The document discusses respiratory problems like colds and flu. It defines colds and flu as viral upper respiratory infections with overlapping symptoms. Over 200 virus types can cause colds, while flu symptoms include fever, aches, and malaise. Complications are more common in young, old, and those with pre-existing conditions. The pharmacist's role is to recommend symptomatic relief based on a patient's age, symptoms, medical history and current medications to safely manage their cold or flu. Treatments may include decongestants, antihistamines, analgesics and staying hydrated.

1. Respiratory Problems (Cold and Flu)
Dr. Omer Q. B. Al-lela
PhD in clinical pharmacy
ISPOR, ISOP member, ICIT
2021-2022

2. Introduction
2
 Cold and Flu A mixture of viral upper respiratory
tract infections (URTIs).
 More than 200 different virus types can produce
symptoms of the common cold, including rhinoviruses
(accounting for 30-50% of all cases), coronaviruses,
parainfluenza virus, …
 Self-limiting but over-the-counter (OTC) medicines
used for symptomatic relief.
 Cold remedies may interact with prescribed therapy

3. Cold and Flu
3
 Flu is generally considered to be likely if:
1. Temperature is 38◦C or higher (37.5◦C in the elderly);
2. A minimum of one respiratory symptom – cough, sore throat,
nasal congestion or rhinorrhoea – is present; or
3. A minimum of one constitutional symptom – Headache, malady,
muscle pain, sweating/chills, prostration – is present.
 Flu often starts with sweats and chills, muscular aches and
pains in the limbs, a dry sore throat, cough and high
temperature.
 There is often a period of generalized weakness and malaise
following the worst of the symptoms.

4. Cold and Flu
4
 True influenza is relatively uncommon compared to the large
number of flu-like infections that occur.
 Flu can be complicated by secondary lung infection
(pneumonia).
 Complications are much more likely to occur in the very
young, the very old and those who have pre-existing heart
disease, respiratory disease (asthma or chronic obstructive
pulmonary disease (COPD), kidney disease, a weak immune
system or diabetes.

5. Cold and Flu
5
 Transmission by coughing and sneezing infected
mucus particles does occur, although it is a secondary
mechanism. This is why good hygiene (washing hands
frequently and using disposable tissues) remains the
cornerstone of reducing the spread of a cold.
 Children contract colds more frequently than adults
with on average 5-6 colds per year compared to 2-4
colds in adults

6. What Pharmacist need to know
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 Age (Child, adult)
 Duration of symptoms
 Runny/blocked nose
 Summer cold
 Sneezing/coughing
 Generalised aches/ headache
 High temperature
 Sore throat
 Earache
 Facial pain/frontal headache
 Asthma
 Previous history
 Allergic rhinitis
 Heart disease
 Present medication

7. Significance of questions
7
Age
Duration :
 True Flu usually comes with rapid onset
 The symptoms of the common cold usually last for 7–14 days.
 Cough, may persist longer
Runny / blocked nose
 Rhinorrhoea occurs in most patients
 Initially a clear watery fluid, may followed by thicker.
 Nasal congestion occurs because of dilatation of blood vessels
that narrows the nasal passages, which are further blocked by
increased mucus production.

8. Significance of questions
Summer colds
 Nasal congestion, sneezing and irritant watery eyes.
Sneezing / coughing
 Sneezing occurs because the nasal passages are irritated.
 A cough may be present either because the pharynx is irritated
or as a result of irritation of the bronchus caused by postnasal
drip.
Aches and pains / headache
 Due to inflammation and congestion of the nasal passages and
sinuses. If persistent or worsened (sinusitis).
 People with flu often report muscular and joint aches.
8

9. Significance of questions
9
Facial pain / frontal headache
Sinuses are air containing spaces in
the bony structures adjacent to the
nose (maxillary sinuses) and above
the eyes (frontal sinuses).
In a cold their lining surfaces
become inflamed and swollen. The
secretions drain into the nasal cavity. If
the drainage passage becomes
blocked, fluid builds up in the sinus
and can become secondarily
(bacterially) infected.

