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JC WCS > Family Medicine JC129: Upper Respiratory Tract Infections > Flashcards

Family Medicine JC129: Upper Respiratory Tract Infections Flashcards

1
Q

Upper respiratory tract

A

Nostrils —> Sinuses —> Nasopharynx —> Oropharynx —> Laryngopharynx —> Epiglottis —> Vocal cord —> Upper part of airway

ALL can be site of infection

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2
Q

Common respiratory problems in HK

A
  1. URI
  2. Acute bronchitis
  3. Allergic rhinitis
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3
Q

Upper Respiratory Tract Infections (URTI)

A
  • NOT all cough, runny nose and sore throat are URTIs

To establish URTI:
- Features of **Acute infection + **URT symptoms

***Different types of URTIs
1. Coryza (common cold) (most common)
2. Influenza
3. Tonsillitis (viral / bacterial)
4. Pharyngitis (viral / bacterial)
5. Acute laryngitis (viral / bacterial)
6. Others

Symptoms for diagnosis:
***記: URT symptoms:
1. Cough / Sputum
2. Runny nose / sneeze
3. Nasal congestion
4. Sore throat
5. Hoarseness

Systemic symptoms of infection:
1. Fever
2. Chills
3. Malaise
4. LOA
5. N+V
(6. Dyspepsia, Abdominal pain)

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4
Q

URTI vs LRTI

A

Acute URI
- **Coryzal (Nasal) symptoms
- Fever
- **Sore throat
1. Coryza (common cold) (most common)
2. Influenza
3. Tonsillitis (viral / bacterial)
4. Pharyngitis (viral / bacterial)
5. Acute laryngitis (viral / bacterial)
6. Others

LRT illness
- **Respiratory distress
- **Lower chest signs (crepitations, wheeze, rhonchi)
- Tachypnea
- Increased work of breathing
- Fever
1. ***Acute bronchiolitis (wheeze (∵ inflammatory exudates in airway) +/- crepitations, usually due to RSV, HMPV (Human metapneumovirus))
2. Pneumonia (viral / bacterial)
3. Asthma

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5
Q
  1. Cough / Sputum
A

NOT all cough and phlegm are due to URIs

Cough / Sputum in URI:
- Acute irritating cough
- **Scanty, **white / yellow sputum
- **Postnasal drip / sore throat
- **Present throughout daytime and before / after sleeping
- General condition good, no SOB / added sound / chest sign
- Self-limiting, lasting 1-3 weeks

History taking:
1. Nature
- Dry cough
- Sputum: colour

  1. Course
    - Acute / Subacute / Recurrent / Chronic
  2. Emergencies
    - **Cyanosis / **Dyspnea / ***Drooling of saliva
  3. Serious
    - **Pneumonia
    - **    TB
    - **Cancer
    - **    CHF (Cardiac cough)
  4. Pitfalls
    - Allergic rhinitis
    - **Asthma
    - **    COPD
    - **Bronchiectasis
    - **    GERD
    - ***Drugs (e.g. ACE inhibitor induced cough)
    - Malignant pleural effusion
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6
Q
  1. Runny nose + 3. Nasal congestion
A

NOT all runny nose are due to URIs e.g. Allergic rhinitis

Nasal symptoms in URI:
- Acute onset
- **Copious + **Clear watery discharge
- Sneezing ++, relatively **little itchiness
- **Little diurnal variation
- Self-limiting, lasting 3-5 days (subside earlier than cough)

Physical examination
- Nasal speculum to examine anterior nose (usually not needed): Nasal mucosa congested with overlying clear discharge (vs Allergic rhinitis: Edematous + Bulky nasal mucosa)
- Ear: look for Otitis media (tympanic membrane congested / fluid level behind)

Runny nose:
- common cause of snoring + anosmia
- complications: **Otitis media, **Sinusitis

History taking:
1. Nature and Course
- Yellow nasal discharge =/= Bacteria!!!

