgeon.
  • Infectious disease specialist: Consider consulting an infectious disease specialist when patients have HIV infection, cancer-related or congenital immunodeficiency, or other immunocompromise.
  • Pulmonologist or otorhinolaryngologist: Patients with a chronic cough after a URI may benefit from a consultation with a pulmonologist or otorhinolaryngologist to evaluate persistent infection, asthma, gastroesophageal reflux disease, or other causes of chronic cough. Patients with 4-5 confirmed group A streptococcal infections in a single year or those with a chronic sore throat and adenopathy unresponsive to treatment over 6 months should be examined by an infectious disease specialist and/or surgeon. Persistent hoarseness after 2 weeks warrants consultation with an otorhinolaryngologist.
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Diet

  • Fluid intake: Increased fluids are warranted to replace insensible losses and reduced oral intake.
  • Probiotics: Antibiotics alter the gastrointestinal flora, and some foods may not be as digestible for days or weeks after antibiotics are used. Consumption of yogurt containing active cultures has been advocated as an aid to restoring normal flora after antibiotic therapy. A meta-analysis suggests that probiotics may prevent antibiotic-associated diarrhea; Saccharomyces boulardii and lactobacilli may be particularly useful in this situation.[34]
  • Alcohol intake: Alcohol may cause swelling of the nasal and paranasal sinus mucosae.
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Activity

  • Rest: Patients with the common cold may consider returning to their usual physical activity, including aerobic activity, if their symptoms are limited to the nose and throat. However, if cough, fever, or other systemic symptoms are present, rest is indicated. Rest is helpful for recovery from an URI.
  • Contact sports: Patients with infectious mononucleosis should be instructed to avoid contact sports for 6 weeks because of the possibility of splenic rupture.
  • Voice rest: This is indicated for patients with laryngitis or laryngotracheitis.
  • Air travel: Patients may experience increased discomfort from upper airway infection during air travel. As atmospheric pressure drops during takeoff, expansion of soft tissues may block the eustachian tubes and increase pressure sensations in the sinuses.
  • Swimming: Chlorine from pools may be irritating to inflamed nasal membranes. Diving, especially at depth, may cause uncomfortable pressure and impair drainage of the paranasal sinuses.
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Contributor Information and Disclosures
Author

Anne Meneghetti, MD  Assistant Professor of Medicine, Tufts University School of Medicine; Medical Broadcaster, Life, Love and Health, RealForMe.com

Anne Meneghetti, MD is a member of the following medical societies: National Ayurvedic Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Gregory William Rutecki  MD, Professor of Medicine, University of South Alabama Medical School

Gregory William Rutecki is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

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Seasonal variation of selected upper respiratory tract infection pathogens. PIV is parainfluenza virus, RSV is respiratory syncytial virus, MPV is metapneumovirus, and Group A Strept is group A streptococcal disease.
CT scan of the sinuses demonstrates maxillary sinusitis. The left maxillary sinus is completely opacified (asterisk), and the right has mucosal thickening (arrow). Courtesy of Omar Lababede, MD, Cleveland Clinic Foundation.
Lateral neck radiograph demonstrates epiglottitis. Courtesy of Marilyn Goske, MD, Cleveland Clinic Foundation.
Gonococcal pharyngitis. Image credit: CDC Public Health Image Library (Flumara NJ, Hart G).
Strep throat with petechiae. CDC Public Health Image Library (Eichenwald HF).
Table. Symptoms of Allergies, URIs, and Influenza
SymptomAllergyURIInfluenza
Itchy, watery eyescommonrare; conjunctivitis may occur with adenovirussoreness behind eyes, sometimes conjunctivitis
Nasal dischargecommoncommoncommon
Nasal congestioncommoncommonsometimes
Sneezingvery commonvery commonsometimes
Sore throatsometimes (postnasal drip)very commonsometimes
Coughsometimescommon, mild to moderate, hacking coughcommon, dry cough, can be severe
Headacheuncommonrarecommon
Feverneverrare in adults, possible in childrenvery common, 100-102°F or higher (in young children), lasting 3-4 days; may have chills
Malaisesometimessometimesvery common
Fatigue, weaknesssometimessometimesvery common, can last for weeks, extreme exhaustion early in course
Myalgiasneverslightvery common, often severe
Durationweeks3-14 days7 days, followed by additional days of cough and fatigue
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