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Upper Respiratory Tract Infection

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Upper Respiratory Tract Infection

  1. 1. Upper respiratory tract Infection
  2. 2. Upper respiratory tract Infection
  3. 3. Causes: Most URIs are viral in origin. More than 200 different viruses are known to cause the common cold. Most viral agents that cause <ul><ul><li>Rhinoviruses cause approximately 30-50% of colds in adults. They grow optimally at temperatures near 32.8°C (91°F), which is the temperature inside the human nares. </li></ul></ul><ul><ul><li>Coronaviruses are a significant cause of colds. However, exact case numbers are difficult to determine, because unlike rhinoviruses, coronaviruses are difficult to culture in the laboratory. </li></ul></ul><ul><ul><li>Enteroviruses, including coxsackieviruses, echoviruses, and others, are also leading causes of common colds. </li></ul></ul><ul><ul><li>Adenoviruses , orthomyxoviruses (including influenza A and B viruses), paramyxoviruses (eg, parainfluenza [PIV]), RSV, EBV, and hMPV account for many URIs. Varicella, rubella, and rubeola infections may manifest as a nasopharyngitis before other classic signs and symptoms </li></ul></ul>
  4. 4. A viral URTI can be complicated by secondary bacterial infections <ul><ul><ul><li>Group A streptococci (approximately 15% of all cases of pharyngitis) Group A beta hemolytic streptococci (GABHS) </li></ul></ul></ul><ul><ul><ul><li>Group C and G streptococci </li></ul></ul></ul><ul><ul><ul><li>N gonorrhoeae </li></ul></ul></ul><ul><ul><ul><li>Arcanobacterium (Corynebacterium) hemolyticum </li></ul></ul></ul><ul><ul><ul><li>Corynebacterium diphtheriae </li></ul></ul></ul><ul><ul><ul><li>Atypical bacteria, eg, M pneumoniae and C pneumoniae (However, absent lower respiratory tract disease, the clinical significance of these pathogens is unce rtain.) </li></ul></ul></ul><ul><ul><ul><li>Anaerobic bacteria </li></ul></ul></ul>
  5. 5. acute respiratory infections symptoms –cough, sore throat, and acute nasal/sinus congestion Acute Respiratory Illness Acute Nasal/Sinus Congestion Cough Sore Throat
  6. 6. PATHOPHYSIOLOGY <ul><li>Viruses cause most URIs, with rhinovirus, parainfluenza virus, coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenza virus accounting for most cases. cause 5% to 10% of cases of pharyngitis in adults. Other less common causes of bacterial pharyngitis include group C beta hemolytic streptococci, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae , and herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae , and Moraxella catarrhalis are the most common organisms that cause bacterial superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae , or C. pneumoniae (TWAR). Direct invasion of respiratory epithelium results in symptoms respective to the area or areas involved. </li></ul>Transmission of organisms causing URIs occurs by aerosol, droplet, or direct hand-to-hand contact with infected secretions, with subsequent passage to the nares or eyes. 8
  7. 8. Upper respiratory tract Infection The Nasal cavity Rhinitis - Inflammation of the nasal mucosa Rhinosinusitis, sinusitis - Inflammation of the nares and paranasal sinuses, including frontal, ethmoid, maxillary, and sphenoid Nasopharyngitis (rhinopharyngitis or the common cold) - Inflammation of the nares, pharynx, hypopharynx, uvula, and tonsils Pharyngitis - Inflammation of the pharynx, hypopharynx, uvula, and tonsils Epiglottitis (supraglottitis) - Inflammation of the superior portion of the larynx and supraglottic area Laryngitis - Inflammation of the larynx Laryngotracheitis - Inflammation of the larynx, trachea, and subglottic area Tracheitis - Inflammation of the trachea and subglottic area
  8. 10. The Nasal cavity <ul><li>Presenting symptoms </li></ul><ul><li>Pain and tenderness </li></ul><ul><li>over sinuses </li></ul><ul><li>Headache </li></ul><ul><li>Mucopurulent nasal </li></ul><ul><li>discharge (>7-10 days) </li></ul><ul><li>Stuffy nose </li></ul><ul><li>Facial pressure </li></ul>
  9. 11. Symptoms of Sinusitis <ul><li>Symptoms specific for frontal sinus infection </li></ul><ul><ul><li>Tender forehead </li></ul></ul><ul><li>Symptoms specific for maxillary sinus infection </li></ul><ul><ul><li>Aching upper jaw </li></ul></ul><ul><ul><li>Aching teeth </li></ul></ul><ul><ul><li>Tender cheeks </li></ul></ul><ul><li>Symptoms specific for ethmoid sinus infection </li></ul><ul><ul><li>Swollen eyelids </li></ul></ul><ul><ul><li>Swelling around eyes </li></ul></ul><ul><ul><li>Pain between eyes </li></ul></ul><ul><ul><li>Tenderness of sides of nose </li></ul></ul><ul><ul><li>Loss of smell </li></ul></ul><ul><ul><li>Stuffy nose </li></ul></ul><ul><li>Symptoms specific for sphenoid sinus infection </li></ul><ul><ul><li>Earaches </li></ul></ul><ul><ul><li>Neck pain </li></ul></ul><ul><ul><li>Aching top of head </li></ul></ul>
