Common Cold - Inpatient (IPD) Treatment Protocol

Background

Indications for IPD Admission

• Severe respiratory distress / acute breathlessness
• SpO2 < 94% on room air
• High-grade fever (>39°C) persisting beyond 3 days or recurring after initial improvement
• Inability to tolerate oral feeds/fluids (especially in elderly, pediatric, or immunocompromised)
• Complications: acute bacterial sinusitis, otitis media, lower respiratory tract involvement (pneumonia), febrile seizures
• Immunocompromised state (HIV, organ transplant, chemotherapy patients)
• Severe comorbidities (COPD, heart failure, diabetes with decompensation)
• "Double sickening" - initial improvement followed by sudden deterioration

IPD Assessment on Admission

1. History: Symptom onset, duration, severity, travel history, exposure to sick contacts, vaccination status (flu, COVID)
2. Examination: Vitals (temp, SpO2, RR, HR, BP), ENT exam (pharyngeal erythema, tonsillar exudate), chest auscultation
3. Investigations:
   • CBC with differential (to distinguish viral vs. bacterial; lymphocytosis suggests viral)
   • CRP / ESR
   • Throat swab for culture (if bacterial superinfection suspected)
   • Rapid Strep test / Monospot (if EBV suspected)
   • Chest X-ray (if lower respiratory symptoms or hemoptysis)
   • Nasopharyngeal swab for influenza / COVID-19 PCR (if indicated)
   • Blood glucose, renal function (for high-risk patients)

IPD Treatment Protocol

1. General Measures (Supportive Care)

2. Symptomatic Pharmacotherapy

A. Fever & Pain (Analgesics / Antipyretics)

• Paracetamol (Acetaminophen) - 500-1000 mg PO/IV Q6-8 hourly PRN (max 4 g/day in adults)
• Ibuprofen - 400 mg PO Q8H with food (preferred for headache, myalgia, ear pain; avoid in renal impairment, peptic ulcer, elderly)
• Note: Ibuprofen is more effective than paracetamol for fever-related discomfort; paracetamol provides short-term relief of rhinorrhea and nasal obstruction

B. Nasal Congestion (Decongestants)

• Oral Pseudoephedrine 60 mg PO Q6H (adults)
  • Avoid in hypertension, ischemic heart disease, hyperthyroidism
• Intranasal Xylometazoline / Oxymetazoline - 2-3 drops/sprays per nostril BD-TDS
  • Limit to 3-5 days only to prevent rebound congestion (rhinitis medicamentosa)
• Nasal saline irrigation (0.9% NaCl) - Q6-8H for nasal hygiene and symptom relief

C. Rhinorrhea / Runny Nose

• First-generation antihistamines (only these are effective for cold - newer non-sedating ones are NOT):
  • Chlorpheniramine maleate 4 mg PO Q6-8H
  • Diphenhydramine 25-50 mg PO Q6-8H (also helps with sleep)
• Intranasal Ipratropium bromide 0.06% - 2 sprays per nostril TDS (most effective for rhinorrhea)

D. Cough

• Dextromethorphan 15-30 mg PO Q6-8H (antitussive, for dry/non-productive cough)
• Guaifenesin 200-400 mg PO Q4H with plenty of water (expectorant for productive cough)
• Honey 10 mL at bedtime (evidence-based; only for patients >1 year old)
• Codeine (if cough is severely distressing and refractory) - use cautiously, not routinely

E. Sore Throat / Pharyngitis

• Warm saline gargles Q4-6H
• Throat lozenges (benzocaine or chlorhexidine-based)
• Analgesics as above

F. Zinc Supplementation (Adults)

• Zinc acetate/gluconate lozenges 13-25 mg elemental zinc Q2H while awake (start within 24 hrs of symptom onset)
• Shown to reduce duration of cold symptoms by ~33%
• Avoid zinc nasal sprays (risk of permanent anosmia)

3. Oxygen Therapy

• Supplement O2 via nasal cannula if SpO2 <94%
• Target SpO2 94-98% (88-92% in COPD patients)

4. Antibiotics - ONLY for Bacterial Complications

5. Antivirals

• NOT indicated for common cold (no proven antivirals for rhinovirus)
• If Influenza confirmed: Oseltamivir 75 mg BD x 5 days (start within 48 hrs of symptoms)
• If COVID-19 confirmed: Follow institutional COVID management protocol

6. Special Populations - IPD Adjustments

7. Treatments to AVOID

• Antibiotics (for uncomplicated viral cold)
• Intranasal corticosteroids (ineffective for acute cold symptoms)
• Non-sedating (2nd-generation) antihistamines (e.g., cetirizine, loratadine - ineffective)
• OTC cough/cold medications in children <4 years (safety concerns)
• Topical nasal decongestants >5 days (rebound congestion)
• Vitamin C, Echinacea, ginseng (insufficient evidence)
• Zinc nasal sprays (risk of permanent anosmia)

Red Flags - Escalate / Reassess

• Fever >38°C persisting beyond 3 days or re-emerging after initial improvement
• Hemoptysis (obtain chest X-ray immediately)
• Worsening respiratory status / SpO2 decline
• Severe unilateral facial pain (orbital cellulitis / cavernous sinus thrombosis risk)
• Sudden neurological changes
• Acute breathlessness

Discharge Criteria

• Afebrile for >24 hours (without antipyretics)
• SpO2 >94% on room air
• Tolerating oral fluids/diet
• Symptoms improving (even if not fully resolved)
• No evidence of bacterial complication requiring IV therapy
• Adequate home support available

Discharge Instructions

• Symptoms typically last 7-10 days; up to 25% may have symptoms for 14 days - this is normal
• Hand hygiene is the best prevention (hand sanitizer superior to hand washing for URI prevention)
• Return if: fever recurs, breathlessness develops, symptoms worsen after initial improvement
• No antibiotics at discharge for uncomplicated cold
• Follow-up with GP in 5-7 days if not improving