common cold,rhino sinusitis,influenza

Common Cold , Rhino sinusitis,Influenza

Dr. Shahid PervaizDr. Shahid Pervaiz

Postgraduate Registrar Postgraduate Registrar

Pulmonology Department Pulmonology Department

Nishtar Hospital MultanNishtar Hospital Multan

Definition: the common cold

benign self-limited syndrome

caused by members of several families of viruses

Mild upper respiratory viral illness

Symptoms: the common cold

Day 1 : sore or “scratchy” throat, +/- low grade fever

Day 2-3 : nasal obstruction, rhinorrhea, sneezing.

Thick purulent nasal discharge does NOT mean bacterial sinusitis!

Day 4-5: cough becomes bothersome, nasal symptoms less severe

• Average duration: 3-7 days

• Virus-induced changes in airway reactivity can persist for up to 4 weeks

Symptoms: the common cold*Day 1

Symptoms: the common cold*Day 2 to 3

Symptoms: the common cold*Day 4 to 5

• thick purulent nasal discharge does NOT mean bacterial sinusitis!

50%

15%

15%

5%5% 10% Rhinovirus

Coronavirus

Influenza

RSV

Parainfluenza

Adeno, Entero

Virology *4,5

Seasonal Patterns

Fall, late spring : Rhinovirus Parainfluenza

Winter, spring: RSV, coronavirus

Summer: Enterovirus (year)

Adenovirus: Outbreaks in Military facilities daycare centers, hospital

Facts: the common cold

• Incubation period 24 to 72 hours• Average duration 3 – 7 days•Virus-induced changes in airway reactivity can persist for up to 4 weeks(Rhinovirus )• 2 to 3 episodes /per year*

Diferential diagnosis: the common cold

•Allergic or seasonal rhinitis •Bacterial pharyngitis or tonsillitis •Sinusitis •Influenza

But how do I know it’s just a cold?

COLD INFLUENZA

Fever Rare 39-40o

Headache Rare Usual

Myalgia Mild Severe

Malaise Mild May last 3 wks

Extreme fatigue Unusual Usual

Nasal congestion Common Common

Sneezing Common Sometimes

Sore throat Common Common

Chest discomfort/ cough

Mild Mod-Severe

Facts: Influenza

•Patients with illnesses which involve the cardiovascular or pulmonary systems •Patients with diabetes mellitus, renal disease, hemoglobinopathy, or immunosuppression.

•Residents of nursing homes or chronic care facilities

•Otherwise healthy individuals over age 50

Facts: Influenza Vaccine

All of the mentionated before Plus

Health care workers

Pregnant women in second or third trimestrer


• Acute Bacterial Sinusitis

• complicate 0.5-2% of colds

• Diagnosis = persistent URTI with no improvement >10-14 days OR worsening after 5 days +

• nasal congestion/ purulent nasal discharge

AND

• facial pain


• Pneumonia =

1. 2 of: fever, new cough, pleuritic chest pain, SOB +

2. Auscultatory findings +

3. New opacity on CXR

•Asthma

Airway reactivity

Vs

Acute asthma attacks exacerbationsUp to 40% of viral upper resp infection

Complications

Sinusitis: Acute bacterial sinusitis develops in 0.5 to

2.5 percent of adult patients after viral *1

Lower respiratory tract disease :

RSV, elderly (CHF) and immunocompromised

Acute otitis media: Eustachian tube dysfunction;

.

FACTS: transmission*

• Hand –to- hand

• most efficient = direct contact

• virus can survive for 2 hours on human skin

• also aerosol

• NOT via saliva

(in 90% of people with colds, no detectable virus in saliva)

FACTS: the common cold

• You can be re-infected by the same virus, but subsequent illness will be milder and shorter

• NO evidence that cold climate increases susceptibility to respiratory illness

Treatment: the common cold

• the ONLY “A” recommendation is NOT to use antibiotics to treat the common cold.

• everything else is “B” (inconsistent or limited quality evidence)

Treatment: what might work

COUGH:

• dextromethorphan (DM) – cough suppressant

• Cochrane review: 2 studies: benefit, 1 study: no benefit

• guaifenesin (Benylin E, Robitussin) – expectorant

•1 study: benefit, 1 study: no benefit

Treatment: what might work

NASAL CONGESTION:

• topical or oral decongestant (pseudoephedrine = Sudafed)

• small benefit of single dose, NO benefit of repeated use over several days

• topical intranasal Atrovent (0.06% spray)

• 2x 42ug sprays per nostril TID-QID x 4 days

• decreased nasal discharge by 26% : only 1 study, expensive

• humidified air and fluid intake

• inconsistent results, but no harm!

