Common Cold, Allergic Rhinitis And Cough Flashcards
1
Q
Cold season
A
Late August to April
2
Q
Pathophysiology of cold
A
Limited to upper respiratory tract: Pharynx, nasopharynx, nose, cavernous sinusoids and paranasal sinus
3
Q
Virus causes most of colds
A
Rhino viruses
4
Q
Peak viral concentration during the cold
A
2-4 days after initial inoculation
5
Q
Life cycle of rhinoviruses
A
16-18 days ( in nasopharynx)
6
Q
Transmission and risk factors for a cold
A
Self-inoculation of the nasal mucosa
Contact with viral-laden secretion on animate( eg. hands) or inanimate ( eg. doorknobs) objects
Aerosol transmission
Higher exposure rate in dense population ( classroom)
Allergic disorders affecting the nose or pharynx
Less diverse social networks
Weakened immune system due to smoking
Sedentary life style
Chronic ( more than one month) psychological stress
Sleep deprivation (Poor sleep quality or Liz than seven months of sleep per night)
7
Q
Symptoms of cold appeared 1 to 3 days after infection
A
Sore throat
8
Q
Symptoms of cold appeared By day two or three
A
Nasal symptoms:
- First secretions are clear thin and or watery
- then become thicker and color may turn yellow or green
- as cold Resolves become clear Thin and or watery again
9
Q
Symptoms of cold appeared by day four or five
A
Cough ( less than 20%)
10
Q
Duration of cold
A
7 to 14 days
11
Q
Common cold symptoms
A
Sore throat mild to moderate Nasal congestion Rhinorrhea Sneezing common Low grade fever( less then hundred) Chills Headache Myalgia Cough less than 20%
12
Q
Allergic rhinitis Symptoms
A
Watery eyes Itchy nose Repetitive sneezing Nasal congestion Watery rhinorrhea Red irritated eyes with conjunctival infection
13
Q
Influenza symptoms
A
Myalgia Arthralgia Fever more than hundred or 102 Nasal congestion Sore throat Non-productive cough Moderate to severe fatigue
14
Q
Exclusion criteria for self care of cold
A
Fever more than 100.4f (38c)oral measurement
Chest pain
Shortness of breath
Worsening symptoms or develop additional symptoms during self treatment
Concurrent underlying Chronic disease ( asthma, copd, chef), aids, Chronic immunosuppressant therapy
Elderly
Infants less than three months old
15
Q
Treatment goals of colds
A
Reduce bothersome symptoms
Prevent transformation of cold viruses to others
16
Q
General treatment approach for cold
A
Mainstay of tx = nonpharmacologic
Use single entity products targeting specific symptoms preferred over combination products
17
Q
Nonpharmacologic therapy
A
Increase fluid intake
Adequate rest
Eat nutritious diet as tolerated
Increase humidification with steamy shower vaporizer humidifier
Saline nasal spray drops
Food products Tea With lemon And honey chicken soup hot broth
18
Q
Decongestant
A
Indication temporary relief of sinus and nasal congestion cough associated With post nasal drip
MOA: stimulate Alpha-adrenergic receptors: constrict blood vessels=>Decreased mucosal edema and sinusoid vessel engorgement
19
Q
Direct acting decongestant
A
Phenylephrine
Oxymetazoline
Tetrahydrozoline
20
Q
Direct acting decongestant
A
Bind directly to adrenergic receptors
21
Q
Direct acting decongestant DDI with TCA ( amitriptyline, nortriptyline, imipramine)
A
Increase blood pressure
22
Q
Indirect acting decongestant
A
Ephedrine
23
Q
Indirect acting decongestant MOA
A
Displace norepinephrine storage vesicle in prejunctional nerve endings
24
Q
Indirect acting decongestant DDI with TCA ( amitriptyline, nortriptyline, imipramine)
A
Decrease ephedrine activity
25
Mixed decongestant
Pseudoephedrine
26
Mixed decongestant MOA
Both direct and indirect activity
27
Systemic Decongestants
Pseudoephedrine
| Phenylephrine
28
Systemic Decongestants PK
Pseudoephedrine well absorbed
Phenylephrine has low bioavailability
Both: Short half lives every 4 to 6 hours
29
Systemic Decongestants Age limitation
Older than two years of age
30
Systemic Decongestants ADE
Cardiovascular stimulation= Increase blood pressure , tachycardia ,palpitation, arrhythmia
CNS stimulation: insomnia, anxiety, tremors , hallucinations
More common in pediatric and geriatric patients
Less common in intranasal products ( topical products =minimally absorbed)
31
Systemic Decongestants CI
May exacerbate diseases sensitive to alpha receptor stimulation ( HTN, DM, coronary/ ischemic heart disease, Intraocular pressure, prostatic hypertrophy)
Coridin HBP, product without decongestant (HTN Specific)
Concomitant With MAO inhibitors ( pnenelzine, selegiline)
32
Systemic Decongestants DDI
Pseudoephedrine and antacid => decreases pseudoephedrine elimination
Pseudoephedrine + linezolid, MAOI= Sever hypertension, HA, hyperpyrexia( More than 106.7f =medical emergency).
