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Winter respiratory infections are among the most common presentations seen in community pharmacy. Although most are self-limiting viral infections requiring reassurance and supportive care, some patients need symptomatic treatment, antiviral or antibiotic therapy, or urgent referral to secondary care.
Distinguishing between these presentations is important for patient safety and good antimicrobial stewardship. As pharmacists take on increasingly advanced clinical roles, respiratory assessment has become a core clinical skill.
This article offers a structured, consultation-based approach to four common winter respiratory infections: common cold, flu, acute bronchitis and community-acquired pneumonia.
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Clinical features
Common cold
Common colds are mild, self-limiting, upper respiratory tract infections (URTI) caused by a range of respiratory viruses, most commonly rhinoviruses. Symptoms develop gradually over one to two days and typically include nasal congestion, rhinorrhoea, sneezing, sore throat and mild cough.
Most patients remain systemically well and can continue their usual daily activities, although many report feeling tired or run down. Fever is uncommon in adults, and significant breathlessness, pleuritic chest pain (pain that worsens with breathing or coughing) or marked systemic illness should prompt consideration of an alternative diagnosis.
Patients usually seek pharmacy advice because their symptoms are troublesome rather than because they feel seriously unwell.
Flu
Flu is an acute respiratory illness caused by influenza viruses. Symptoms develop abruptly and typically include cough, coryza (acute inflammation of the mucous membranes in the nasal cavities) and systemic features such as fever, rigors, headache, myalgia and fatigue.
Patients often describe becoming unwell “all at once” and may recall the exact time their symptoms began. Unlike those with a common cold, they frequently feel too unwell to continue their normal activities and may spend several days in bed.
Acute bronchitis
Acute bronchitis is a self-limiting, usually viral, lower respiratory tract infection (LRTI) that often follows an URTI. Typically developing over several days, it is characterised by a persistent cough that usually lasts two to three weeks.
Patients may also report sputum production, wheeze, occasional low-grade fever and chest discomfort caused by frequent coughing. Breathlessness is usually minimal and clinical observations are typically normal.
Community-acquired pneumonia
Community-acquired pneumonia (CAP) is an acute LRTI affecting the lung parenchyma and is most commonly caused by bacteria. Symptoms typically develop over several days and include fever, cough, breathlessness, pleuritic chest pain and focal chest signs.
Compared with acute bronchitis, patients are usually more breathless, have abnormal clinical observations and are significantly more unwell.
Older adults may present atypically with new confusion, falls, reduced mobility or general deterioration, while immunocompromised patients may have relatively subtle symptoms despite significant infection. Delayed treatment can lead to serious complications.
The distinguishing clinical features of these conditions are summarised in Table 1.
| Table 1: Distinguishing common winter respiratory infections | ||||
| Feature | Common cold | Flu | Acute bronchitis | CAP |
| Onset | Gradual | Sudden | Gradual | Often gradual |
| Fever | Uncommon | Common | Occasional | Common |
| Systemic illness | Mild | Marked | Usually mild | Moderate to severe |
| Cough | Mild | Common | Predominant symptom | Common |
| Breathlessness | Uncommon | Mild | Minimal | Common |
Assessment
Assessment begins as soon as the patient walks into the pharmacy. Their appearance, breathing effort and ability to speak in full sentences can provide early clues to illness severity.
History
A thorough history should explore the onset, progression and severity of symptoms, as well as risk factors for complications.
Ask when symptoms began and how they have progressed. Sudden onset with prominent systemic symptoms is more suggestive of flu, whereas gradual progression is typical of the common cold and many cases of acute bronchitis.
Worsening breathlessness, persistent fever or progressive illness should raise suspicion of CAP or other complications.
Cough
Ask about the duration and nature of the cough, including whether it is dry or productive, the presence and colour of sputum, and any haemoptysis (coughing up blood).
Patients often associate green or yellow sputum with bacterial infection and expect antibiotics. However, sputum colour reflects inflammation rather than bacterial infection and should not be used in isolation to guide prescribing decisions.
Haemoptysis is a red flag that requires urgent medical assessment.
Breathlessness
Assess breathlessness using functional questions rather than simply asking whether it is present. Ask whether the patient can walk across a room, climb a flight of stairs or carry out their usual daily activities, as functional limitation is a better indicator of illness severity than breathlessness alone. A marked reduction in functional capacity or breathlessness at rest should prompt further assessment.
Chest pain
Ask the patient to describe the nature of any chest pain. Musculoskeletal chest pain that occurs only with coughing is common in viral respiratory infections and acute bronchitis.
Pleuritic chest pain increases suspicion of CAP and warrants further assessment. Central, crushing or exertional chest pain should always be treated as a potential cardiac emergency requiring urgent medical assessment.
Systemic symptoms
Ask about systemic symptoms including fever, rigors, fatigue, myalgia, headache and confusion. Marked fatigue and myalgia are particularly suggestive of flu, while new confusion should raise suspicion of serious infection, particularly in older adults.
Identify patients at increased risk of complications, as they warrant a lower threshold for referral. These include:
- People aged 65 years or older
- Pregnant women
- People with significant comorbidities
- Immunocompromised.
Clinical observations
Clinical observations provide an objective assessment of illness severity. Although no single observation confirms a diagnosis, abnormal findings may indicate serious infection and help identify those patients who require escalation of care.
Respiratory rate: Respiratory rate is one of the most useful indicators of illness severity and is measured by counting the patient’s breaths over 60 seconds. A normal adult respiratory rate is 12-20 breaths per minute. Tachypnoea, or a raised respiratory rate, may be an early sign of clinical deterioration and is a key feature of CAP and sepsis.
Temperature: Temperature should be measured using a validated thermometer. Fever, generally defined as a temperature of 38°C or above, supports the presence of infection but does not distinguish viral from bacterial illness.