  1. Serious
    - ***NPC (mixed with blood)
  2. Pitfalls
    - **Allergic rhinitis
    - **    Polyps
    - Foreign body in nose
    - ***Sinusitis
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7
Q
  1. Sore throat
A
  • **>90% acute sore throat due to **Viral URIs
  • Enlarged tonsil are normal in children (as long as symmetrical + no exudates)
  • Exudates can mean Viral / Bacterial!!! (although mostly ***bacterial)

History taking:
1. Emergency
- ***Acute epiglottitis (drooling of saliva)

  1. Serious
    - **Bacterial tonsillitis
    - **    Peritonsillar abscess (Quinsy)
    - TB
    - Lymphoma
  2. Pitfalls
    - Postnasal drip
    - Irritation
    - Foreign body ingestion
    - ***Infectious mononucleosis
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8
Q

***CENTOR criteria for sore throat

A

Estimate probability that pharyngitis is Streptococcal (distinguish from Viral)
- Bacterial if not treated with antibiotics can present with complications

4 criteria (1 point for each positive criterion):
(記: Fever, Exudates, Lymphadenopathy, Absence of cough)
1. History of fever
2. Tonsillar exudates
3. Tender anterior cervical lymphadenopathy
4. Absence of cough

Modified CENTOR criteria (add patient’s age to criteria)
5. Age <15 (+ 1 point)
6. Age >44 (- 1 point)

Score range: -1 to 5
- -1 to 1: No antibiotic / throat culture necessary
- 2/3: Consider **rapid strept testing / culture + Treat with antibiotic if positive result
- 4/5: Consider **rapid strept testing / culture + Treat with antibiotic if positive result

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9
Q
  1. Hoarseness
A
  • Indicate pathology in Larynx
  • If ***Acute: most likely Viral URI
  • If Chronic: consider other DDx

DDx:
1. ***Vocal cord polyps / nodules

  1. Serious
    - **Carcinoma of larynx
    - **    Acute epiglottitis (A/E care)
    - ***Croup (A/E care)
  2. Pitfalls
    - Sputum
    - Laryngeal injury / compression
    - Trauma from intubation
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10
Q

Disease burden of URI

A
  • Most common infection in human
  • Annual incidence from 5-7 in children to 1-2 in elderly
  • Rarely lethal
  • Significant health + economic burden
    —> Doctor consultation
    —> Manpower loss
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11
Q

Pathogens of URIs

A

> 90% Viral:
- Rhinovirus
- Adenovirus
- Influenza
- Parainfluenza
- RSV
- Coronavirus

<10% Bacterial:
- Group A Strept
- Haemophilus influenzae
- Strept pneumoniae
- Moraxella catarrhalis
- Staph aureus

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12
Q

Transmission of Common cold

A
  • Contacts + Droplets
  • Maximum viral shedding on Day ***2 and 3 from symptom onset
  • Found on hands, cough / sneeze
  • Natural infectivity rate 38-88%
  • Median incubation ***3 days (1-10)
  • ***70-90% infected are symptomatic
  • Diagnosis:
    —> Clinical
    —> Viral culture (rarely needed)
    —> Serology ***useless
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13
Q

Investigations of URI

A

No need for most cases

Unless specific indications:
1. CXR
2. **Sputum / Throat swab for culture (if suspected Strept throat)
3. **Nasal aspirate for culture
4. Blood test
5. Others

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14
Q

Natural course of Simple Viral URTI

A

Usually within **2 weeks even without treatment
**記: Cough同Hoarseness最耐
- Cough: 2-20 days
- Headache: 1-14 days
- Hoarseness: 2.5-20 days
- Muscle ache: 2-14 days
- Runny nose: 2-14 days
- Sore throat: 2-14.3 days