33
Pseudoephedrine-containing Products
Kept behind the counter or locked cabinet
Require state or federal ID at time of purchase and ID Match person
Seller must obtain Written or electronic logbooks
-transactions for at least two years from date of purchase
-information contained name and address of buyer name of the product quantity and date and time of transaction
Buyer sign verifying information is correct
Self certification of retailers
34
Pseudoephedrine-containing Products Quantity limit
Maximum 3.6 to grams in one day
Max 9 g in 30 days
Mail order or mobile vendor: Maximum 74 and 5 g in 30 days
Individual packing less than 60 mg are exempt still behind counter
35
Nexafed
New product of pseudoephedrine
New technology to Decrease conversion to methamphetamine
Unique polymer Matrix that inhibit the extraction And conversion of active ingredient to methamphetamine
30 mg tablets
36
Short acting intranasal decongestant
Ephedrine
Naphazoline
Phenylephrine
37
Long acting intranasal decongestant
Xylometazoline ( 8 to 10 hours)
| Oxymetazoline 12 hours
38
Intranasal decongestants Age limitation
Older than two years
39
Intranasal decongestant ADE
Burning stinging sneezing local dryness
| Trauma from tip of administration device
40
Intranasal decongestant rhinitis medicamentosa ( rebound congestion)
Short Acting products, preservative agents, long duration of treatment contributed to the problem
41
Intranasal decongestant duration of therapy
3 to 5 days
42
Intranasal decongestant Treatment
Slowly withdrawing topical decongestant ( one nostril at a time)
Replace decongestant With normal saline
43
Antihistamine monotherapy for cold
Not effective in decreased rhinorrhea ( nasal cavity fill with significant amount of fluid) and sneezing due to cold
44
Local anesthetics for cold ( agents)
Benzocaine
| Phenol
45
Local anesthetics for cold ( indication)
Temporary relief of sore throats
46
Local anesthetics for cold Frequency
Every 2 to 4 hours
47
Local anesthetics for cold Age limitation
Children older than two years old
48
Systemic analgesic for cold ( agents)
ASAP
ASA
Ibuprofen
Naproxen
49
Systemic analgesic for cold Indication
Aches or fever associated with colds
50
Systemic analgesic for cold CI
ASA containing Products should not be used in children with viral illness => Reye’s syndrome
51
Antitussives and Protussives for a cold
Nonproductive cough associated with cold
Not Recommended
Antitussives = Questionable efficacy
Protussive= Not effective in natural colds
52
Antitussives
Codeine
| Dextromethorphan
53
Protussive
Guaifenesin
54
Cold Treatment at pregnancy
Non drug treatment = first line
| Oxymetazoline
55
Cold treatment during lactation
```
Pseudoephedrine = First line
Intranasal phenylephrine
Oxymetazoline
Dextromethorphan
Guaifenesin
Benzocaine camphor, menthol
```
56
Complementary therapies for a cold
High dose zinc => GI distress
| High dose vitamin C (> 4g/day)=> GI distresses
57
Risk factors for allergic rhinitis
Fam Heritage Of allergic disorder in one or both parents
Filaggrin (skin barrier protein) gene mutations
Increased IgE
Higher socioeconomic class
Eczema
Positive allergy skin test
58
Triggers of allergy
```
Outdoor = pollen, mold, spores,0zone particles
Indoor = house dust mites, mold spores, pet dander, cigarettes smoke
Occupational = wool dust, latex, resins, biologic enzyme, organic dusts
```
59
Pathophysiology of allergic rhinitis
Phase 1 sensitization
- Allergen stimulates beta-lymphocyte-mediated IgE production
Phase 2 early phase
- rapid release of preformed mast cell mediators ( histamine, protease)
-production of additional mediators (prostaglandins, neuropeptides)
Phase 3 cellular recruitment
- circulating leukocytes ( eosinophils) attracted to nasal mucosa
- release Inflammatory mediators
Late phase mucus hypersecretion
60
Clinical presentation of allergic rhinitis
Systemic symptoms: fatigue, irritability, malaise, cognitive impairment
61
Complications of acute allergic rhinitis
Sinusitis
