UPPER respiratory tract

Question 1

What is an upper respiratory tract infection?

Answer 1

The upper respiratory tract - the nose, throat, sinuses (small spaces in the skull behind the eyes and nose), trachea, larynx and bronchial tubes.

Question 2

URTIs

Answer 2

Infections of the throat (larynx),
or the main airway (trachea),
or the airways going into the lungs (bronchi) are common.
These infections are sometimes called laryngitis, tracheitis, or bronchitis.
Doctors often just use the term upper respiratory tract infection (URTI) to include any, or all, of these infections. Most URTIs are due to a viral infection.

Question 3

What is an upper respiratory tract infection?

Answer 3

Upper respiratory tract infections include :
the common cold (rhinitis),
influenza,
laryngitis (inflammation of the voice box),
pharyngitis (sore throat),
sinusitis,
tonsillitis,
and croup (in children).

Question 4

what is a cough? how common is it?

Answer 4

most common symptom of upper respiratory tract infections. It may linger even after the infections gone, because the swelling in the airways can take a while to settle down. A cough can take up to three weeks to completely go.

Question 5

Why do we cough?

Answer 5

Coughing is a reflex action.
Its aim is to remove secretions or foreign material from the airways.
The cough reflex is a vital part of the body’s defence mechanisms.

Question 6

Cough stimuli, receptors, centre, respiratory muscles

Answer 6

Stimuli; Excessive mucus
Foreign BodyCough Receptors;
Epithelial Layer of pharynx and trachea
Cough Centre; Medulla Oblangata
Respiratory Muscles;
diaphragm, chest wall ,abdomen

Question 7

What Causes a Cough?

Answer 7

Viral cough associated with cold (tends to be dry and lasts 7- 10 days)

Post nasal drip

Allergy related cough

Croup –viral in origin affects children age 9 -18 months, barking cough. Occurs commonly in the middle of the night treated with steam inhalation or referral

Question 8

Chronic bronchitis, asthma

Answer 8

Chronic bronchitis (coughing up mucus on most days for more than 3 months for 2 years) associated with smoking and cough worse on waking

Asthma (9% of the population) can present as just a none productive cough especially in young children

Question 9

Coughs can ALSO be provoked by:

Answer 9

Smoking,

Sucking material into the breathing tubes from your mouth.
Gastro-oesophageal reflux.

Medicines used in heart disease called angiotensin converting enzyme (ACE) inhibitors.

Question 10

Coughs can ALSO be provoked by:

Answer 10

Damage to the nerves that supply the vocal chords (known as vocal chordpalsy) and chronic cough can occur.
Rarely coughing can be provoked by:
Psychological illness
Heart failure
TB
Pneumonia
Carcinoma of the lung

Question 11

Types of Cough

Answer 11

Productive; producing sputum
Non- productive; dry with no sputum

Question 12

Productive coughs

Answer 12

A productive, chesty cough, in which sputum/phlegm is coughed up
The over secretion of sputum causes the cough.

Question 13

Colour Of Sputum.

Answer 13

Clear or white

Of little significance.
Pink /Frothy

Congestive Heart FailureThick Yellow, green or brown

Lower RTIClear Straw Coloured

Allergic originRed/ brown

Blood

Question 14

Treating productive coughs:

Answer 14

Should be treated with an EXPECTORANT cough mixture to help loosen the phlegm and make it easier to cough up from the airways.

Expectorants contain ingredients such as
guaifenesin,
ipecacuanha
ammonium citrate.

Question 15

Treating productive coughs:

Answer 15

Two mechanisms of action:

stimulating bronchial mucus secretion
making sputum less viscous (MORE PROBABLE)

irritation of gastro intestinal tract which subsequently affects the respiratory tract

Question 16

Non- productive coughs

Answer 16

A non-productive, dry, tickly or irritating cough, in which no phlegm is coughed up
Usually viral and self limiting

Question 17

Non- productive coughs

Answer 17

Treated with a cough suppressant to reduce the cough reflex.
Cough suppressants include:
Pholcodine,
Dextromethorphan
Codeine.

Question 18

Dextromethorphan

Answer 18

Less potent than pholcodine and codeine
May cause drowsiness
Less potential for abuse
Rare reports of mania in overdose
Watch for repeat purchases

Question 19

Other ways of treating coughs

Answer 19

Demulcents, coat and soothe the back of the throat.
Simple linctus,
Glycerin and lemon and honey.
Bronchodilator
Theophylline used to be available in OTC cough medicines but is best avoided. (Chest-eze)
Antihistamines
Diphenhydramine and promethazine.
Ipratropium bromide nasal spray also reduces watery nasal secretions that can cause postnasal drip and contribute to a cough.
Some cough remedies also contain sympathomimetics such as pseudoephedrine,

Question 20

Expectorants and cough suppressants together??