10. Significance of questions
High temperature
 Those suffering from a cold often complain of feeling hot, but in
general a high temperature will not be present.
 The presence of fever may be an indication that the patient
has flu rather than a cold
Sore throat
 The throat often feels dry and sore during a cold and may
sometimes be the first sign.
10

11. Significance of questions
Earache
 Earache is a common complication of colds, especially in children.
 When nasal catarrh is present, the ear can feel blocked. This is
due to blockage of the Eustachian tube
 Middle ear is an air-containing compartment. This is an ideal site
for a secondary infection to settle.
 When this does occur, the ear becomes acutely painful and is
called acute otitis media (AOM).
11

12. Significance of questions
Previous history
 People with a history of COPD may be advised to see their doctor
if they have a bad cold or flulike infection
Present medication
 The pharmacist must check any medicines being taken by the
patient.
 It is important to remember that interactions might occur with
some of the OTC medicines.
 If medication has already been tried for relief of cold symptoms
with no improvement and if the remedies tried were appropriate
and used for a sufficient amount of time, referral to the doctor
might occasionally be needed.
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13. When to refer
 Earache not settling with analgesic
 In the very young, In the very old
 Heart or lung disease, e.g. COPD, kidney disease, diabetes,
Asthma
 Compromised immune system (immunosuppressive agent)
 With persisting fever and productive cough
 With delirium
 With pleuritic-type chest pain
Treatment timescale
 Once the pharmacist has recommended treatment, patients
should be advised to see their doctor in 10–14 days if the
cold has not improved.
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14. Management
 The pharmacist’s role is to select appropriate treatment based on the patient’s
symptoms and available evidence, and taking into account the patient’s preferences.
 Antibacterials are not effective or appropriate as both infections are viral.
 The same non-prescription medicines are used to treat the symptoms of both the
common cold and influenza.
 To reduce the likelihood of catching or passing on infection (5):
1. If possible, stay away from people with colds or influenza.
2. Avoid crowded places where the risk of infection is greater.
3. Do not touch nose or eyes after being in physical contact with somebody who has
a cold or influenza.
4. Wash hands thoroughly, especially after blowing the nose.
5. Throw away paper tissues and Keep rooms well aired.
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15. Management
15
A-Non pharmacological measures: Non -drug therapy include:
1-Saline solution can soothe the irritated tissue and moisturized nasal
mucosa (4). And it can be given to all age group and pregnancy (1).
There are already formulated saline drops or spray products in the
market: Dose: use as often as needed (5).
2-Regarding influenza (1, 5):
-Rest, preferably by staying in bed.
-Try to get plenty of sleep.
-Drink as much as possible, as large amounts of fluid are lost during a
fever.
-Adequate nutrition.

16. Management
16
A- Pharmacological treatment
1-Decongestants (sympathomimetics): Decongestants constrict the dilated blood vessels of the
nose (5).
a-Systemic (oral) decongestants: like Pseudoephedrine, phenylphrine and ephedrine (3, 5).
C/I: Systemic (oral) decongestants cause stimulation of the heart, increase the BP and may cause
hyperglycemia. Therefore they should avoid in (3) : (D.M, Ischemic heart disease (angina, M.I),
hypertension, and hyperthyroidism).
b-Topical (drop/spray) Nasal Decongestants ( sympathomimetics): recommended for those
patients in whom Systemic (oral) decongestants are to be avoided
Dose
Example(s)
Type
2 drops/sprays q 6 hours p.r.n
Phenylphrine, Naphazoline,
tetrahydrozoline
Short acting
(4-6 hours).
2 drops/sprays q 8 hours p.r.n
Xylometazoline (Otrivine®):
0.1%: >12 years
0.05%: <12 years
Intermediate acting
(8-10 hours).
2 drops/sprays q 12hours p.r.n
Oxymetazoline(Nazordine®):
0.05%: >12 years
0.025%: < 12 years
Long acting
(12 hours).