| Otitis media with effusion
62
Complications of chronic allergic rhinitis
Nasal polyps
Sleep apnea
Sinusitis
Hyposmia( decreased sense of smell)
63
Symptoms of allergic rhinitis
Bilateral symptoms, worst upon awakening,improve during the day then may worsen at night
Sneezing frequent paroxysmal
Pruritis ( itching) of eyes, nose, and/or palate frequent
Nasal obstruction
Conjunctivitis ( Red irritated eyes, with prominent conjunctival blood vessels) frequent
Sinus pain ( due to congestion),throat pain ( due to postnasal drip irritation)
Anosmia, epistaxis rare
64
Allergic shiners (feature of allergic rhinitis)
Preorbital darkening second to venous congestion
65
Dennie’s lines (feature of allergic rhinitis)
Wrinkles beneath the lower eyelids
66
Allergic crease (feature of allergic rhinitis)
Horizontal crease near bulbar portion of nose ( 2nd to allergic salute)
67
Allergic salute( feature of allergic rhinitis)
Rub the tip of the nose upward with the palm of the hand
68
Allergic gape (feature of allergic rhinitis)
Open mouth breathing ( Second to nasal obstruction)
| Nonexudative cobblestone appearance of posterior oropharynx
69
Intermittent allergic rhinitis
Less than four days per week or less than four weeks
70
Persistent allergic rhinitis
More than four days per week and more than four weeks
71
Mild allergic rhinitis
No troublesome symptoms
| No impact on sleep or Daily activities
72
Moderate to severe allergic rhinitis
One or more of the following: Impaired sleep impaired daily activities troublesome symptoms
73
Treatment goals of allergic rhinitis
Decrease symptoms
Improve functional status
Improve sense of well being
74
General approach for allergic rhinitis
Allergens avoidance
Pharmacotherapy ( intranasal, corticosteroid, antihistamines, decongestant )
Immunotherapy
75
Exclusions to self-care of allergic rhinitis
Children younger than 12 years old
Pregnant or lactating women
Symptoms of non-allergic rhinitis
Symptoms of otitis media, sinusitis, bronchitis, or other infections
Symptoms of undiagnosed or uncontrolled lower respiratory disease ( copd, asthma)
Symptoms are unresponsive to treatment
Sever or unacceptable side effects of treatment
76
Non-pharmacological Therapy for allergic rhinitis
Allergen avoidance
- Lowering household humidity to less than 40%
-remove mite harboring dust ( carpets, Stuffed animal) From bedroom
Wash bedding at least weekly in hot water
Avoid activities that disturb decaying plant material
Venting food preparation area, Repairing basements, apply fungicide to moldy areas
Keep kitchen areas cleaned and tightly sealed, and treated infested area with pesticides
Avoid Outdoor activities when pollen counts are high
Use ventilation systems with high efficiency particulate air ( HEPA) Filter to remove pollen, mold spores
Use nasal wetting agents ( sailing, propylene) or irrigation with warm saline to relieve nasal mucosal irritation/dryness
77
Intranasal corticosteroids (INCS)
Most effective treatment for nasal symptoms itching sneezing congestion
First line therapy
78
Intranasal corticosteroids (INCS) MOA
Inhibit multiple cell types and mediators (histamine) and stop the allergic cascade
79
Intranasal corticosteroids (INCS) direction
Take at least one week before symptoms appear Or as soon as possible before expected Allergan exposures (completed symptoms may not seen up to one week)
Instruct to shake the bottle well before each use
Discard product after 60 or 120 doses even bottle is not empty
80
Intranasal corticosteroids (INCS) PK
Minimal systemic absorption
81
Intranasal corticosteroids (INCS) ADE
```
Well tolerated (ADE = nasal discomfort bleeding sneezing)
Serious side effects: change in vision glaucoma increased risk of infection, growth inhibition
```
82
Intranasal corticosteroids (INCS)
Triamcinolone acetonide
Fluticasone propinate
Fluticasone furoate
Budesonide
83
Triamcinolone acetonide (generic)
Nasacort allergy 24 hours ( brand)
84
Triamcinolone acetonide (age limitation)