Treatment: what WON’T work

COUGH:

• codeine – works for chronic cough, NOT for acute cough

• antihistamines – no benefit

Treatment: what WON’T work

NASAL CONGESTION:

• Antihistamines *1

• no benefit, significant adverse effects

• Saline nasal spray

• no benefit


COMPLEMENTARY/ ALTERNATIVE:

• Vitamin C

• no effect if started after onset of symptoms

• inconsistent results if started before: may slightly decrease cold duration if 200mg daily

• Exercise

• decreased incidence in overweight postmenopausal women who exercised 5x/week


COMPLEMENTARY/ ALTERNATIVE:

• Echinacea

• no evidence in well-designed studies

• Zinc

• inhibits viral growth in vitro

• inconsistent study results

QUIZ: the common cold

What is the most common culprit?

a. rotavirus

b. coronavirus

c. rhinovirus

d. echovirus

e. influenza virus


Patient wants to spend his money on treatments that he can be sure will help his symptoms. What do you suggest?

a. Antibiotics

b. Antihistamine

c. Codeine

d. Dextromethorphan

e. Pseudoephedrine

f. D. or E.

g. None of the above – just rest and fluids


a. Antibiotics

b. Antihistamine

c. Codeine

d. Dextromethorphan

e. Pseudoephedrine

f. D. or E.

g. None of the above – just rest and fluids

RHINO-SINUSITISRHINO-SINUSITIS

SINUSITIS AND ITS MANAGEMENT

Anatomy of sinuses

• Where are the Where are the sinuses? sinuses?

• Four pairs of Four pairs of paranasal sinuses paranasal sinuses • Frontal-above eyes in Frontal-above eyes in

forehead boneforehead bone• Maxillary-in Maxillary-in

cheekbones, under eyescheekbones, under eyes• Ethmoid-between eyes Ethmoid-between eyes

and noseand nose• Sphenoid-in center of Sphenoid-in center of

skull, behind nose and skull, behind nose and eyeseyes

EMBRYOLOGICAL DEVELOPMENT

• The sinuses are hollow air-filled The sinuses are hollow air-filled sacs lined by mucous membrane. sacs lined by mucous membrane.

• The ethmoid and maxillary The ethmoid and maxillary sinuses are present at birth. sinuses are present at birth.

• The frontal sinus develops during The frontal sinus develops during the 2the 2ndnd year and the sphenoid year and the sphenoid sinus develops during the 3sinus develops during the 3rdrd year year

EMBRYOLOGICAL DEVELOPMENT

• At birth, the ethmoid, sphenoid At birth, the ethmoid, sphenoid and maxillary sinuses are tiny and and maxillary sinuses are tiny and cause problems in infants and cause problems in infants and toddlers.toddlers.

• Frontal sinuses develop between 4-Frontal sinuses develop between 4-7 years of age, causing problems in 7 years of age, causing problems in school aged children and school aged children and adolescents.adolescents.

Inflammation of paranasal sinuses

INFLAMED SINUSES

DEFINATION AND INCIDENCE• An acute inflammatory process An acute inflammatory process

involving one or more of the involving one or more of the paranasal sinuses. paranasal sinuses.

• A complication of 5%-10% of URIs in A complication of 5%-10% of URIs in children.children.

• Persistence of URI symptoms >10 Persistence of URI symptoms >10 days without improvement. days without improvement.

• Maxillary and ethmoid sinuses are Maxillary and ethmoid sinuses are most frequently involvedmost frequently involved

PATHOGENESIS:

• Usually follows rhinitis, which may be viral or Usually follows rhinitis, which may be viral or allergic.allergic.

• May also result from abrupt pressure changes (air May also result from abrupt pressure changes (air planes, diving) or dental extractions or infections. planes, diving) or dental extractions or infections.

• Inflammation and edema of mucous membranes Inflammation and edema of mucous membranes lining the sinuses cause obstruction.lining the sinuses cause obstruction.

