Diseases of the Upper Respiratory Tract PDF

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Diseases of the Upper Respiratory Tract Common cold – acute coryza Most commonly caused by; Rhinovirus infection – mostly picornavirus group Spread by? Sneezing/coughing -> droplets Highly infectious in the early stages of infection Incubation period? 12 hrs – 5 days Common cold – acute coryza Symptoms include Tiredness Mild pyrexia Malaise Sore nose and pharynx Nasal discharge – persists for up to a week Initially profuse and watery Later stages thick and mucopurulent Sneezing in early stages Secondary bacterial infection may develop in a minority Common cold – acute coryza Treatment Symptomatic Mild analgesics Decongestant nasal sprays Oral decongestants Throat pastilles

How long should a patient use a nasal decongestant for, and why? - 7 days -> due to rebound congestion can occur when stopping Which patients should not be given oral decongestants? -hypertension - monamine oxidine inhibitors -narrow angle glycoma Quick Quiz Which of these antibiotics are used to treat sinusitis? A. Amoxicillin B. Doxycycline C. Clarithromycin D. Co-amoxiclav Sinusitis An infection of the paranasal sinuses Causes? streptococcus pneumoniae/ haemophilus influenzae

Often a complication following a cold or allergic rhinitis Reservoir of infection – recurrent infections Possible Pseudomonas reservoir in CF patients Sinusitis Symptoms? Sinusitis Treatment NICE clinical knowledge summaries http://cks.nice.org.uk/sinusitis Sinusitis Antibacterials used only for persistent symptoms and purulent discharge lasting at least 7 days or if severe symptoms. Also, consider for those at high risk of serious complications (e.g. in immunosuppression, cystic fibrosis). Antibiotic choices; Which of these would you avoid in a pregnant patient? Sinusitis The PARI Sinus™ Pulsating Aerosol System Active Principle Aerosol delivery to the sinuses

http://www.pari.com/us-en/products/sinus/sinusTM-pulsating-aerosol-system/ https://www.youtube.com/watch?v=YaUVvxbwOkA Allergic Rhinitis Sneezing attacks, nasal discharge/blockage for over an hour most days: Seasonal rhinitis – during a limited period of the year Perennial allergic rhinitis – throughout the year There are other non-allergic forms of rhinitis some are: Non-allergic rhinopathy (NAR) Atrophic rhinitis Senile rhinitis Gustatory rhinitis Rhinitis medicamentosa Hormone induced Seasonal allergic rhinitis – hay fever Most common allergic disease Maximum prevalence in second decade of life Most common in summer -> june/july (in UK)

Seasonal allergic rhinitis – hay fever Symptoms: - nasal irritation sneezing Watery rhinorrhea Perennial rhinitis Perennial allergic rhinitis

Major cause allergen Der p1 in house dust mite faecal particles Next most common – household pets Perennial non-allergic rhinitis As mentioned earlier Rhinitis – treatment Video link demonstrating use of nasal sprays http://www.nationalasthma.org.au/how-to-videos Video link for use of eye drops http://www.rnib.org.uk/eye-health/glaucoma-guide/using-your-eye-drops Rhinitis – Stepping up treatment NICE Clinical Knowledge Summary (Oct 2015) http://cks.nice.org.uk/allergic-rhinitis Taking oral antihistamine – add intranasal corticosteroid Using intranasal corticosteroid – good technique – max dose Maximum dose intranasal corticosteroid – oral antihistamine or rhinorrhoea – intranasal ipratropium Rapid resolution of severe symptoms – oral corticosteroids Rhinitis When would you avoid/use chlorphenamine? - if causes drowsiness in pt -> driving - some people like to use at night Why did my daughter go ‘crazy’ after taking piriton syrup? - can cause paradoxical excitation -> neurological cholinergic effect -> increased energy, nervousness etc Can I wear contacts and use antihistamine eye drops? Depends on type of lenses: hard or soft. Hard you can (don’t absorb stuff) not if you soft. Hard needs to be taken out for 15 mins. Nasal corticosteroid or oral antihistamine? Cortico are more effective for controlling symptoms on a regular basis Can my six year old use fluticasone nasal spray? Not OTC, ONLY IF PRESCRIBED BY GP Rhinitis – further treatment Allergen immunotherapy injections given to reduce sensitivity to allergens, available for common allergens, including pollens, cat and dog dander, dust mites, and moulds. The shots contain solutions of the allergen(s) to which the patient is allergic and are made up specifically for the patient. The process of immunotherapy changes the patient's immune response to the allergens over time. As a result, being exposed to the allergen causes fewer symptoms and may even eliminate symptoms altogether.

Throat conditions Pharyngitis

Tonsillitis Laryngitis Epiglottitis Are covered in the NICE CKS for sore throat; http://cks.nice.org.uk/sore-throat-acute#!scenario Pharyngitis Sore-throat Common cause – adenovirus Around a third are bacterial – Cause? Can develop into tonsillitis – see later Pharyngitis Treatment Symptomatic Throat sprays Pastilles/lozenges Analgesics avoid food or drink that is too hot, as this could irritate the throat eat cool, soft food and drink cool or warm liquids adults and older children can suck lozenges, hard sweets, ice cubes or ice lollies avoid smoking and smoky environments regularly gargling with a mouthwash of warm, salty water may help reduce swelling or pain drink enough fluids, especially if you have a fever Tonsillitis Inflammation of the tonsils Most cases are caused by a viral infection, such as the viruses that cause the common cold or flu virus. Some cases can also be caused by a bacterial infection, typically group A streptococci. There are four main signs that tonsillitis is bacterial: white pus-filled spots on tonsils tends not to come with cough High temp Swollen and tender lymph nodes and glands