Answer 20

Expectorants promote coughing
Suppressants prevent coughing
They do the opposite to one another – so should not be combined in one preparation

Question 21

When to refer

Answer 21

Coughing up phlegm that is green, rusty brown, yellow, blood-stained or foul smelling.
Chest pain.
Shortness of breath or wheezing.
Pain and swelling in the calf (deep vein thrombosis)
Recurrent night-time cough (asthma)

Question 22

When to refer

Answer 22

Whooping cough or croup.
Worsening smoker’s cough.
Sudden weight loss.
Fever and sweating.
Hoarseness of the voice with a chronic cough that doesn’t clear up spontaneously.

Question 23

Children

Answer 23

Parents and carers should be encouraged to use the following medicines to alleviate the symptoms of coughs and colds in children:
single-constituent paracetamol or ibuprofen;
simple cough medicines (e.g., those that contain glycerol or honey and lemon); vapour rubs and inhalant decongestants (which can be applied to a
child’s clothing);
and, particularly in infants, saline nasal drops
Non-prescription cough and cold medicines that contain the following active ingredients should not be used in children younger than 6 years:
– brompheniramine, chlorphenamine, and diphenhydramine (antihistamines)
– dextrometorphan and pholcodine (antitussives)
– guaifenesin and ipecacuanha (expectorants)
– phenylephrine, pseudoephedrine, ephedrine, oxymetazoline, and xylometazoline (decongestants)
For children older than 6 years, cough and cold medicines are considered safe at the recommended doses, which should be followed carefully and not exceeded.
Parents and carers should be advised not to give a child more than one cough and cold medicine because different brands may contain the same active ingredient (s)

Question 24

Products that can be used

Answer 24

The product lists explain:
* List 1: The products parents can still use to treat coughs and colds in children under 6 years of age
* List 2: The cough and cold products that can still be given to children over 6 years of age
NB: Single ingredient pain relief products for children are not affected by this announcement.

Question 25

Key information:

Answer 25

Cough and cold remedies containing the above ingredients should no longer be used in children under 6 years as the balance of benefits and risk has not been shown to be favourable
Products for children from six to 12 years will continue to be available in pharmacies where advice can be given
Medicines to treat cough and colds in older children (6 to 12 years) can be considered supplementary to basic principles of best care
Some combinations (such as cough suppressants and expectorants) are being phased out
All liquid products containing these ingredients will in future be in a child resistant container

Question 26

Codeine

Answer 26

Codeine has been used in medicines for many years for cough suppression and pain relief. Medicines that contain codeine for the relief of dry, non-productive coughs are available over the counter in pharmacies in the UK. All products containing codeine indicated for cough are sold or supplied under the supervision of a pharmacist (Pharmacy (P) legal status).
A UK review of scientific evidence has concluded that the risks associated with over-the-counter oral liquid cough medicines containing codeine outweigh the benefits in children and young people under 18 years.
over-the-counter oral liquid medicines containing codeine should no longer be used to treat cough in children and young people under 18 years.
In addition:
all over-the-counter oral liquid codeine medicines will be supplied in child-resistant containers.
Drug Safety Update article (published October 2010) and Public Assessment Report (published October 2010) present a summary of the evidence and conclusions from the review.

Question 27

Sore throat

Answer 27

Symptoms: There is a raw feeling at the back of the throat, discomfort on swallowing, occasional earache, redness and swelling of the throat, enlarged and tender lymph glands in the neck, and slight fever.

Question 28

Area of infection

Answer 28

Tonsillitis is inflammation due to infection of the tonsils.
Pharyngitis is inflammation of the oro-pharynx but not tonsils.
In laryngitis there are few visible signs of infection but with soreness lower down the throat often associated with a hoarse voice.

Question 29

Differential diagnosis

Answer 29

Viral infection.
Coxsackie virus.
Infectious mononucleosis (glandular fever).
Streptococcal infection.

Question 30

Treatment…

Answer 30

Many people do not seek medical advice, and most sore throats resolve within one week.
Symptomatic treatment should be advised
Antipyretic analgesics like paracetamol and ibuprofen are of value.Pastilles, lozenges and warm drinks-
One of the most effective treatments for a sore throat is producing saliva to lubricate the throat and wash any infection away.
Many pastilles contain demulcents (relieves irritation).
Antiseptic pastilles-
Some pastilles also contain antiseptic agents for example benzalkonium, dequalinium, cetylpyridinium, phenol and tyrothrycin (a weak antibacterial drug).
Salt water-Salt water-
Gargling can be a good way to relieve a sore throat.
Gargles should not be swallowed, but spat out after gargling is done.
Local anaesthetics-
For example benzocaine, lignocaine are used in both lozenges and throat sprays.
If there is difficulty swallowing due to a sore throat these can be helpful and reduce pain.
Children or elderly people should not use local anaesthetic lozenges or sprays.
No one should use them for more than 5 days.

