Diagnosis and Pathophysiology
The diagnosis is the common cold. Rhinovirus is the most significant virus that results in a common cold (Kuchar, Miśkiewicz, Nitsch-Osuch, & Szenborn, 2015). In individuals that do not have asthma, the symptoms of rhinovirus infection are primarily limited to the upper airway leading to the condition being classified as an upper airway infection. The most prominent symptoms are nasal obstruction and rhinorrhea. These symptoms result from an inflammatory response primarily driven by neutrophils. Neutrophils release cytokines that act on the respiratory epithelium resulting in heightened stimulation of mucus secretion from the glands lining the airway and increased vascular permeability (Kuchar et al., 2015). Cough is a less frequent but significantly troublesome symptom of rhinovirus infection. It results from irritation of the airway by secretions draining into the posterior pharynx and/or infection of the airways by the virus (Kuchar et al., 2015). This irritation may cause the throat to appear erythematous and also causes sneezing. The inflammatory response may, in some instances, become extensive to the point of resulting in obstruction of the Ostia of the sinuses and eventually Eustachian tube dysfunction. This blockage of the connection between the middle ear and the pharynx leads to a buildup of fluid within the middle ear, causing ear pain (Kuchar et al., 2015). Fever is a characteristic of the inflammatory response and is usually low-grade often at or below 100 degrees.
Interventions
Non-Pharmacologic Interventions
Non-pharmacologic interventions are usually effective in most non-complicated cases of the common cold in individuals without other respiratory comorbidities such as asthma. The child needs to get enough rest and stay hydrated. Hydration is key to replacing fluids lost through coughing, sneezing, and the effects of fever. Breathing moist air will help to soothe the airway and prevent drying up and irritation. It also reduces nasal congestion and softens the nasal discharge making it easy to blow out using a handkerchief, therefore, improving drainage of the upper airway and reducing Eustachian tube dysfunction. The parents can administer moist air using a humidifier or encourage the child to take a hot steamy shower.
A Neti Pot or saline nasal spray is helpful for nasal stuffiness. The parents will also need to ensure that the child gets a balanced diet to provide the necessary nutrients required to fight the infection. Warm chicken soup is a good option. The child should avoid consuming dairy products because they have the potential of thickening phlegm and worsening the cough.
Pharmacological Interventions
Acetaminophen. The pain relief medication of choice to deal with right ear pain is acetaminophen. This drug is cheap and readily available as Tylenol in various formulations.
Pharmacokinetics. Acetaminophen is absorbed from the gastrointestinal tract and attains peak plasma levels at about 10 to 60 minutes after administration. This provides rapid relief of symptoms. It is metabolized in the liver and excreted in urine (Matalová, Urbánek, & Anzenbacher, 2016). The common cold does not affect these organs; hence, there is no risk of toxicity. However, the parent needs to be educated on the maximum dose per day to give the child (Matalová et al., 2016).
Pharmacodynamics. Acetaminophen acts on the hypothalamus producing antipyresis (Ghanem, Pérez, Manautou, & Mottino, 2016). It also inhibits prostaglandin synthesis in the central nervous system through mechanisms independent of the cyclooxygenase pathway. Thus, there are no gastrointestinal adverse effects.
Antihistamines. Antihistamines are effective in reducing the magnitude of the inflammatory response that is causative of the symptoms of the common cold. Second-generation antihistamines are preferred because they result in less drowsiness (Hu, Sieck, & Hsu, 2015). These include drugs such as loratadine and fexofenadine.
Pharmacokinetics. Loratadine is absorbed through the gastrointestinal tract and is available in various formulations. The onset of effect is within one to three hours and acts for about 24 hours (Hu, Sieck, & Hsu, 2015). This enables once-daily dosing and improved tolerance. It is metabolized by the liver and excreted in both urine and feces. These organ systems are not affected by the common cold. Therefore, there are low risks of adverse effects.