Older than two years old
85
Triamcinolone acetonide ( Adult dose)
Two sprays in each nostril daily 220 mg per day
86
Triamcinolone acetonide (special consideration)
Nasal symptoms
87
Fluticasone propinate ( generic)
Flonase allergy relief( brand)
88
Fluticasone propinate( age limitation)
Older than four years old
89
Fluticasone propinate ( Adult dose)
Two sprays in each nostril daily 200 µg per day
90
Fluticasone propinate ( special consideration)
Nasal and Ocular (Itchy watery eyes )symptoms
91
Fluticasone furoate ( generic)
Flonase sensimist ( Brand)
92
Fluticasone furoate Age limitation
Older than two years old for nasal treatment
| Older than 12 years old for ocular treatment
93
Fluticasone furoate adult dose
Two sprays In each nostril daily 110 mg per day
94
Fluticasone furoateSpecial consideration
Titrate down to One Spray in each nostril Daily when symptoms improved
Shake the bottle vigorously with the cap on before each use
Prime the bottle ( cap left off more than 5 days or unused more than 30 days)
95
Budesonide ( generic)
Rhinocort
96
Budesonide Age limitation
Older than six years old
97
Budesonide( adult dose)
Two sprays in each nostril 128 µg per day
98
Budesonide special consideration
Nasal symptoms
Initial symptom control 10 hours after first dose
Complete symptoms control two weeks
Shake bottle gently before each use
Prime before first use or not used More than two days
99
First generation antihistamine moa
Nonselective
| Complete with histamine atCentral and peripheral histamine 1 ( H1) Receptor site
100
First generation antihistamine PK
Cross Blood brain barrier
Highly selective for Histamine 1 receptors
Anticholinergic, anti serotonin, anti alpha adrenergic
Quick onset, Short duration required multiple doses
101
First generation antihistamine ADE
CNS- sedative, appetite Stimulation
Anticholinergic = dry mouth, nose, vagina, blurred vision, urinary hesitancy/retention, constipation, reflex tachycardia
Photosensitive = use sunscreen and wear protective clothing
Paradoxical CNS stimulation, Especially in children
102
First generation antihistamine CI
Infants, lactating women, narrow angle glaucoma
103
First generation antihistamine drugs
Ethanolamine
| Alkylamine
104
Ethanolamine class (drugs)
Clemastine
Diphenhydramine
Doxilamine
105
Ethanolamine sedation property
Highly sedative
Strong anticholinergic
Large dose =seizure, arrhythmia
106
Alkylamine class ( drugs)
Chlorphenoramine
Brompheniramine
Pheniramine
107
Alkylamine sedation properties
Moderately sedative
Strong anticholinergic
Higher risk CNS paradoxical stimulation
108
Second Generation of anti-histamine MOA
Peripherally selective
Complete with histamine atCentral and peripheral histamine 1 ( H1) Receptor site
Inhibits release of must cell mediators
109
Second Generation of anti-histamine PK
Do not readily cross blood brain barrier
Highly selective for Histamine 1 receptors
Fast onset
Long duration
110
Second Generation of anti-histamine ADE
No sedation
111
Second Generation of anti-histamine classes of drugs
Piperazine
| Piperidine
112
Piperazine class drugs
Cetirizine
| Levocetirizine
113
Piperidine class drugs
Fexofenadine
| Loratadine
114
Cetirizine ( brand)
Zyrtec
115
Fexofenadine ( brand)
Allegra
116
Loratadine brand
Claritin
117
Levocetirizine brand
Xyzal
118
Cetirizine dose
10 mg PO daily
119
Fexofenadine dose
60 mg PO twice daily
| 180 mg PO daily
120
Loratadine dosed
10 mg PO daily
121
Levocetirizine dose
5 mg PO daily
| 2.5 mg PO daily less severe symptoms
122
Cetirizine Age limitation
Older than six years old
123
Cetirizine Special consideration
More Potent
Sedation In about 10% of patients
Longer duration than fexofenadine and loratadine
124
FexofenadineAge limitation
Older than six years old
125
Fexofenadine Special consideration
Should not be taken with any fruit juices together fruit juice decrease concentration of drug = directly inhibiting OATP
Separate FexofenadineAnd fruit juice by at least two hours
126
