This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr Paul Nelson Williams — the perfect person to be talking about common colds or upper respiratory infections (URIs).
The common cold is benign; it’s self-limited by definition, and now COVID-19 for most people is like a common cold, and it’s going to be treated that way. We’ll talk about isolation a little later in the video.
Many patients can be treated over the phone or even with some back-and-forth patient portal messages. Hey, my sinuses are a little stuffy. What can I try? Our guest, Dr Amber Bird, said that if she gets two or three portal messages back and forth from a patient, that’s when she says, “Just come in.”
But if it’s just one question, Hey, what can I take for this symptom? You can answer that with the portal message, especially if it’s a patient who is otherwise healthy and not immunocompromised.
If patients make it into the office, their vital signs are very high yield because if they have a normal temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation, your worry for that person goes way down.
But Paul, what exam are you doing?
Paul N. Williams, MD: I’m trying to primarily rule out pneumonia or possibly sinusitis, the two things that the exam might be most helpful for. But I mainly do the exam for validation of the patient’s symptoms, so they don’t feel foolish for going to the doctor. This goes a long way when you’re doing the counseling later on because it feels bad to be sick.
Basically, I’m doing an exam of the organ systems that are affected. I’ll look in the eyes. I’ll look up the nose. I’ll look in the ears. I’ll look in the throat. I will also listen to the lungs, make sure there’s no wheezing or any evidence of consolidation or anything that would be embarrassing to miss.
You want to make sure that you’re not anchoring to the common cold and missing something a little bit more sinister. Especially during cold season, it’s very easy to be dismissive if you’re not careful.
Watto: What about testing? A lot of patients come in asking me for a rapid strep test or a flu swab. Do you think those are helpful?
Williams: To some extent, yes. Our guest, Dr Bird, acknowledged that they don’t change management all that often. If you catch it in the time course — if you actually pick up influenza early enough, certainly that is a reason to test, and the same goes for COVID in a patient who is high risk. That can be a benefit, but it doesn’t change much of what you do.
It may change counseling. It’s important to think about your patient’s exposures and who they’re going to be around once you send them home. If they are going home to someone who is immunocompromised or sick or works in healthcare, then knowing that they have the flu or COVID becomes more important in terms of counseling on isolation, hygiene, and return to work. It may not change your management in terms of treatments, but it may change how you counsel them in terms of when they go back to work and related issues.
Watto: Some patients really want to know what they have. And the isolation guidelines have changed. I get a lot of questions about this. Basically, now they have lumped all URIs together, with the same guidance. It’s what we did before the pandemic to some extent.
As long as they haven’t had a fever in 24 hours and their symptoms are generally getting better, they can return to being around other people. The guidance for everyone regardless of what respiratory infection they have — whether it’s COVID or not — is to be cautious for 5 days. Don’t breathe in anyone’s face for 5 days, essentially. It might be reasonable to mask or make sure that there is good air circulation for 5 days afterwards. I feel like that’s just common courtesy with any respiratory infection.
Williams: It’s what we should have been doing for years anyway, the COVID pandemic notwithstanding.
Watto: What about the counseling? Counseling is key when you’re seeing a patient with a cold because these people feel bad, and they just want you to tell them that it will eventually go away and that they will feel better again.
Williams: By definition, these infections tend to be self-limited. So, if you’ve made the diagnosis correctly, then this is about a 5- to 7-day course of just feeling kind of crummy. The cough, however, can linger, and it’s important to counsel patients about that. It’s an average of 18 days or so after the illness that the cough can hang on for. Patients expect to be completely done but they can be coughing for a couple of weeks afterward, so it’s important to let patients know that. They shouldn’t be alarmed if their symptoms do persist a little bit, because that’s not abnormal.
What about treatment for URIs?
Watto: For treatment, I ask them about their most bothersome symptom and then try to target that.

We don’t have great evidence for any of the treatments. You might find a positive trial, but you also find a negative trial for any of these treatments. In general, if it’s sinus congestion, Dr Bird said that fluticasone — an intranasal steroid — and nasal saline irrigation seem to help, and perhaps topical decongestants such as oxymetazoline or phenylephrine nasal spray.
Oral decongestants such as pseudoephedrine are behind the pharmacy counter, at least in the United States. Oral phenylephrine doesn’t work and might be taken off shelves eventually.
What if the patient has more of a cough — what are you reaching for in that case?
Williams: Even for cough, none of the treatments have superheavy evidence to support them. I think there’s some evidence for dextromethorphan, so it’s one of those things where you can try and see if it helps.
I really appreciate the conversation in this episode about benzonatate, which I think we have all prescribed because it’s a prescription cough medication, so we feel like we are doing something, but the evidence is not super great. Benzonatate has toxicities, especially with kids, so make sure that medication is properly secured, if you do prescribe it, and you counsel patients around that.
Watto: Yes, kids can overdose on it. That is terrifying. I had no idea.
Williams: Dextromethorphan and benzonatate are probably the main options. There is anecdotal evidence for guaifenesin, but it’s not very compelling. If a patient feels one of these treatments helps them, I say, go with God, but I don’t advocate strongly for one treatment vs another.
Watto: It’s often the sinuses that are causing the cough and congestion, so I mostly go after the sinuses. My threshold for antibiotics is when the patient has “double sickening,” where they felt bad for a couple of days, then got better, but then started to feel worse again. Or if they have persistent symptoms after 7-10 days — that’s when I’m thinking about a 5-day antibiotic course, usually with amoxicillin. Doxycycline would be my second choice if the patient is allergic to penicillin.
We also talked on the podcast about some of the traditional remedies listed here.

I would recommend that people listen to the full podcast episode here.