Question 31

Complications

Answer 31

Otitis media, usually confined to those under 5.
Sinusitis.
A very rare complication (epiglottitis).

Question 32

When to refer..

Answer 32

Sore throat lasting more than a week
Hoarseness persisting for more than 3 weeks, which might indicate laryngeal cancer
Dysphagia, (difficult in swallowing). This can be a sign of abscesses or glandular fever.
Appearance, white spots, or pus
Thrush, which produces white plaques

Question 33

Common cold….

Answer 33

Is a mild viral infectious disease of the upper respiratory system.
Symptoms include
sneezing,
sniffling,
nasal congestion;
scratchy, sore, or phlegmy throat;
coughing;
headache;
tiredness.
Colds typically last three to five days, with residual coughing lasting up to three weeks.
It is the most common of all human diseases, infecting subjects at an average rate of slightly over one infection per year per person.
More than 200 different viruses can cause colds.

Question 34

Common cold: causes

Answer 34

Rhinoviruses are responsible for up to a third of all upper respiratory infections. Other common viruses that lead to stuffy heads and runny noses include adenoviruses, coronaviruses, parainfluenza and influenza viruses
Ninety-five percent of people exposed to a cold virus become infected, although only 75% show symptoms. The symptoms start 1–2 days after infection
Generally a cold starts with a sore throat, without any respiratory blockage.
From then onwards the symptoms are a result of the body’s defence mechanisms: sneezes, runny nose, and coughs to expel the invader, and inflammation to attract and activate immune cells.
OTC ;Development of a cold

Question 35

Treatment

Answer 35

Steam inhalation
Decongestants
Antihistamines
Analgesics

Question 36

Steam Inhalation

Answer 36

Steam inhalation involves sitting with the head over a bowl of hot water. A towel is placed over your head and steam inhaled. The steam may help to ease congestion, by loosening mucus and making it easier to clear by blowing the nose. Ingredients - such as menthol, eucalyptus, camphor, thymol or pine oil - can be added to the water
Care is required to avoid getting steam in your eyes as this can burn.
Steam inhalation is not advised for children because of the risk of scalding. Instead, a child may benefit from sitting in a hot, steamy bathroom.

Question 37

Decongestants

Answer 37

Decongestants
This type of medicine can be taken by orally mouth or used as a nasal spray. They work by constricting the dilated blood vessels in the nasal mucosa. Hence the nasal membranes shrink, improving mucus drainage and air circulation.
There is limited evidence to show how effective decongestants are, and this type of medicine may therefore only provide symptom relief for some people. When decongestants do work, they often only ease symptoms for a very short period of time.
Cochrane review data for cold and cough medidines.
The 3 main components of most cough and cold medicines are antihistamines, decongestants, and cough suppressants.
DecongestantsThis is the only ingredient that Cochrane reviewers found to be modestly effective. When compared to a placebo, decongestants did relieve short-term nasal congestion in adults. But the relief was very small: Patients reported a 6 percent decrease in their symptoms after a single dose and only a 4 percent decrease with repeated doses.

Question 38

Nasal decongestants topical

Answer 38

Nasal decongestants such as oxymetazoline, xylometazoline, phenylephrine and ephedrine.
Nasal decongestants should not used for more than 5-7 days. (rebound congestion)

Question 39

Symptomatic treatment: congestion

Answer 39

Oral decongestants
Pseudoephedrine,
Phenylpropanolamine
Phenylephrine
Oral decongestants can cause a rise in blood pressure and heart rate, leading to a feeling of being more alert.
Oral decongestants may interact with some antidepressants and beta-blockers.
Cautions: high blood pressure, heart disease, hyperthyroidism and diabetes or glaucoma.
Phenylpropanolamine has been linked to stroke

Question 40

Pseudoephedrine/Ephedrine

Answer 40

The following legal restrictions were put in place from April 1, 2008:
* Small packs of products that contain no more than 720 mg pseudoephedrine (the equivalent of 12 tablets or capsules of 60 mg, or 24 tablets or capsules of 30 mg) may be purchased from retail pharmacies
* Small packs that contain no more than 180 mg ephedrine may be purchased from retail pharmacies
* A limit of one equivalent pack per customer per purchase

Question 41

Antihistamines

Answer 41

Antihitamines can reduce the symptoms of a cold (runny nose and sneezing) - the effect may be due to their atropine-like action on the nasal mucous membranes rather than the antagonism of histamine receptors
They are not as effective at reducing congestion
They can be used in cold remedies to help sleeping i.e. they cause drowsiness
Interactions:
Alcohol
Hypnotics
Sedatives
Anticholinergics
Betahistine

Question 42

Antihistamines - cautions

Answer 42

Closed angle glaucoma
Prostatic obstruction
Epilepsy
Liver disease

Question 43

Complications

Answer 43

Bacteria that are normally present in the respiratory tract can take advantage of the weakened immune system during a common cold and produce a co-infection.
Middle ear infection (in children) and bacterial sinusitis are common co-infections.