• This provides for an opportunistic bacterial This provides for an opportunistic bacterial invasioninvasion

PATHOGENESIS:

• With inflammation, the mucosal lining of With inflammation, the mucosal lining of the sinuses produce mucoid drainage. the sinuses produce mucoid drainage. Bacteria invade and pus accumulates Bacteria invade and pus accumulates inside the sinus cavities. inside the sinus cavities.

• Postnasal drainage causes obstruction of Postnasal drainage causes obstruction of nasal passages and an inflamed throat. nasal passages and an inflamed throat.

• If the sinus orifices are blocked by swollen If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the mucosal lining, the pus cannot enter the nose and builds up pressure inside the nose and builds up pressure inside the sinus cavities.sinus cavities.

PREDISPOSING FACTORS

• Allergies, nasal deformities, cystic Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection.fibrosis, nasal polyps, and HIV infection.

• Cold weatherCold weather

• High pollen countsHigh pollen counts

• Day care attendanceDay care attendance

• Smoking in the homeSmoking in the home

• Re-infection from siblingsRe-infection from siblings

AETIOLOGY

• 70% of bacterial sinusitis is caused by:70% of bacterial sinusitis is caused by:• Streptococcus pneumoniaeStreptococcus pneumoniae• Haemophilus influenzaeHaemophilus influenzae• Moraxella catarrhalisMoraxella catarrhalis

• Other causative organisms are:Other causative organisms are:• Staphylococcus aureusStaphylococcus aureus• Streptococcus pyogenes,Streptococcus pyogenes,• Gram-negative bacilliGram-negative bacilli• Respiratory virusesRespiratory viruses

SYMPTOMS:

• History of URI or allergic rhinitisHistory of URI or allergic rhinitis• History of pressure changeHistory of pressure change• Pressure, pain, or tenderness over Pressure, pain, or tenderness over

sinusessinuses• Increased pain in the morning, Increased pain in the morning,

subsiding in the afternoonsubsiding in the afternoon• MalaiseMalaise• Low-grade temperatureLow-grade temperature

SYMPTOMS:

• Persistent nasal discharge, often Persistent nasal discharge, often purulentpurulent

• Postnasal dripPostnasal drip• Cough, worsens at nightCough, worsens at night• Mouthing breathing, snoringMouthing breathing, snoring• History of previous episodes of History of previous episodes of

sinusitissinusitis• Sore throat, bad breathSore throat, bad breath• HeadacheHeadache

CLINICAL FEATURES:

• Periorbital edemaPeriorbital edema• CellulitisCellulitis• Nasal mucosa is reddened or swollenNasal mucosa is reddened or swollen• Percussion or palpation tenderness over a Percussion or palpation tenderness over a

sinussinus• Nasal discharge, thick, sometimes yellow Nasal discharge, thick, sometimes yellow

or greenor green• Postnasal discharge in posterior pharynxPostnasal discharge in posterior pharynx• Difficult trans-illuminationDifficult trans-illumination• Swelling of turbinatesSwelling of turbinates• Boggy pale turbinatesBoggy pale turbinates

DIAGNOSTIC TESTS:

• Imaging studies, such as sinus Imaging studies, such as sinus radiographs, ultrasonograms, or CT radiographs, ultrasonograms, or CT scanning – indicated if child is scanning – indicated if child is unresponsive to 48 hours of unresponsive to 48 hours of antibiotics and if the child has a toxic antibiotics and if the child has a toxic appearance, chronic or recurrent appearance, chronic or recurrent sinusitis, and chronic asthma. sinusitis, and chronic asthma.

• Laboratory studies, such as culture of Laboratory studies, such as culture of sinus puncture aspirates.sinus puncture aspirates.