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15
Q

Management of Simple Viral URI

A
  • Body’s immune system is most effective
  • Mean resolution **2-3 days (75% **7 days, cough up to 10 days)
  • **Rest + **Adequate fluid + ***Stress reduction are important
  • Infection control: Wash hands, Wear masks
  • ***Self-limiting: Curative treatment is usually not needed

Symptomatic treatment:
- Not a pill for every illness / symptom
- Evidence-based
- Benefit vs Harm

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16
Q

Systemic symptoms / Sore throat management

A
  1. Aspirin
    - CI in children / influenza (***Reye’s syndrome)
  2. ***Paracetamol
    - proven to be effective and safe
  3. ***NSAID (Ibuprofen)
    - more effective but more SE (e.g. gastric upset)
  4. Throat lozenges
    - no large-scale quality trials
  5. Steroids
    - do more harm than good
17
Q

***Cough and Sputum management

A
  • NO good evidence for effectiveness of OTC cough medicines
  • NOT a must to offer cough medication
  • Important to reassure patients on the expected course of cough in simple URI e.g. persist up to ***3 weeks even without treatment

***Cough mixture (may contain >=1):
- Cough suppressant (e.g. Dextromethorphan, Codeine, Pholcodine)
- Expectorant (e.g. Guaifenasin)
- Antihistamine (e.g. Diphenhydramine)
- Decongestant (e.g. Pseudoephedrine, Phenylephrine)
- Mucolytic (e.g. Bromhexine, Acetylcysteine)
- Herb (e.g. Echinacea, Squill)

18
Q

Cough suppressant

A

Opioid (NOT recommended)
- Dextromethorphan, Codeine, Pholcodine
- MOA: **Central suppression of non-productive cough
- Uncertain effectiveness for URTIs
- **Not recommended in children
- SE: Sedation, GI disturbance

Non-opioid (Sedating antihistamines)
- Diphenhydramine (Benadryl expectorant), Dexbrompheniramine
- Inconsistent results from RCT
- SE (Anticholinergic): Drowsiness, Blurred vision, Dry mouth, Urinary retention (esp. in BPH patients) etc.

19
Q

Cough expectorants

A

MOA:
- Thin the mucus / respiratory secretions —> making it easier to be coughed up

Common preparations (mostly non-sedative):
- Ammonium chloride (e.g. MES (Ammonia and Ipecacuanha))
- Ipecacuanha (e.g. MES)
- ***Guaifenesin (e.g. Robitussin)
- Squill (e.g. Cocillana compound syrup)

  • Effectiveness NOT proved by RCT, except some evidence on Guaifenesin
  • SE: High dose may cause N+V
20
Q

Mucolytics

A

Bromhexine, Acetylcysteine

  • NO RCT to prove efficacy in URI

MOA:
- Loosens and thins bronchial secretions by reducing surface tension + viscosity of mucus

SE:
- Dizziness, Headache, GI disturbance etc.

21
Q

Inhaled / Oral β agonists

A
  • May be effective for prolonged (>1 week) cough in URI, esp. in patients with bronchial hypersensitivity
  • SE: **Palpitations, **Tremor etc.
  • Seldom necessary
22
Q

Nasal symptoms management

A
  1. Antihistamine
    - Sedating, Non-selective e.g. Chlorpheniramine may reduce sneezing / rhinorrhoea —> ***more effective but less selective
    - Non-sedating, Selective antihistamines are much less effective
  2. Nasal decongestant
    - e.g. Pseudoephedrine, Phenylpropanolamine (PPA), Phenylephrine
    - may provide transient relief of nasal obstruction
    - SE: common, can be serious, caution in ***HT patients
  • Both NO proven efficacy in children and adults for URI
  • FDA warning: Avoid both in children ***<2 yo (potential life-threatening SE: convulsions, tachycardia, death)
  1. ***Topical Ipratropium (Atrovent)
    - treatment option for nasal congestion in >6 yo and adults
    - expensive
  2. Heated humidified air
    - conflicting results
    - but benign and possibly beneficial
23
Q