Loratadine Age limitation
Older than six years old younger than 65 years old
127
Levocetirizine Age limitation
Older than two years old younger than 65 years old
128
LevocetirizineSpecial consideration
Sedation take in the evening avoid alcohol
| Longer duration than fexofenadine and loratadine
129
Decongestant for allergic rhinitis indications
Treat allergic rhinitis associated congestion
| Use systemic decongestant or topical nasal decongestant ( no more than five days)
130
Cromolyn Sodium MOA
Blocking influx of calcium into mast sell preventing mediator release
Mast cell stabilizer
131
Cromolyn Sodium direction
One spray in each nostril 3 to 6 times daily at regular intervals
132
Cromolyn Sodium Age limitation
Older than two years old
133
Cromolyn Sodium Treatment duration
3 to 7 days for initial treatment efficacy
2 to 4 weeks to achieve max benefits
More effective if started before symptoms begin
134
Cromolyn Sodium ADE
Sneezing burning stinging
135
Antihistamines CI during the pregnancy
Fexofenadine ( Allegra)
136
Antihistamines CI during lactation
Cetirizine
Diphenhydramine
Fluticasone propionate
137
General duration of therapy of antihistamines
14 days
138
Pathophysiology of cough
Initiated by stimulation of sensory pathways in laryngeal, esophageal, tracheobronchial airway epithelium
Medullary brainstem network = cough control center process sensory input and stimulate motor efferents
Voluntary cough is controlled by cerebral cortex
Cough start with deep inspiration
Follow by closure of the glottis and forceful contraction of the chest wall, abdominal wall and diaphragmatic muscles against the closed glottis
139
Acute cough
```
Less than three weeks
Viral URTI
Pneumonia
Acute left ventricular heart failure
Asthma
Foreign body aspiration
```
140
Subacute cough
3 to 8 weeks
Post infectious cough
Bacterial sinusitis
Asthma
141
Chronic cough
More than eight weeks
GERD, COPD
ACEI ( lisinopril, benazepril)
Left ventricular heat failure
142
Productive cough clinical Presentation
Wet, chesty, phlegm
Expels secretions from the lower respiratory tract
Effective ( secretions easily expelled)
Ineffective ( difficult to expel secretions)
143
Nonproductive cough clinical presentation
Dry, hacking, tickling in the throat
| Causes: viral and atypical bacterial infection, GERD, cardiac disease
144
Cough Secretions
Not a reliable diagnostic indication
Clear= bronchitis
Purulent = bacterial infection
145
CI For self-care for cough
Children younger than four years of age
Cough more than seven days or that comes and goes
High fever more than 103 or lower fever that does not improve with self care
Cough with: Shortness of breath ,chest pain chills ,night sweats, hemoptysis, rash, persistent headache, tight feeling in the throat, swollen legs/ankles, cyanosis, unintentional weight loss, rash, persistent headache
Thick, yellow, tan, or green mucus or pus like secretions
Worsens after cold or flu but resolved
Drag induced cough ( ACEI)
Chronic diseases with cough: asthma, COPD, heart failure chronic bronchitis, cough associated with inhalation of dust, particles or objects
146
Treatment goals for cough
Decreased number and severity of cough episodes
Prevent complications
Cough treatment = symptomatic
-Need to treat underlying disorder
147
Antitussives ( cough suppressants)
Drug of choice For nonproductive cough
| Should not use in productive cough unless benefits risks ( nocturnal cough)
148
Protussive ( expectorant)
Change consistency of mucus
Increase volume of sputum
Provide relief for cough that expel thick , tenacious secretion
149
Cough Nonpharmacologic therapy
Non-medicated lozenges/ hard candies
Increased humidity
Stay well hydrated
150
Codein Special consideration
```
C V
Prescription antitussives
Gold standard
Pregnancy category C( only use if benefit >> risk)
Caution in elderly ( sedation)
```
151
Codein MOA
Acts centrally on medulla to increase cough threshold
152
Codein ADE
N/v/dizziness constipation sedation
153