DIFFERENTIAL DIAGNOSIS

• septum deviation)septum deviation)• Nasal foreign body Allergic rhinitisNasal foreign body Allergic rhinitis• Non-allergic rhinitisNon-allergic rhinitis• Infectious rhinitisInfectious rhinitis• Drug-induced rhinitisDrug-induced rhinitis• Nasal polypsNasal polyps• Dental abscessDental abscess• Carcinoma of sinusCarcinoma of sinus• Cluster headacheCluster headache• Structural defectsStructural defects

MEDICAL TREATMENT

• Acetaminophen or ibuprofen to relieve Acetaminophen or ibuprofen to relieve painpain

• DecongestantsDecongestants

• AntihistaminesAntihistamines

• Nasal salineNasal saline

ANTIBIOTIC TREATMENT:

• Antimicrobials-treat for 10-14 days, Antimicrobials-treat for 10-14 days, depending upon severity, with one of depending upon severity, with one of the following:the following:

• Amoxicillin:20-40mg/kg/d in 3 Amoxicillin:20-40mg/kg/d in 3 divided doses(>20kg, 250mg tid)divided doses(>20kg, 250mg tid)

• CLAVUNATED AMOXICILLIN:CLAVUNATED AMOXICILLIN:25-25-50mg/kg/d in 2 divided doses, 50mg/kg/d in 2 divided doses, Use Use suspension if child is less than 40kg.suspension if child is less than 40kg.

TREATMENT

• SEPTRAN: CO-SEPTRAN: CO-TRIMOXAZOLE+TRIMETHOTRIMOXAZOLE+TRIMETHOPRIMPRIM

• CEFACLOR:500MG:1 *TDSCEFACLOR:500MG:1 *TDS

• STEAM INHALATIONSTEAM INHALATION

FOLLOW UP INSTRUCTIONS

Humidifier to relieve the drying of Humidifier to relieve the drying of mucous membranes associated with mucous membranes associated with mouth breathingmouth breathing

• Increase oral fluid intakeIncrease oral fluid intake

• Saline irrigation of the nostrilsSaline irrigation of the nostrils

• Moist heat over affected sinusMoist heat over affected sinus

• Prolonged shower to help promote Prolonged shower to help promote drainagedrainage

PATIENT EDUCATION:

• Child should not dive.Child should not dive.• Child should not travel by airplane.Child should not travel by airplane.• Urge parent to eliminate triggers in the home Urge parent to eliminate triggers in the home

(dust, smoking)(dust, smoking)• Have all members of the family treated, if Have all members of the family treated, if

indicated. indicated. • Instruct parent to call in 48 hours if condition of Instruct parent to call in 48 hours if condition of

child has not improved.child has not improved.• Instruct parent to bring child in for a recheck in Instruct parent to bring child in for a recheck in

2 weeks.2 weeks.

ALLERGIC RHINITIS

ALLERGIC RHINITIS

Def. of Rhinitis: Is an inflammation of the nasal mucous membranes.

However, with allergic rhinitis, other organs or tissues are involved, such as eyes, ears, sinuses, oropharinx.

ALLERGIC RHINITIS

•-Is an Immunologic Hypersensitivity Disorder Type I

•-Is often a predisposing factor or exacerbation of asthma, rhinosinusitis, nasal polyps.

•-Characterized by one or more nasal Sx- sneezing, itching, congestion, rhinorrhea.

•-Diagnosis is based on Hx, physical findings, and Lab.

Impact of Allergic Rhinitis

•Most common form of atopic disease

•Affects 40 million Americans

•Prevalence estimates: 10/30% of adults, 40% of children

•Peak incidence in childhood and adolescence

•Almost 70% of the patients have nasal congestion

•Nearly 17 million office visits a year

Impact of Allergic Rhinitis

•Direct costs per year of about 6 billion dollars

•Increase absenteeism and reduced productivity

•75/80% of patients with asthma have allergic rhinitis.

Genetics:

High incidence in families with atopic disease (eczema, asthma)

Classification:

Seasonal: Yearly intervals, periodic symptoms, often due: to outdoor allergens-pollens, tree pollens (spring), grass (summer), ragweed (mid August). Mold spores

Classification:

Perennial: Throughout the entire year, due to multiple seasonal allergies or continue exposure to: indoors allergen: Dust mite (Dermatophagoides), animal dander, cigarette smoke, hair ,spray, paint, mold, cockroaches outdoor allergens: Pollens, tree pollens (spring), grass (summer), ragweed (mid August).Mold spores

PATHOPHYSIOLOGY

Allergens bind to specific IgE on Mast cells in Respiratory mucosa Enzymatic reactions occurs within the cell Release of mediators (histamine, leukotrienes, prostaglandins) from mast cells triggering IgE, leads to a complex interaction of inflammatory mediators, causing inflammation of the mucous membranes of eyes, nose, Eustachian tube, sinuses and/or pharinx.

