Viral rhinitis Flashcards
rates in adults and children
children 6-8 colds/year
adults (over60) 2-4 colds/year
viral rhinitis is the leading cause of work and school absenteeism
true
When can infection occur and how many infecting agents
can occur any time of year
-over 200 different VIRUSES
Rhinoviruses
- how many ID’d serotypes
- when prevalence high
most common in all age groups (30-50%)
- over 100 serotypes
- higher prevalence in early fall, late spring
Coronaviruses
- percent cases
- prevalence
10-20%
high prevalence during mid winter early spring
other common viruses
RSV - respiratory syncytial virus
adenovirus
parainfluenza
enterovirus
Modes of inoculation
1) self inoculation - of nasal mucosa or conjunctiva following hand contact with virus laden secretions
+directly from an infected person (animate objects, hands)
+indirectly from environmental surfaces (inanimate objects, dorrknobs, phones)
2) prolonged contact with airbourne droplets produced by coughing, sneezing, talking
- small particle aerosols lingering in air
- direct hit by large particle aerosols from infected person
order of responses in flare response to infection
viral infection of nasal epithelium –> immune response –> mediators –> symptoms
immune response
- killer T cells activated
- antibody production begins
Mediators
- bradykinin,
- PG’s,
- Histamine,
- other cytokines
symptoms
- sore throat
- cough
- nasal congestion
- rhinorhhea
- sneezing
- fever/chills
- cough
incubation period
24-72 hours
-symptoms largely due to immune response to infection rather than direct viral damage to respiratory tract
VR is self limiting t/f
true
how long do symptoms of VR last
7-14 days
1-2 weeks
what is the first symptom
throat discomfort
symptoms/time
day 1
-throat discomfort
day2/3
- nasal congestion and rhinorrhea
- nasal discharge is CLEAR and WATERY at beginning and becomes MUCOPURULENT
day 4-5
- cough may be present; may persist for 1-2 weeks
- dry at beginning then often becomes productive
Physical assessment
- slightly red pharynz w/ evidence of postnasal drainage
- nasal obstruction
- mildly to moderate tender sinuses on palpation
-low-grade fever possible
+rarely >37.8
+children more often than adults
complications
may cause exacerbations of asthma or COPD
AND OR
predispose indivs to bacterial complications:
-sinusitis, pneumonia, bronchitis, ostitis media (kids)
Acute cough
less than 3 weeks
-caused by VR
subacute cough
3-8 weeks
-cause: infection, bacterial sinusitis, asthma
chronic cough
greater than 8 weeks
- GERD why 8 weeks
- over 12 weeks attributable to smoking
cause: post nasal drip syndrome asthma GERD some meds
productive cough
- wet or chesty
- expells secretions from LRT
- if retained impair ventilation and lungs and ability rss infection
-secretions may be: \+clear (bronchitis) \+purulent (bacterial infection) \+discoloured (yellow w/ inflammatory disorders) \+maloderous 9anaerobic infection
non productive cough
dry or hacking
- no useful physiologic purpose
- assocaited w/ viral RTI, GERD, cardiac disease, some meds, atypical bac infections
URTI prevention measures
- avoid touching nasal mucosa/conjunctiva
- routine handwashing (20s)
-alcohol based hand rub
+not supplement HW
+not effective if hands visibly soiled
+efficacious ABHR=62-95%
- antiviral/disinfectant commercial products
- sneeze and cough etiquette
children avoid sharing bevs or food
Cough treatment
dry - antitussive
productive - protussive
sore throat treatment
anesthetic or antiseptic
fever and pain treatment
analgesic/antipyretic
nasal treatment
systemic decongestant
topical decongestant
1st generation antihistamine
CCMs are generally safe
true
in what population are CCMs being re-evaluated
pediatric
- no strong evidence of efficacy
- toxicities and death
Paradoxical excitation
when child gets very energetic instead of calming down with use of diphenhydramine
Problems with CCMs in children
- completely contraindicated in kids younger than 2
- used to sedate children
- use in a daycare setting - trust idiot not mess up dose
- combining 2 or more meds with same API
- misidentification of product
- use nonRx for adults on kids (buckleys)
- failure use measuring device
SEs of children using OTC CCMs
convulsions, inc HR, dec conciousness, abnorm heart rhythms, hallucinations
CCMs in children
current treatment only target symptom reduction
lack evidence for vast majority of interventions for management of VR
changes in CCM labeling
ages 6-11 - limited evidence but dose provided on packaging
4 banned therapeutic catagories for CC in children under 6
antihistamines IN CCMs
antitussives
expectorants
decongestants
NO MORE EFFECTIVE THAN PLACEBO IN VIRAL INDUCED COUGH
antitussives
- MoA
- OTC evidence
- OTC antitussives
- hydrocodone
- where avoid
- MoA, act centrally on the medulla to inc cough threshold
- evidence of OTC cough prods is limited and conflicting
-OTC antitussives
+codeine - only available with 2 other ingredients, adult dose (12+) 10-20mg q4-6, max 120mg/d
+dextromethorphan - adult dose 30mg q6-8h _____ age 6-11 5-10mg q4h OR 15mg q6-8 (ER) max 60mg/day
hydrocodone available by prescription
avoid use in productive cough
does diphenhydramine have antitussive action?