Coryza novel treatments

A
  1. Vitamin C 1-3g
    - no benefit if taken at onset of illness
  2. Zinc
    - within 2 days of onset
    - may shorten illness by 1-3 days
    - inconsistent evidence
    - cannot prevent illness
    - up to 20% have SE: N+V, diarrhoea etc.
24
Q

Combination preparations for URIs

A

Antihistamine + Decongestant + Antitussive + Expectorants
- risk of overdosing in children + associated with sudden infant deaths
- Shotgun therapy ↑ SE:
—> Aspirin + PPA
—> Antihistamine overdose from cold medicine + cough mixture

25
Q

Antibiotics / Steroids

A
  • Antibiotics / Steroids are NOT doing any good for Viral URTI
  • SE of drugs
  • Antibiotic resistance
26
Q

Importance of Sleep

A

Adequate sleep can effectively reduce chance of developing a cold

27
Q

Influenza

A
  • 3 types of Influenza virus: **A, **B, C

Clinical features:
1. Criteria of Influenza-like illness (ILI): **Fever >= 38oC + Cough / Sore throat
2. **Severe systemic upset
3. ***Generalised myalgia
4. Nasal symptoms (mild than common cold)

  • Rapid test not more accurate than Clinical diagnosis
  • Most cases are ***self-limiting

Complications:
- ***Pneumonia (5-20% esp. high risk groups)

28
Q

Influenza vaccination

A
  • Effective in preventing illness, complications, hospitalisation, death
  • 2020-21: All available seasonal influenza vaccines are ***Quadrivalent vaccines
  • Should be given annually at the ***beginning of peak season (Oct - Nov), expected to cover winter + summer surge
  • Effective ***2 weeks post-vaccination (develop sufficient Ab)
  • Effectiveness 20-90% (depends on age of recipient)

2 types:
1. Inactivated influenza vaccine (most given IM)
- more widely used
- age 6 months / above

  1. Live attenuated influenza vaccine (Intranasal)
    - one brand available: FluMist
    - consider for non-pregnant, non-immunocompromised people 2-49 yo
29
Q

Priority groups for Flu vaccine

A

At risk of severe influenza / Transmitting influenza to those at high risk:
1. ***Health care workers

  1. ***Institutionalised persons
    - elderly / disabled in care home
  2. Age >50
  3. ***People with chronic medical problems
    - chronic lung, CVS, renal, metabolic disease, obesity, immunocompromised, children on long term aspirin, people with chronic neurological condition that can compromise respiratory function / self care ability / lead to increased risk of aspiration
  4. ***Children 6 months - 11 yo
    - vaccination of primary school student via mobile teams
  5. ***Pregnant women
    - CI for live attenuated vaccine
  6. **Poultry workers / Pig farmers / Pig slaughtering industry personnel
    - minimise emergence of **    novel influenza virus with pandemic potential
30
Q

Influenza Drug Treatments

A
  1. ***Oseltamivir Oral (Tamiflu)
  2. ***Zanamivir Inhaled (Relenza)
  3. Peramivir IV (Rapivab)
  4. ***Baloxavir marboxil Oral (Xofluza) (Newest drug)

Effect:
- Shorten illness by 1-2 days if given within **48 hours
- **Reduce complications

SE:
- Oseltamivir: N+V
- Zanamivir: Bronchospasm
- Peramivir: Diarrhoea
- Baloxavir marboxil: Unknown yet

31
Q

Summary

A
  • URI are common and highly infectious
  • NOT all URT symptoms are caused by URIs
  • NOT all URIs are COVID-19
  • Different URIs have different pathogenesis and natural courses
  • Curative treatments are limited are usually unnecessary
  • Benefit of symptomatic treatments need to be balanced against harm
  • Personal hygiene and influenza vaccine very important in prevention esp. Influenza
  • Flu anti-viral drugs may be considered in patients with influenza depending on circumstances

JC WCS (134 decks)

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