A normal temperature does not exclude serious infection, particularly in older adults and those who are immunocompromised, in whom CAP may present without fever.
Pulse: Pulse can be assessed by manual palpation or using a validated electronic device. A resting pulse of 60-100 beats per minute is generally considered normal in adults, although pulse rate varies with factors such as age, fitness and underlying health.
Tachycardia (a pulse above 100 beats per minute) may indicate fever, dehydration, pain or systemic illness. A pulse that is disproportionately elevated for the degree of fever should raise concern about significant physiological stress, dehydration or sepsis.
Oxygen saturation: Oxygen saturation is measured using a pulse oximeter. In most healthy adults, a normal oxygen saturation is 95-100%. Reduced levels should prompt urgent medical assessment. However, a normal oxygen saturation does not exclude CAP, particularly early in the course of the illness.
Blood pressure: Blood pressure should be measured using a validated monitor and appropriately sized cuff. Interpret results in the clinical context, taking account of the person’s usual blood pressure where known. A systolic blood pressure of 90mmHg or less, or more than 40mmHg below the person’s usual systolic blood pressure, is a high-risk criterion for sepsis.
| No single observation confirms a diagnosis of a winter respiratory infection |
Chest examination: Where appropriate and within their scope of practice, pharmacists may perform chest auscultation (listening to the internal sounds of the lungs and airways) as part of the clinical assessment. Findings should always be interpreted alongside clinical history and observations, as no single sign is diagnostic in isolation. Common findings include:
- Wheeze: may occur in asthma, COPD or viral bronchitis
- Coarse crackles: commonly reflect airway secretions; often heard in acute bronchitis
- Fine inspiratory crackles: suggest alveolar involvement, particularly when localised, and increase suspicion of CAP
- Bronchial breathing: suggests lung consolidation and increases suspicion of CAP
- Reduced air entry: may indicate consolidation, pleural effusion or significant airway obstruction.
Normal chest sounds do not exclude CAP, particularly early in the course of the illness.
Using CRB-65 screening to assess severity: When CAP is suspected, the CRB-65 score can help assess severity and support referral decisions. It should complement, not replace, clinical judgement. The CRB-65 score allocates one point for each of the following:
- Confusion: new disorientation (place or time), or an abbreviated mental test score of 8 or less
- Respiratory rate: 30 breaths per minute or more
- Low blood pressure: diastolic BP of 60mmHg or less, or systolic BP less than 90mmHg
- Age: 65 years or older.
A score of 0 indicates a low mortality risk. Home management may be appropriate.
A score of 1-2 indicates intermediate mortality risk. Hospital assessment should be considered, particularly for patients with a score of 2.
A score of 3-4 indicates a high mortality risk and warrants urgent hospital admission.
Clinical judgement should always take precedence over scoring systems. Patients who appear significantly unwell should be referred regardless of their CRB-65 score.
| Table 2: Red flags requiring urgent assessment | |
| Red flag | Why it matters |
| Severe or worsening breathlessness | May indicate severe respiratory illness or respiratory failure |
| Reduced oxygen saturation | Suggests impaired gas exchange |
| Respiratory rate ≥30 breaths/minute | Suggests severe illness |
| New confusion | May indicate hypoxia, sepsis or severe infection |
| Hypotension | Suggests sepsis or significant physiological compromise |
| Central chest pain | May indicate an acute cardiac cause |
| Haemoptysis | May indicate serious underlying pathology |
| Cyanosis | Indicates significant hypoxaemia |
| Rapid clinical deterioration | Suggests serious infection or clinical instability |
Management
Patient management should be guided by the most likely diagnosis, illness severity and risk of complications. Most patients with a common cold, flu and uncomplicated acute bronchitis can be managed with self-care advice and symptomatic treatment.
Patients with suspected bacterial infection, severe illness or risk factors for complications may require a prescription or hospital referral.
Self-care and symptomatic treatment
Where self-care is appropriate, advise patients to rest as needed, maintain adequate hydration and use suitable symptomatic treatments, including:
- Paracetamol or ibuprofen for pain and fever
- Honey for cough in adults and children over one year of age
- Saline nasal spray for nasal congestion
- Throat lozenges or sprays for sore throat.
Explain that symptoms usually resolve gradually and that cough following acute bronchitis often persists for up to three weeks, although it may last longer.
Antiviral treatment
Antiviral treatment may be appropriate for patients with flu who are at increased risk of complications, such as older adults, pregnant women and those with significant comorbidities. It should be prescribed in accordance with current national guidance. Starting treatment within 48 hours of symptom onset is most effective. Treatment beyond 48 hours is off-label but may still provide clinical benefit in selected patients.
Antibiotic treatment and stewardship
Most winter respiratory infections encountered in community pharmacy are viral and do not require antibiotics. Unnecessary antibiotic prescribing exposes patients to adverse effects and contributes to antimicrobial resistance.
Acute bronchitis is usually viral, even when sputum is purulent. In contrast, patients with suspected CAP usually require antibiotic treatment. Pharmacist prescribers should follow local antimicrobial guidance.
Referral
Timely referral is essential for patients with suspected serious respiratory infection. Patients with suspected CAP, significant physiological abnormalities or features of severe illness should be referred promptly for medical assessment. Key red flags are summarised in Table 2.
Safety-netting
Every consultation should end with clear safety-netting advice on when and where to seek further medical attention. Advise patients to seek urgent help if they develop any red flag symptoms; if they have difficulty eating or drinking; or if their symptoms persist or worsen.
Conclusion
No single symptom or clinical finding reliably distinguishes winter respiratory infections. Combining a thorough history, clinical observations and exercising clinical judgement enables pharmacists to make safe decisions about self-care, prescribing and referral.
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