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Am Fam Physician. 2014;90(5):335

Clinical Question

Is advice to use an analgesic “only as needed,” regular dosing of an analgesic, steam inhalation, or any combination effective in treating cold symptoms?

Bottom Line

Advice regarding the use of steam inhalation, ibuprofen alone or with acetaminophen, acetaminophen alone, and regular vs. as-needed use of analgesics did not show any improved effectiveness in treating symptoms of acute respiratory tract infections. Ibuprofen may be beneficial in patients with chest symptoms and in children. However, ibuprofen advice was associated with a slight increase in the number of patients seeking a second visit for the same illness. (Level of Evidence = 1a)


These investigators enrolled 889 patients at least three years of age who presented to one of 25 primary care practices with a respiratory tract infection of any sort. The authors needed a lot of patients because they were assigned, using concealed allocation, to one of 12 groups. The patients were given advice to treat symptoms: take acetaminophen (paracetamol), ibuprofen, or alternate both analgesics; use regular dosing or as-needed dosing; and use steam (inhaled via a bathroom shower for five minutes three times per day) or no steam.

This was an “advice study”—the patients received advice and not the actual drugs. As a result, the drug dosing was similar between the regular dosing and as-needed use, and was below the maximal doses of either medication (e.g., fewer than three doses of acetaminophen per day and two doses of ibuprofen per day, on average). Steam was used, on average, only twice per day.

Respiratory symptoms were rated by patients on a seven-point scale from “no problem” to “as bad as it could be” two to four days after the visit. Neither advice on analgesic dosing nor on steam inhalation was significantly associated with changes in outcomes. The study had sufficient power to find a difference in these outcomes, if one existed. In specific subgroups, there was no difference between ibuprofen and acetaminophen in patients with otalgia, fever, or severe symptoms. Ibuprofen seemed to be more effective in patients with chest infections, and it also improved symptom scores in children. Patients receiving ibuprofen or the analgesic combination were slightly more likely to return to the office for unresolved symptoms.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Reference: LittlePMooreMKellyJet alPIPS Investigators. Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial. BMJ.2013; 347: f6041.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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