Chapter 13 - part 3
Illustrative patient pathway
to self care: cough and colds
Self care advice and guidance: take PART
Think of the range of advice and guidance about self care you might give to patients who consult you with cough and colds (see Box 13.1).
Range of self care advice and guidance for coughs and colds to give to patients and carers
P Prevention: cough is a symptom of a large number of illnesses. The commonest cause is an infection of the upper respiratory tract with other symptoms of fever, runny nose, sore throat, swollen neck glands, etc, usually labelled as a cold or ’flu-like illness. Look at Box 13.2 for suggestions about advice you can give to patients and the public about the prevention of colds and coughs.
A Await resolution of the symptoms: the NHS Direct algorithms on self care for coughing adults and coughing children give advice as to whether the cough requires treatment by a doctor or emergency services.1 If the algorithm excludes a serious underlying cause, the cough is likely to be due to an upper respiratory tract infection (URTI). Uncertainty by both health professionals and the public about the natural course of coughs and colds may be partly responsible for the high consultation and repeat consultation rates and antibiotic use in primary care. A study of pre-school children with URTI symptoms found that only half had recovered by the tenth day and nine out of ten by the 25th day after symptoms started.10 Many children still have nasal discharge and cough one week after presenting in a consultation in primary care, so that ideas about ‘colds last a week’ appear to be unrealistic.11 Although fever may subside after a few days, symptoms due to mucus production (catarrh) may persist for 2-4 weeks in both children and adults. Decisions about the use of antibiotics should be based on the likely presence of bacterial infections, not by the length of time the illness has continued. Antibiotic treatment of people with URTI is not supported by current evidence from randomised trials.12-14
R Use self care for relief of symptoms: see outline in Box 13.3. Other advice on self care is given in the NHS Direct algorithm for colds and ’flu for children and adults.1
T Learn to tolerate symptoms: if symptoms continue without improvement, check with the NHS algorithm to ensure that symptoms have been evaluated correctly.1 Persistent cough, or other symptoms may require medical examination or investigations.
Educate adults and parents about the simple measures to take to prevent coughs and colds (see Box 13.2) and to relieve the symptoms of straightforward colds and coughs (see Box 13.3), and give patients written information about self care. Avoid prescribing, as that tends to reinforce the tendency to attend for minor illnesses. If the patient expected an antibiotic, give a leaflet about antibiotic use. Ensure that adults and parents have access to information to make them more confident about diagnosing cough and colds and when they might need to seek other advice.1 Information about prevention may be better targeted by posters and leaflets, or in response to queries.
Advice to give patients and the public about prevention of colds and coughs
If children or adults attend with a continuing cough this may be a symptom of a large number of conditions. The history is most likely to help with the diagnosis.17 Adults who smoke are at risk of lung cancer and COPD. In asthma, persistent cough may be a symptom of poor control (see Chapter 12).
Complications of colds
Small babies under the age of three months are more likely to develop secondary bacterial infections. Young children may develop bronchiolitis, viral pneumonia and croup.9 Adults over the age of 60 years are more likely to develop a lower respiratory tract infection, but the evidence for treatment with antibiotics is inconclusive. Most trials suggest that antibiotics shorten the course of bronchitis by about a day and are possibly associated with a higher risk of adverse effects.18 A co-existing condition, such as COPD or diabetes, may change the balance of risks and benefits towards the use of antibiotics
Otitis media occurs in around 2% of people with a cold and infection of the paranasal sinuses in around 0.5%.19 Similar dilemmas exist about using antibiotics in these conditions. Antibiotics provide a small benefit for acute otitis media in children. As most cases will resolve spontaneously, this benefit must be weighed against possible adverse reactions.20 Antibiotic treatment may play an important role in reducing the risk of mastoiditis in populations where it is more common.21 The Cochrane review on treatments for maxillary sinusitis in adults found that antibiotics can help some people a bit but will not make a major difference to most.21
Advice to give patients and the public about the relief of symptoms in coughs and colds
Delayed prescription of antibiotics may help with the dilemma until the evidence is clearer about which patients may benefit most from antibiotics for secondary infections or complications.22
2 Schroeder K and Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings (Cochrane Review). The Cochrane Library, Issue 4. Oxford: Update Software; 2004.
3 Whyno Antibiotic? (Patient information leaflet) www.prodigy.nhs.uk/ProdigyKnowledge/
4 Common cold advice leaflet for adults www.prodigy.nhs.uk/ProdigyKnowledge/ PatientInformation/Content/pils/PL294.htm
5 Common cold advice leaflet for children www.prodigy.nhs.uk/ProdigyKnowledge/ PatientInformation/Content/pils/PL43.htm
6 Cherry DK, BurtCWand Woodwell DA. National Ambulatory Medical Care Survey: 2001 summary. Advance Data. 2003; 337: 1–44.
7 Morice AH. Epidemiology of cough. Pulmonary Pharmacology and Therapeutics. 2002; 15: 253-9.
9 Prodigy guidance on common cold. www.prodigy.nhs.uk
10 Hay AD, Wilson A, Fahey T and Peters TJ. The duration of acute cough in pre-school children presenting to primary care: a prospective cohort study. Family Practice. 2003; 20: 696-705.
11 Hay AD and Wilson AD. The natural history of acute cough in children aged 0-4 years in primary care: a systematic review. British Journal of General Practice. 2002; 52: 401-9.
12 Fahey T, Stocks N and Thomas T. Systematic review of the treatment of upper respiratory tract infection. Archives of Disease in Childhood. 1998; 79: 225–30.
14 Aroll B and Kenealy T. Antibiotics for the common cold and acute purulent rhinitis (Cochrane Review). The Cochrane Library, Issue 4. Oxford: Update Software; 2003.
15 Ernst E (ed). The Desktop Guide to Complementary and Alternative Medicine: an evidence based
approach. London: Harcourt Publishers; 2001.
16 Prasad AS, Fitzgerald JT, Bao B, Beck FW and Chandrasekar PH. Duration of symptoms and plasma cytokine levels in patients with the common cold treated with zinc acetate. A randomized, double-blind, placebo-controlled trial. Annals of Internal Medicine. 2000; 133: 302–3.
17 Hopcroft K, Forte V. Symptom Sorter. Oxford: Radcliffe Medical Press; 1999.
18 Fahey T, Smucny J, Becker L and Glazier R. Antibiotics for acute bronchitis (Cochrane Review). The Cochrane Library, Issue 4. Oxford: Update Software; 2004.
20 Glasziou PP, Del Mar CB, Sanders SL and Hayem M. Antibiotics for acute otitis media in children (Cochrane Review). The Cochrane Library, Issue 1. Oxford: Update Software; 2004.
21 Williams JW, Aguilar C, Cornell J et al. Antibiotics for acute maxillary sinusitis. The Cochrane Library, Issue 2. Oxford: Update Software; 2003.
22 Arroll B, Kenealy T, Goodyear-Smith F and Kerse N. Delayed prescriptions (editorial). British Medical Journal. 2003; 327: 1361–2. http://bmj.bmjjournals.com/cgi/content/ full/327/7428/1361