Codein DOA
Quick onset 15 to 30 minutes
| Duration 4 to 6 hours
154
( brand) Benzonatate
Tessalon perles
155
Benzonatate MOA
Topical anesthetic action on the respiratory stretch receptors
156
Benzonatate ADE
N/ dizziness/ HA, sedation, numbness of tongue, month and throat ( capsules are broken or chew)
157
Benzonatate Special consideration
Done chew or crash
| Rx
158
Benzonatate dose
100 to 200 mg 3 times a day as needed
159
Dextromethorphan ( brand)
Delsym
| OTC
160
Dextromethorphan MOA
Act centrally in the medulla to increase cough threshold
161
Dextromethorphan ADE
Drowsiness/n/v ( well tolerated)
162
Dextromethorphan DDI
Monoamine oxidase inhibitors ( MAOI) =>> serotonin syndrome
| Alcohol antihistamine psychotropic
163
Diphenhydramine brand
Benadryl
| OTC
164
Diphenhydramine MOA
Nonselective first generation antihistamine
Act centrally in the medulla to increase cough threshold
Significant sedation and anticholinergic effects
165
Diphenhydramine ADE
```
Drowsiness
Disturbed coordination
Respiratory Depression
Anticholinergic ADE
Paradoxical excitation In children
```
166
Diphenhydramine DDI
Potentiate depressant effects ( Narcotic, analgesic, alcohol)
Intensify anticholinergic activity (MAOI, other anticholinergic)
167
Diphenhydramine Caution
Drug disease DDI ( worsen disease due to anticholinergic effect)
Narrow angle glaucoma, asthma, hypertension, benign prostatic hypertrophy, elevated intraocular pressure
168
Diphenhydramine Special consideration
First generation antihistamine plus systemic decongestant => Acute cough , post nasal drip and throat clearing
Avoid in elderly ( anticholinergic effect)
Pregnancy category B
169
Dextromethorphan Caution
Take 14 days after d/c MAOI
| Overdose = confusion excitation irritability drowsiness severe n/v
170
Dextromethorphan Special consideration
Ineffective for cough due to common cold
Use for short term symptomatic relief of cough associated with bronchitis acute and chronic and Post-infectious subacute cough
Abused for euphoric effect
Pregnancy category
Caution in Elderly sedation
171
Chlophedianol MOA
Antihistamines derivatives
| Centrally acting antitussives
172
Chlophedianol ADE
```
Excitation
hyper-irritability
Nightmares
Hallucinations
Hives
```
173
Chlophedianol DDI
MAOI - Should not take Chlophedianol for at least 14 days after MAOI discontinuation
174
Chlophedianol Caution
Overdose = dry mouth vertigo Visual disturbances , n/v , drowsiness
175
Chlophedianol Special consideration
```
Slow onset
Longer duration ( vs codeine)
```
176
Guaifenesin brand
Mucinex
177
Guaifenesin Indication
Expectorant
| Symptomatic relief of acute ineffective productive cough
178
Guaifenesin dose
Immediate release 200 to 400 mg PO every four hours maximum 2.4 g a day
Extended release 600 to 1200 mg PO every 12 hours maximum 224 g per day
179
Guaifenesin MOA
Loosens and thins Lower Respiratory tract secretions
Making minimally productive cough more productive
Well tolerated
180
Guaifenesin ADE
N/v, dizziness, HA, rash, diarrhea, drowsiness, stomach pain
Large dose might cause renal calculi (Take with full glass of water)
181
Topical antitussives
Camphor menthol not for chronic cough
Ointments = Camphor Menthol
Lozenges = menthol
Inhalation= camphor menthol
182
Topical antitussives counseling points
Camphor and menthol ointments creams and solutions May cause serious burns if:
- near an open flame
- Placed in hot water or in microwave oven
183
Topical antitussives DDI
Menthol +warfarin = decreases warfarin response
184
Pediatric for self care treatment of cough and colds
FDA: Cough and cold products Are not recommended for use in children younger than two years old
No FDA approved dosing ( CI)
Manufacture: Do not use in children younger than four years of age
185
Follow up and duration of therapy
When to seek medical attention
No improvement in 7 to 10 days
Cough persists more than three weeks even with some symptomatic improvement with self-care
Duration of therapy seven days