yes
precautions antitussives: codeine
AE: drowsiness/sedation, nausea, constipation
significant abuse potential
contraindication: MAOI
DI: CYP2D6 inhibitors; CNS depressants
precautions antitussives: dextromethorphan
AE: well tolerated; occaisonal dizziness, drowsiness, nausea
abuse potential: present if used in high dose
contraindications: MAOIs
DI: CYP2D6 inhibitors
why codeine and dextromethorphan DI with CYP2D6 inhibitors
DM/C blocks seretonin reuptake ——-> serotonin syndrome
AVOID OTHER SEROTONERGIC MODULATING DRUGS (SSRIs)
codeine less risk than DM
antitussives in children
no more effective than placebo for cough
Expectorants
- evidence for URTI
- action
- what congestion
- guaifenesin
- SE?
- abuse potential?
- DI?
- any reports of guaifenesin poisoning?
-limited evidence for acute cough in URTI for ALL AGES
-acts peripherally
+MAY reduce viscosity and aid in expectoration of sputum
-may be used for chest congestion
guaifenesin
-NOT INDICATED FOR KIDS UNDER 6
- side effects are rare
- no abuse potential
- no DIs
- no specific or individual reports of guaifenesin poisoning
guaifenesin dose
Adult: 200-400mg q4-6 max 2.4g/day
6-11: 100-200mg q4-6h (~12mg/kg/day) max 1.2g/day
Topical antitussives: menthol and camphor
Menthol and camphor
- present in lozenges and topical ointments
- increases perception of nasal breathing
- no improvement in objective measures
topical antitussives: vapor rub doses
2-5: 5mL once daily
6-11: 10mL once daily
how do topical antitussives work/do they work
-problems
work by distracting brain
-increase perception of nasal breathing
work for kids but not adults
-improve cough severity and quality of sleep
PROBLEMS
- strong smell children may not tolerate (start low and build up)
- MAY be effective in common cold in children
- NOT SAFE BY NOSTRILS -> child aspirates
Oral decongestants evidence
moderately effective for cold symptoms
-nasal congestion, sinus pain
oral decongestant MoA
alpha-adrenergic agonist; vasoconstriction of nasal BVs, reducing vessel engorgement and mucosal edema
what casues stuffiness
vasodilation of nasal BVs
Oral decongestants onset of action
~30 minutes
what are the 3 types of oral decongestants
pseudophedrine, phenylephrine, and phenylpropanolamine
what oral decongestant was removed from the market
phenylpropanolamine removed from market in 2000 due to risk of hemorrhagic stroke in women
pseudophedrine
- oral decongestant
- widely used
- 60mg q4-6h OR 120mg q12h (long -acting preparations) max 240mg/day
- 6-11 years: 30mg 1 4-6hr max 120mg/day
- MOST EFFICACIOUS
- makes crystal meth
phenylephrine
oral decongestant
-more readily available OTC because less risk diversion
10mg q4h max 60mg/day
6-11 years: 5mg q4h, max 30mg/day
what are the only 2 medications that can manage congestion
psueophedrine and phenylephrine
Oral decongestants ADR and precausions
ADR - INSOMNIA, tremor, irritability, nervousness, restlessness, diziness, headache, tachycardia, palpitatio, Inc BP in hypertensive patients
precautions
- avoid oralD in hypertension
- heart disease
- beta blockers
- uncontrolled hyperthyroidism
- diabetes
ON EXAM contraindications
- narrow angle glaucoma
- prostatic hypertrophy
- avoid w/ MAOIs -> hypertensive crisis
- uncontrolled hypertension
why should you not take an oralD 24H release unless in morning
oralDs cause insomnia as ADR
nasal decongestants
- MoA
- onset
- long acting
- short acting
MoA
-constrict BVs in nose
Onset of action
- less than 10 minutes
Long acting nasal decongestants
-zylometazoline
-oxymetazoline
DOSE 2-3 sprays ea nostril q10-12h UP TO BID
Short acting
-phenylephrine
DOSE 2-3 spreays ea nostril q4h
advantage of nasal decongestants
less systemic absorption
-less AEs
avoid what when using nasal decongestants
avoid with MAOIs
- hypertensive crisis
- wait at least one week after
Disadvantage of nasal decongestants
can cause rebound congestion (medicamentosa) especially with short acting agents
Rhinitis medicamentosa
- prevention
- treatment
- how long until mucous membrane returns to normal
prevention
-only use topical decongestants for max of 3-5 days
treatment
- slowly withdraw the nasal decongestant (1 nostril at a time)
- replace with topical nasal saline
- abrupt works but difficult (patient congested days-week)
MORE SEVERE
-use systemic decongestant and topical corticosteroid
MM return to normal
- 1-2 wks
nasal decongestants APIs (3)
oxymetazoline HCl
xylometazoline HCl
phenylephrine HCl
Antihistamines
- indication
- CC use?
