"It Is Only a Cold, I Can Fly" Syndrome

September is one of the most beautiful months to fly in Michigan. Our weather is getting cooler leading to better density altitude performance.

The leaves have a hint of hue change that will eventually lead to spectacular fall colors. The college and professional football teams bring fans excitement and anticipation. I am pulling out my September pre-cold and flu checklist. I also pulled out my cold and flu toolbox to prepare for a season of coughs, colds, sinus congestion, and a blah feeling. Welcome to my ounce of prevention is worth a pound of cure season.

September was the first month of availability to receive the influenza vaccine for 2022/2023. The CDC has estimated that there have already been between 1300 and 3600 flu deaths between October 1, 2022, and November 5, 2022. During the 2021-2022 influenza season, CDC estimated that influenza was associated with 9 million illnesses, 4 million medical visits, 10,000 hospitalizations, and 5,000 deaths. The influenza burden was similar to that observed during the 2011-2012 season (CDC preliminary in-season burden estimate 2022). The 2022 egg vaccine contains Influenza A/Victoria, H1N1 pdm09, A/Darwin, B/Austria, and B/Phuket. 

Influenza symptoms include fever/chills, body aches, cough, sore throat, runny or stuffy nose, headaches, fatigue, and in some people, nausea, and diarrhea (children). Symptom relief can be achieved with acetaminophen (TylenolÒ), gargling with water or salt water throughout the day, decongestants, and ginger tea for nausea. Acetaminophen is a non-aspirin medication that works well for fever and chills. Be aware that no more than 4 grams of acetaminophen can be taken by mouth daily. Any more than 4 grams increase the risk of liver toxicity. Available decongestants include oxymetazoline (Afrin nasal sprayÒ), saline nasal spray, and pseudoephedrine. Oxymetazoline use duration is no greater than three days. A huge nasal congestion rebound is observed for use longer than three days and then discontinued. Pseudoephedrine products are over the counter, and you will have to sign for it plus show ID such as a driver's license. Be aware that if you are taking a urine drug test while taking or immediately after, pseudoephedrine may appear as a false positive for amphetamine and methamphetamine.

Cough product studies show no difference from drinking plenty of fluids with humidification to help clear mucous. Guaifenesin (MucinexÒ) is found in liquid form and capsules to decrease cough frequency and mucous thickness. There is also an increase in mucous clearance in the respiratory tract. The data is lacking on how efficacious this OTC medication is (Respir Med. 2015;109(11):1476-1453). Dextromethorphan is an expectorant found in many cough and cold products. Dextromethorphan toxicity includes hypertensive emergency, seizures, respiratory depression, coma, and psychosis. It could take anywhere from 12 hours to 4 days to clear dextromethorphan. Stay on the ground if you use a cough suppressant with dextromethorphan.

Treatment modalities for influenza are to start within 1 – 2 days of symptom onset. Anti-virals for influenza decrease fever and symptoms and lessen influenza's duration by one day. Anti-virals also reduce the severity of the flu in high-risk patients and decrease hospitalizations. Oseltamivir (TamifluÒ) is generic and comes in oral and capsule forms. Oseltamivir is used in patients 14 days and older. Zanamivir (RelenzaÒ) is an inhaler for patients seven years of age and older. The inhaler is the same device used for asthma and COPD. Peramivir is given through an intravenous line for patients six months and older. Baloxavir is a pill for patients five to 12 years of age who do not have chronic diseases. Baloxavir is not a treatment choice in pregnant, breastfeeding, and complicated chronic disease patients.

The standard cold season is typically in the winter and spring. The symptoms of a cold are sore throat, runny nose, coughing, sneezing, body aches, and headache. The course of a cold is usually 7-10 days. After day 10 of a cold, the person runs a risk of bacterial overgrowth, which may lead to a bacterial infection. A pneumonia diagnosis will receive antibiotic treatment. The most common virus seen in colds is the rhinovirus. Other viruses that cause a cold are respiratory syncytial virus (RSV), adenovirus, coronavirus, and parainfluenza. High-risk patients who contract RSV are greater than 65 years of age, have chronic heart or lung disease and are immunocompromised. RSV infections in older adults can have serious consequences. Per the CDC, in 2021, 60,000 – 100,000 older adults were hospitalized, and 6,000 – 10,000 died.

Treatments for a cold are two-fold, decreasing the duration of the cold and symptomatic relief. Therapies studied which may have a benefit are zinc therapy, gargling, masking, chicken soup, and probiotics. Symptomatic relief for colds is antihistamines (non-sedating), decongestants, and NSAIDs.

Zinc supplementation for cold prevention comes from observational studies in children. Zinc was given prophylactically vs. placebo for a year. There were a lower number of colds in the zinc arm of the study. School absences also decreased (Cochrane Database Syst Rev 2011;(2): CD001364). This data also applies to adults, even though very few studies exist.

Probiotics prophylaxis has some small studies indicating that upper respiratory infections (URIs) can decrease in children who were given a yogurt-like drink in the hospital containing Lactobacillus rhamnosus. Gargling with plain water vs. povidone-iodine showed that plain water can lower the rate of URIs (Am J Prev Med 2005;29:302-7). Chicken soup has anti-inflammatory, hydration, nutrition, cytotoxic effects, and mucous clearance effects (Chest 2000;118;1150-1157). Therapies offered not to work are Vitamin C, vapor rub, Ginseng, antibiotics, honey, and echinacea.

Symptomatic relief for muscle pain is acetaminophen and ibuprofen. Always take ibuprofen with food. Please only use non-sedating antihistamines for runny noses. Do not use diphenhydramine (Benadryl), as it stays in the body for 60 hours. Non-sedating antihistamines are loratadine (ClaritinÒ), fexofenadine (AllegraÒ), and cetirizine (ZyrtecÒ). Decongestants for colds, as in influenza, are oxymetazoline (AfrinÒ) and pseudoephedrine. Stuffed sinuses and coughing spells may become significant physical problems at altitude. My recommendation is not to fly until the resolution of all symptoms.

Covid-19 is still out there, so let's not let our guard down. If a family member or yourself has tested positive with mild to moderate symptoms, an anti-viral medication is available called nirmatrelvir with ritonavir (PaxlovidÒ). For PaxlovidÒ, see your healthcare provider within five days of symptoms. PaxlovidÒ is a 5-day therapy. Side effects of PaxlovidÒ are impaired sense of taste, abdominal pain, and increased blood pressure. The EPIC-HR trial studied high-risk patients with mild to moderate symptoms. There was an 89% decrease in hospitalizations in patients taking PaxlovidÒ (N Engl J Med 2022; 386:1397-1408).

Enjoy your holiday season with many beautiful flights with friends and loved ones. My goal and mission are to keep our lives flu and cold-free. Your flight bag is rich in resources and is loaded with information to decrease the symptoms and duration of the flu and the common cold. Only fly when you are 100% symptom negative and cognitively sharp. Be well and safe.

Larry M. Diamond, PharmD, CFII

Larry Diamond has a Doctor of Pharmacy Degree and has been a pharmacist for 37 years. Larry’s pharmacy practice has been as a Clinical Pharmacy Specialist in Cardiology, Orthopedic Surgery Specialist and most recently Clinical Pharmacy Coordinator. He is a CFII, a pilot for 33 years and has been an AOPA member since 1984.
Topics: Pilot Health and Medical Certification, Pilot Health and Medical Certification, Pilot Health and Medical Certification

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