There are 2 phases of allergic response:Early phase response to antigen: < 5- 30 minutes after allergen exposure.-Allergen comes in contact with IgE-primed mast cells and basophils-Caused by the immediate release of histamine and other mediators (leukotrienes). -Causing bronchoconstriction, edema, and stimulation of mucous gland that leads to: Production of secretions: Increase in vascular permeability leads to plasma exsudation Vasodilation leads to nasal congestion and sinus pressure

Late phase response to antigen: 2-12 hours after allergen exposureCharacterized by sx beginning 4-8 hours after allergic exposure. This phase occurs because of inflammation resulting from the recruitment of inflammatory cells (Cytotoxic proteins released by neutrophils, eosinophils, macrophages, lymphocytes – damaging the Epithelial cells) to the mucous membranes.This phase has more congestion, rhinorrhea and less sneeze/itching.

S/S: Seasonal: Clear and watery drainage from nose (rhinorrhea) tearing of the eyes and red eyes frequent sneezing Lesser mouth breather Itching of their nose, eyes, palate / throat (erythema can be seen) eczema, family Hx. of atopy support the Dx. of allergic rhinitis.

Perennial: Year round symptoms, nasal congestion (major complaint) post-nasal drainage (dry cough)

mouth breather decreased sense of smell/or taste.

Other SX: ↓ in physical functioning, energy and fatigue, social events, ↑ in pain and limitations of emotions, ↓ quality of life

“allergic shiners” Dark circles under the eyes (Moonshiners). Chronic venous stasis from sinus congestion“Dennie-Morgan”: single or double lines under the eyes due to chronic edema.Allergic salute: Rubbing of the tip of the nose upward to ↓ itching

Allergic crease: Transverse line near the tip of the nose, secondary to rubbingNasal mucosa: Pale color, edema of turbinates (inferior), clear watery secretion, colored mucus secretion Nasal polyps: Gray color, peeled-grape appearance, insensitivity to touch

Upper Respiratory Infection-Common ColdEtiology: Rhinoviruses, Parainfluenza, RSV, Adenovirus

Risk factors: Day care, smoking, crowding, temperature changes

Upper Respiratory Infection-Common Cold

S/S: Nasal/throat irritation

Sneezing, nasal congestion, rhinorrhea

Sore throat, postnasal drip

Low grade fever, HA, malaise, myalgia

Can lead to AOM, Sinusitis, asthma

TX: Fluids, supportive

INFECTIOUS RHINITIS

Most common cause of nasal symptoms in children is viral URI. Specially in day care/kindergarten/winter months

Last between 7-14 days, symptoms resolving around the 7th/8th dayFever may or may not appear

INFECTIOUS RHINITIS

Clear mucus discharge, changing to green/yellow after a few days, Cough post nasal drip

Turbinates can be swollen and erythematous. Secretions are watery or thick, clear or colored.

Complicated by sinusitis or obstruction by adenoidal hypertrophy

TX: ATB (purulent mucus), mucolitics, cough syrup

LAB:

CBC- Eosinophilia

Nasal cytology- Eosinophilia. Greater than 10% is (+)

Skin testing- Prick/puncture in skin 10-20 allergens. Immediate hypersensitivity with immediate results. There is a small chance of triggering a severe allergic reaction in someone highly allergic.

LAB:

RAST– Radio Allergo Absorbent Test: Measure allergen- specific IgE, measure specific IgE to individual allergen in a sample of blood. Is less sensitive than skin testing.

Total IgE: Elevated in allergic rhinitis

TX:Environmental control: Avoidance of specific allergens.1-Outdoor allergents: Pollens/outdoor molds: limit outdoor activity during allergy season Keep windows and doors closed Wear a mask while doing yard work.

2-Indoors: Use dust mite anti-allergic pillow and mattress plastic covers Reduce indoor heat and humidity decreasing proliferation of mites Eliminate carpeting, and use linoleum, tiles. Avoid feathers in pillows and covers. Molds: Eliminate areas of dampness and standing water Clean mold area Pets : Avoid as much as possible or don’t have them Use HEPA filters and A/C Eliminate cockroaches

Nasal Steroids: Effective for itching, sneezing, rhinorrhea,

nasal congestion

More effective than oral antihistamine.