Pharmacodynamics. Loratadine and other second-generation antihistamines have high selectivity for histamine H1 receptors located outside the central nervous system (Hu, Sieck, & Hsu, 2015). They block the effects of histamine at its receptors reducing vascular permeability and mucus secretion with the benefit of having very little or no sedative effect because they do not have any responses on the central nervous system unlike first-generation antihistamines (Hu, Sieck, & Hsu, 2015).
Nasal Decongestants. Nasal decongestants are drugs that act on the blood vessels of the upper airway, causing constriction and reduced permeability to reduce nasal stuffiness. These include drugs such as oxymetazoline, phenylephrine, and pseudoephedrine.
Pharmacokinetics. Pseudoephedrine is minimally absorbed from the gastrointestinal tract. The onset of action is within 30 minutes of administration. It is metabolized by the liver and excreted through the kidneys (Cox & Wise, 2018). Minimal systemic absorption reduces systemic adverse effects while ensuring effective nasal decongestion.
Pharmacodynamics. Pseudoephedrine is an alpha-adrenergic agonist that targets receptors present on the respiratory mucosa. Activation of these receptors on mucosal blood vessels results in vasoconstriction (Cox & Wise, 2018). The effects of pseudoephedrine on beta-adrenergic receptors lead to smooth muscle relaxation and thus, bronchial dilation (Cox & Wise, 2018). However, it also causes a raised heart rate, which is an adverse effect.
Resources Available for The Parent to Support the Treatment Decision
The common cold syndrome is largely a self-limiting condition that resolves with supportive pharmacological and non-pharmacological interventions. Mr. Smith will have access to the medication above as well as access to local physicians and pharmacists at the destination of the trip.
Communication Plan
Communication to Mr. Smith
Mr. Smith needs to be informed that most upper airway infections and, in this case, the common cold is viral in origin. As a result, antibiotics are not required in their management, especially the uncomplicated ones (Kuchar et al., 2015). He will need to keep the child well hydrated and provide nutritious meals. To reduce the congestion, he can provide a humidifier and warm soup often. He will need a detailed explanation of the medication available, the mode of administration, frequency, and the anticipated side effects. In case of any side effects such as increased heart rate and drowsiness, he will be advised on how to manage the child adequately. Since a small percentage of upper airway infections have bacterial superinfection, he shall be counseled on detecting the signs of bacterial infection such as significant fever above 100 degrees and throat exudate and the action to take including consulting a physician immediately.
Communication to the Child
The child will be reassured that the infection is common but often of short duration. He or she will be sensitized to the need for plenty of rest, taking fluids frequently, and taking medication. The child will be encouraged to inform the parent as soon as he/ she feels that the symptoms are worsening or new ones are developing.
References
- Cox, D., & Wise, S. (2018). Medical treatment of nasal airway obstruction. Otolaryngologic Clinics of North America, 51(5), 897-908. doi: 10.1016/j.otc.2018.05.004
- Ghanem, C., Pérez, M., Manautou, J., & Mottino, A. (2016). Acetaminophen from liver to brain: New insights into drug pharmacological action and toxicity. Pharmacological Research, 109, 119-131. doi: 10.1016/j.phrs.2016.02.020
- Hu, Y., Sieck, D., & Hsu, W. (2015). Why are second-generation H1-antihistamines minimally sedating? European Journal of Pharmacology, 765, 100-106. doi: 10.1016/j.ejphar.2015.08.016
- Kuchar, E., Miśkiewicz, K., Nitsch-Osuch, A., & Szenborn, L. (2015). Pathophysiology of clinical symptoms in acute viral respiratory tract infections. Advances in Experimental Medicine and Biology, 25-38. doi: 10.1007/5584_2015_110
- Matalová, P., Urbánek, K., & Anzenbacher, P. (2016). Specific features of pharmacokinetics in children. Drug Metabolism Reviews, 48(1), 70-79. doi: 10.3109/03602532.2015.1135941