17. Management
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Nasal Spray or Drop (1, 3):
-Nasal sprays are preferable for adults and children aged over 6 years
because spray has a faster onset of action and cover a large surface area.
-Nasal drops are preferable for children aged below 6 years because their
nostrils are not sufficiently wide to allow effective use of sprays. (But the drops
cover a limited surface area and easily swallowed which increase the possibility
of systemic effects).
-Duration of treatment with Topical Nasal Decongestants
(sympathomimetics): (drops or sprays) decongestants are to be recommend,
the pharmacist should advice the patients not to use the product for longer
than 7 days (3) (3-5 days in some references (1)) because: Rebound
congestion (Rhinitis medicamentosa).

18. Management
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2-Antihistamines:
Antihistamine can reduce some of symptoms of a cold: runny nose (rhinorrhoea) and
sneezing but are not so effective in reducing nasal congestion (3).
Antihistamine can be classified into:
A-Sedating Antihistamine:
Examples of OTC sedating antihistamine are: chlorphenamine (chlorpheniramine),
dexchlorpheniramine , clemastine, triprolidine and diphenhydramine.
S/Es: include sedation and drowsiness (patients should be informed) and
anticholinergic S/Es (i.e. dry mouth, urinary retention, constipation…) and the elderly
patients are more susceptible to these (8).
Accordingly they are not recommended (3) (or used with caution (7)) for patients with:
Glaucoma, or prostate hypertrophy and in elderly patients.
Drug Interactions: the sedative effects of antidepressants, anxiolytics, and hypnotics
are likely to be enhanced by sedating antihistamine(7).

19. Management
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B-Non-Sedating Antihistamine:
Examples of OTC non-sedating antihistamine are: Loratadine and cetirizine.
They are generally preferable over the older antihistamines because of much lower
incidence of S/Es (8).
Adult dose of Loratadine: 10 mg once daily.
Note: although the drowsiness is rare, but the warning that these drugs may affect
driving and skilled tasks is still present (7, 8).
Important : Because of their antimuscarinic actions the sedating antihistamines should
be used with care in conditions such as angle-closure glaucoma, and prostatic
hyperplasia; antimuscarinic adverse effects are not a significant problem with the
non-sedating antihistamines (9).

20. Management
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3-Combination products: sympathomimetics (for congestion) + Antihistamine (for
rhinorrhoea and sneezing):
The antihistamine is usually combined with Sympathomimetics because :
A-The suppression of rhinorrhea can provokes congestion so the sympathomimetics will
offset this effect.
B-Sympathomimetics may also help to counteract sedation caused by the antihistamines
(because the Sympathomimetics cause CNS stimulation) (6).
4-Analgesics, antipyretics:
-Paracetamol, aspirin and ibuprofen can be used to reduce fever, if present, and ease
headache and muscle pains in influenza and general discomfort with colds.
-Aspirin is restricted in its use by its pronounced side-effect profile, and may not be
given to children under 16 years because of its association with Reye’s syndrome, a
rare but occasionally fatal encephalopathy in children (5).

21. Management
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5-Inhalants:
Preparations containing volatile substances for inhalation, either directly or via steam,
produce a sensation of clearing the nasal passages and are used for the relief of cold
symptoms. They have few, if any, contraindications (5).
6-Vitamin C in common cold:
Vitamin C does not prevent colds and even high-dose vitamin C (over 1 g/day)
produce minimum benefits (2, 3, 6) .
In case of vitamin C effervescent tablets, large quantities of sodium bicarbonate are
required in this formulation, which could disturb the electrolyte balance of patients with
cardiovascular diseases , especially those whose sodium intake is restricted (6).

22. References
1- Handbook of Non-prescription drugs.2010
2- Community Pharmacy. Symptoms, Diagnosis and Treatment. By Paul
Rutter.2011
3- Symptoms in the pharmacy. A guide to the managements of common illness. 6th
edition By Alison Blenkinsopp and Paul Paxton .2009
4-Applied therapeutics :the clinical use of drugs.2004
5- Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical
Press; 2008.
6-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical
Press; 2010.
7-BNF. 68
8-A. Nathan .How to treat hay fever and associated allergic conditions in the
pharmacy . the pharmaceutical journal (vol 268). 27 April 2002 pages 575-578.
9-Martindale. 36.

23. TQ