Gruesome picture alert White pus filled spots on tonsils Tonsillitis Symptoms sore throat that can feel worse when swallowing high temperature (fever) over 38C (100.4F) coughing headache

Tonsillitis Treatment; Tonsillitis Prescribing of antibiotics; Consider a delayed prescribing strategy Consider a 2 or 3-day delayed prescription or immediate antibiotics for people with a Centor score of 3 or 4 (presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough). Prescribe an antibiotic for: Those with features of marked systemic upset. Those at increase risk of serious complications. Those with valvular heart disease. Laryngitis Inflammation of the larynx (Voice box) Occasional complication of upper respiratory infection Caused by parainfluenza and measles viruses In acute laryngotracheobronchitis inflammation extends narrowing and obstructing the airway Laryngitis Symptoms; Laryngitis Treatment Not smoking & avoiding smoky, dry & dusty environments Drinking plenty of fluids to avoid dehydration Analgesics such as paracetamol or ibuprofen Gargling with a mouthwash of warm, salty water or an over-the-counter solution, or sucking lozenges Using menthol inhalation and air humidifiers Avoiding speaking/only speaking softly when needed Laryngotracheobronchitis - Croup Mild: Occasional barking cough and no audible stridor at rest. No or mild suprasternal and/or intercostal recession. The child is happy and is prepared to eat, drink, and play. Moderate: Frequent barking cough and easily audible stridor at rest. Suprasternal and sternal wall retraction at rest. No or little distress or agitation. The child can be placated and is interested in its surroundings. Severe: Frequent barking cough with prominent inspiratory (and occasionally, expiratory) stridor at rest. Marked sternal wall retractions. Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia). Tachycardia occurs with more severe obstructive symptoms and hypoxaemia. Laryngotracheobronchitis - Croup Stridor https://www.youtube.com/watch?v=tNBmnIKWpLA

NHS choices video - management of croup https://www.youtube.com/watch?v=16LV6Zo8FLY Paracetamol Fluids UCL advice for parents https://www.uclh.nhs.uk/PandV/PIL/Patient%20information%20leaflets/Croup%20in %20children.pdf Laryngotracheobronchitis - Croup http://cks.nice.org.uk/croup Give all children with mild, moderate, or severe croup a single dose of oral dexamethasone (0.15 mg / kg body weight). As a rough guide 1.5–2 mg for a child of average size aged 12–15 months and 2–3 mg for a child of average size aged 3–4 years. Oral prednisolone (1–2 mg per kg body weight) is an alternative if dexamethasone is not available. Consider giving a second dose if residual symptoms of stridor are still present the following day. Immediately admit a child who has moderate or severe croup, or impending respiratory failure. Laryngotracheobronchitis - Croup Can present as a medical emergency which may require Intravenous corticosteroids Nebulised adrenaline Intubation and oxygen Rarely tracheostomy Epiglottitis Inflammation of the epiglottis Common cause – H. influenzae Vaccine introduced 1993 88% reduction Can be life threatening Epiglottitis Symptoms Severe sore throat Difficulty and pain when swallowing Difficulty breathing, which may improve when leaning forwards Stridor Pyrexia 38C (100.4F) or above Irritability and restlessness Muffled or hoarse voice Drooling Epiglottitis Treatment; Influenza Caused by;

Influenza A – pandemics Influenza B – localised milder outbreaks Incubation period 1-3 days For further information see Kumar and Clark’s Clinical Medicine 2012 page 108 Influenza Symptoms: Pyrexia of 38C (100.4F) or above Tiredness and weakness Headache Myalgia (muscle aches and pains) Dry, chesty cough Can cause postviral syndrome lasting weeks or months Debility and depression Influenza Treatment: http://cks.nice.org.uk/influenza-seasonal Symptomatic management unless you; are 65 or over are pregnant have a lung, heart, kidney, liver or neurological disease have a weakened immune system have diabetes Oseltamivir (Tamiflu) Zanamivir (Relenza) to reduce the risk of complications of flu. Influenza When is an antiviral indicated? The person is in an 'at risk' group of people who are likely to suffer a worse prognosis than otherwise healthy people. The national surveillance scheme indicates that influenza is circulating. The person is able to start treatment within 48 hours of the onset of symptoms Influenza How are Oseltamivir and Zanamivir given? Oseltamavir (Tamiflu) http://www.medicines.org.uk/emc/PIL.20372.latest.pdf Zanamivir (Relenza) http://www.medicines.org.uk/emc/PIL.3789.latest.pdf Influenza Why is zanamivir (Relenza) given via inhalation?

See also advice re immunisation available at; https://cks.nice.org.uk/immunizations-seasonalinfluenza#!scenario Inhalation of foreign bodies Children age 1-3 in particular peanuts, grapes, seeds, popcorn Coins, marbles, eraser, buttons, beads Adults – excess alcohol/ under anaesthetic Teeth or dentures Impaction generally occurs in the right main bronchus

Inhalation of foreign bodies Symptoms Choking Persistent monophonic wheeze Later, persistent suppurative pneumonia Lung abscess is common Inhalation of foreign bodies Treatment Emergency Procedure;

http://www.sja.org.uk/sja/first-aid-advice/breathing/choking-adults.aspx Non-emergency – fibreoptic bronchoscopy Antibiotics Breathing support Inhalation of foreign bodies Advice on prevention Cut food to an appropriate size Teach children to chew well Discourage talking laughing and playing while eating Avoid whole grapes, nuts, popcorn, hard sweets in children under 3 Keep small objects out of reach of children Teach children not to place small objects in body cavities...