Budesonide (Rhinocort), flonase, nasonex

Antihistamine: Block H1 receptors suppressing most of symptoms

First generation: H1 antagonist with anticholinergic effects (sedating, dry mouth, tachycardia)

Effective for most Sx. of allergic rhinitis, but on congestion is limited.

Benadryl (dyphenhydramine)

Second generation:

H1 antagonist with no/less anticholinergic sedating effect.

Effective for most symptoms, improved but not efficient on congestion.

Zyrtec (cetirizine), Clarinex (desloratidine)

Singulair (montelukast-Leukotrienes blockers)

Topical cromolyn sodium (Nasalcrom-Intal): Mast cell stabilizer Used above 6 years of age

Oral decongestants: alpha-1-adrenergic agonists: phenylephrine, phenylpropalamine.- SudafedCause vasoconstriction, ↓ blood supply to nasal mucosa / edemaTopical decongestants: Sympathomimetics. Side effects-drying and burning of the mucosa. Using more than 5 days- rebound vasodilation and congestion. Oxymetazoline -Afrin

Combined oral decongestant and antihistamines: Extendryl / Rondec- chlorpheniramine

Mucolytics: Thin mucus, improving mucociliary flow. Steam, NS drops, Guaifenesin, N-acetylcysteine

Immunotherapy: Given to patients that not responded to drug therapy and good environmental control

POS

ALLERGIC RHINITIS

INFLUENZA

Define influenza

Influenza commonly called Influenza commonly called “the flu” is a highly contagious “the flu” is a highly contagious infection of the nose, throat, infection of the nose, throat, bronchial tubes, and lungs.bronchial tubes, and lungs.

Infective agent

• Influenza is caused by viruses that infect the Influenza is caused by viruses that infect the respiratory tract.respiratory tract.

• Two main types:-Two main types:-1.Influenza type-A1.Influenza type-A2.Influenza type-B2.Influenza type-B• These viruses can under go two types of These viruses can under go two types of

changes.changes.• ““Antigenic drift” – gradual evaluation of Antigenic drift” – gradual evaluation of

virus.virus.• ““Antigenic Shift” _ occurs only occasionally.Antigenic Shift” _ occurs only occasionally.

How do people get influenza

• Influenza occurs world wide. The Influenza occurs world wide. The major types of influenza virus live major types of influenza virus live and change inside animals, and change inside animals, primarily birds, pigs, and horses.primarily birds, pigs, and horses.

• It spreads through the Air, most It spreads through the Air, most often when an infected person often when an infected person sneezes, cough, or speaks.sneezes, cough, or speaks.

Signs and symptoms

• Abrupt feverAbrupt fever• Muscle achesMuscle aches• Severe tirednessSevere tiredness• CoughCough• Sore throatSore throat• Runny or stuffy noseRunny or stuffy nose• HeadacheHeadache These symptoms typically appear 1-5 These symptoms typically appear 1-5

days after infection.days after infection.

How is influenza diagnosed

• Health care provider will Health care provider will diagnose influenza based on diagnose influenza based on typical symptoms of fever, typical symptoms of fever, chills, headache, cough and chills, headache, cough and body aches.body aches.

Who is at risk for influenzaAny one can get. but the risk of complication in Any one can get. but the risk of complication in

highest in these groups.highest in these groups.1.Person aged 65 years and older1.Person aged 65 years and older2.Residents of nursing home2.Residents of nursing home3.Adults and children with long lasting disorders of 3.Adults and children with long lasting disorders of

the lungs or heart.the lungs or heart.4.Adults and children with diabetes, kidney disease, or 4.Adults and children with diabetes, kidney disease, or

weakened immune systemsweakened immune systems5.Health-care workers, house hold members and 5.Health-care workers, house hold members and

others who are contact with persons at high risk for others who are contact with persons at high risk for influenza. influenza.

Treatment for influenza

• There is no cure for influenza.There is no cure for influenza.

• Rest and liquids are main treatment.Rest and liquids are main treatment.

• Antiviral drug- Tamiflu is licensed for Antiviral drug- Tamiflu is licensed for treatment of both the main types of treatment of both the main types of influenza in humans (type A and type B) influenza in humans (type A and type B) it may prevent or reduce the severity of it may prevent or reduce the severity of influenza.influenza.

common cold,rhino sinusitis,influenza

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