Question 43

Analgesics

Answer 43

Paracetamol, ibuprofen or aspirin
Ibuprofen should not be used if there is a history of stomach ulcer, indigestion, asthma, or kidney disease.
Aspirin should not be taken by children under 16 years of age or women who are breastfeeding.
Paracetamol is the painkiller of choice for the short-term relief of mild-moderate pain and fever during pregnancy.
Ibuprofen and paracetamol can be taken alternately over the course of a day.
Advice for children changes regularly; see BNF and NHS website.
Paracetamol, ibuprofen and aspirin are also included in some over-the-counter cold medicines with other ingredients.
Throat lozenges containing flurbiprofen have been shown to relieve the symptoms of sore throat that may be associated with a cold.

Question 44

Differential diagnosis – cold or flu

Answer 44

True influenza is relatively uncommon and much more unpleasant than a cold
Flu is more likely if:
Onset is sudden
Temperature is over 38C
Respiratory symptoms are present
Constitutional symptoms are present (e.g.. Headache, malaise, muscle aches, sweats and chills, patient is bed bound)
Complications of flu are much more likely in the very young, very old and in those with existing heart or lung conditions.

Question 45

When to refer…

Answer 45

Earache, especially in children it might be otitis media
Facial pain sinusitis
Flu
Very young
Very old
Those with lung or heart disease
Persisting fever or productive cough
Delirium
Pleuritic chest pain (A knife like pain, aggravated by breathing or coughing)
Asthma attacks can be triggered by viral infections

Question 46

Differential diagnosis – cold or flu

Answer 46

True influenza is relatively uncommon and much more unpleasant than a cold
Flu is more likely if:
Onset is sudden
Temperature is over 38C
Respiratory symptoms are present
Constitutional symptoms are present (e.g.. Headache, malaise, muscle aches, sweats and chills, patient is bed bound)
Complications of flu are much more likely in the very young, very old and in those with existing heart or lung conditions.

Question 47

When to refer…

Answer 47

Earache, especially in children it might be otitis media
Facial pain sinusitis
Flu
Very young
Very old
Those with lung or heart disease
Persisting fever or productive cough
Delirium
Pleuritic chest pain (A knife like pain, aggravated by breathing or coughing)
Asthma attacks can be triggered by viral infections

Question 48

Transmission

Answer 48

The viruses are transmitted from person to person by droplets from coughs or sneezes. The droplets or droplet nuclei are either inhaled directly, or transmitted from hand to hand via handshakes or objects such as door knobs, and then introduced to the nasal passages when the hand touches the nose or eyes.

Question 49

Stop things spreading

Answer 49

Catch coughs and sneezes in a tissue
Dispose of tissues quickly and safely
Regularly wash your hands with soap and water
Hand Gels
Anti viral tissues
Cough into your sleeve!

Question 50

Prevention

Answer 50

Avoid close contact with existing sufferers
Wash hands thoroughly and regularly,
Avoid touching the face.
Anti-bacterial soaps have no effect on the cold virus - it is the mechanical action of hand washing that removes the virus particles.
Tobacco smoking has also been linked with the weakening of the immune system; non-smokers are known on average to take fewer days off sick than the smoking population

Question 51

Self care

Answer 51

Hydration:
Rest
Avoid being around people who smoke and avoid smoke-filled environment.
Raising the head of your bed slightly

Hydration: drinking plenty of non alcoholic fluids - this is especially important for children.

Smoke irritates the nose and throat. Try to avoid being around people who smoke and avoid smoke-filled environment. If you are a smoker, try to smoke as little as possible while you are feeling unwell.
Raising the head of your bed slightly by placing a pillow under the mattress can help reduce coughing at night.

Question 52

Preventing flu

Answer 52

At risk patients should receive annual flu vaccinations. These are:
Over 65s
Those with chronic respiratory disease (including asthma)
Chronic heart disease
Diabetes
Immuno-compromised patients

Question 53

Cure for the common cold

Answer 53

Zinc – two systematic trials found that it can reduce symptoms at 7 days compared to placebo
Vitamin C – a systematic review found that that over 1g per day reduces cold duration by half a day
Echinacea – A systematic review found that some preparations may be better than placebo in preventing or treating colds. Variations in preparations meant there was insufficient evidence to recommend a specific product