- why used in night prods
- precautions
Indicated for
- runny nose
- may also have antitussive action
Questional benefit in CC
-drying effect with anticolinergic activity (exagerated in 1st generation)
+second generation limited value
Used in nightime products
-sedative effect to outweight decongestant stimulation
precautions
- sedation, anticholinergic side effects (dry mouth, constipation, increased heart rate)
- caution with narrow angle glaucoma, heart disease, hyperthyroidism, rpostatic hypertrophy
why avoid use of 1st generation AH in elderly
sedation
-fall risk
Antihistamines in children
no more effective than placebo for COUGH
first generation antihistamines
diphenhydramine HCL
Chlorpheniramine maleate
cyproheptadine HCL
triprolidine HCL
brompheniramine maleate
pheniramine maleate
doxylamine succinate
what 1st generation antihistamine is only in combo products
triprolidine HCL
antihistamine + decongestant in children
no more effective than placebo for cough
what does DM indicate on a pkg
dextromethorphan (antitussive)
what does D indicate on pkg
Decongestant
what does E indicate on pkg
expectorant (guaifenesin)
daytime
contains decongestant
nighttime
includes antihistamine
sinus on pkg
analgesic + decongestant
Single vs combo drugs
WHENEVER POSSIBLE
-try give patients single entity product
+mixed products often extras that are uneeded
Pros and cons of combo
PRO
-practical, inc patient compliance (less pills)
CON
- no flexibility
- symps peak and resolve at var times
Expectorant + antitussive
irrational combo
analgesic + decongestant
sinus headache/pain
decongestant + antihistamine
some benefit in acute cough due to PND
-may be helpful at bedtime due to insomnia with decongestants
Combination products why not recommended
less flexibility in dosing
unnecessary drugs
more AEs
possible OD (mult prods w/ acetaminophen)
why combination products used
more convenient for multiple symptoms
-increase compliance and reduce cost
Pasteurized Honey
- what ages
- effects
- efficacy
safe in children above 1 yeah
-under 1 risk of botulism
demulcent, antioxidant, antimicrobial effects
EFFICACY
- parents rated honey highest for symptomatic relief of nocturnal cough and sleep difficulty due to URTI
- no strong evidence for or against use
what type of pasturized honey usually used
buckweed honey
-thicker, darker, less sweet
why does honey work for children
likely due to coating area
-rather than antiviral
Nonpharm measures for children with URI (6)
- rest
- nasal bulb syringe
- upright positioning - helps with airway and breathing
- adequate fluid intake (avoid dehydration)
- increase air humidity
- normal saline (as decongestant, kids prefer drops over spray)
what should parents/caregivers rely on for children younger than 6 in URI
nonpharmacologic measures
Nasal irrigation with saline
- alleviates sore throat
- thins nasal secretions
- can reduce need for nasal decongestants and mucolytics
nasal irrigation with saline in children
may be effective for common cold in children
analgesics/antipyretics
headache, pain, fever
acetaminophen
- 10-15mg/kg/dose
Ibuprofen
- 5-10mg/kg/dose
- beneficial for discomfort or pain cuased by the viral illness
- do not significantly reduce total symptom score or duration of cold
Implement
- what tell (2)
- nonpharm
- screen
tell patient few interventions have evidence that support use
provide strong messages on
- self limited nature of common cold
- importance of preventative measures
- treatments which are safe and effective, which are not
- nonpharm measures may be effective in relieving some of discomfort of cold symptoms
- screen self-treating pateitns thoroughly for signs and symptoms of more serious condition that warrants referal
Follow up
2-14 days assess efficacy and safety of therapy
-if someone with risk factor go with 2
7 or less days of nonRx drug therapy should relieve most symptoms
symptoms improve but persist
re-evaluate
-if cough persists but has improved at follow-up, patient should continue therapy until cough resolved
development of S/S of possible complications
-how monitor
REFER -monitor by measuring: \+T \+assess nasal secretions \+respirations \+facial/neck pain
when does change of mucous colour indicate secondary bacterial sinus infection
clear to yellow/green colour occurs normally in course of common cold
indicates 2ndary bac sinus infec when fails to resolve after 10-14 days
Monitoring: cold symptoms
able perform daily activities
- patient: monitor daily
- RPh: next visit or phone in 2-3days
- optimize nonpharm measures/change treatment
Monitoring: insomnia (oral decongestant)
able to sleep?
- patient: daily
- RPh: one week
- change med schedule or D/C
Monitoring: High BP (patients with hypertension):
elevation in BP above baseline?
- patients daily
- RPh: BP 2x in week one
- stop med if BP elevate above baseline
Monitoring: Drowsiness (antihistamine)
Drowsiness?
- patients: daily
- RPh: next visit or phone when checking efficacy
- d/c treatment if still causing drowsiness
Monitoring: drowsiness (certain antitussives)
drowsiness?
Patient: daily
RPh: next visit or phone when checking efficacy
change medication schedule or treatment
symptoms dont improve or worsen after 14 days
refer
examples of worsening symptoms
-T>40.5degC for one day or fever longer 72hrs
cough lasting>3wks
thick green nasal discharge for more than two weeks
yellow eye discharge
ear or sinus pain
CHILD APPEARS DEHYDRATED