  10. 12. Complication sinusitis <ul><li>Orbital complications </li></ul><ul><li>: preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis (dural thrombophlebitis). </li></ul><ul><li>Intracranial complications </li></ul><ul><li>: Intracranial (CNS) complications, namely, meningitis, subdural empyema, epidural abscess and cerebral abscess may all complicate acute and chronic sinusitis </li></ul><ul><li>Meningitis </li></ul><ul><ul><li>Fever and chills </li></ul></ul><ul><ul><li>Severe headache </li></ul></ul><ul><ul><li>Nausea and vomiting </li></ul></ul><ul><ul><li>Stiff neck (meningismus) </li></ul></ul><ul><ul><li>Sensitivity to light ( photophobia ) </li></ul></ul><ul><ul><li>Mental status changes </li></ul></ul><ul><li>Bony complications </li></ul><ul><li>: Osteomyelitis (and osteitis) are usually related to acute frontal sinusitis </li></ul>
  11. 13. Investigation sinusitis <ul><li>Sinusitis includes: </li></ul><ul><li>Physical examation </li></ul><ul><li>X-ray of sinuses </li></ul><ul><li>CAT scan of sinuses </li></ul><ul><li>Nasal swab tests </li></ul><ul><li>Physical exam </li></ul><ul><li>Sinus X-ray </li></ul><ul><li>MRI scan </li></ul><ul><li>CT scan </li></ul>
  12. 14. presenting with an acute sore throat
  13. 15. Epiglottiditis is a true medical emergency. <ul><ul><li>Sore throat </li></ul></ul><ul><ul><li>Drooling </li></ul></ul><ul><ul><li>Odynophagia or dysphagia, difficulty or pain during swallowing, globus sensation of a lump in the throat </li></ul></ul><ul><ul><li>Muffled dysphonia or loss of voice </li></ul></ul><ul><ul><li>Dry cough or no cough </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia </li></ul></ul><ul><ul><li>Fatigue or malaise (may be seen with any URI) </li></ul></ul>
  14. 16. Tonsillitis <ul><li>Symptoms </li></ul><ul><li>Pain in the throat (sometimes severe) that may last more than 48 hours and be associated with difficulty in swallowing. The pain may spread to the ears. </li></ul><ul><li>The throat is reddened, the tonsils are swollen and may be coated or have white spots on them. </li></ul><ul><li>Possibly a high temperature. </li></ul><ul><li>Swollen lymph glands under the jaw and in the neck. </li></ul><ul><li>Headache. </li></ul><ul><li>Loss of voice or changes in the voice. . . </li></ul>
  15. 17. complications Tonsillitis <ul><li>Local Complication </li></ul><ul><ul><li>Peritonsillar abscess </li></ul></ul><ul><ul><li>Superlative cervical Lymphadenitis </li></ul></ul><ul><li>Systemic complication </li></ul><ul><ul><li>A secondary infection may occur in the middle ear or sinuses . </li></ul></ul><ul><ul><li>If the sore throat is due to a streptococcus infection, there may be a rash ( scarlet fever ). </li></ul></ul><ul><ul><li>An uncommon complication is a throat abscess which occurs usually only on one side. If sufficiently large this can need surgical drainage (Quinsy throat). </li></ul></ul><ul><ul><li>** Beta – hemolytic streptococci group </li></ul></ul><ul><ul><li>In very rare cases, diseases like rheumatic fever </li></ul></ul><ul><ul><li>a particular kidney disease (glomerulonephritis) can occur. This is much less commonly observed now than it was several decades ago. </li></ul></ul><ul><ul><li>Acute endocarditis </li></ul></ul>
  16. 18. Assessment : Detailed history <ul><ul><li>- Onset and nature of symptoms: location and duration of pain (throat, sinuses, joints) </li></ul></ul><ul><ul><li>Itchy, watery eyes , Nasal discharge , Nasal congestion , Sneezing , Sore throat , Headache Fever MalaiseFatigue, weakness , Myalgias </li></ul></ul><ul><ul><li>- Cough (productive/non productive) </li></ul></ul><ul><ul><li>- Fever and nasal discharge </li></ul></ul><ul><ul><li>- Existing co-morbidities </li></ul></ul><ul><ul><li>- History of rheumatic heart disease </li></ul></ul><ul><ul><li>- Known sinus polyps </li></ul></ul><ul><ul><li>- Immuno-suppression </li></ul></ul><ul><ul><li>- Prosthetic heart valve </li></ul></ul><ul><ul><li>-Respiratory diseases like asthma, COPD </li></ul></ul><ul><ul><li>- Other family members with recent sore throat </li></ul></ul><ul><ul><li>- History of foreign travel </li></ul></ul><ul><ul><li>- History of foreign body </li></ul></ul>
  17. 19. Physical assessment <ul><ul><li>- General appearance, toxicity, respiratory distress, vital signs </li></ul></ul><ul><ul><li>- Inspection of throat, tonsillar exudates, redness, oedema 1 </li></ul></ul><ul><ul><li>- Palpate sinuses; oedema or bogginess over adjacent bony areas </li></ul></ul><ul><ul><li>- Inspect peri orbital area, assess for visual and neurological disturbance </li></ul></ul><ul><ul><li>- Palpate for lymphadenopathy, splenomegaly, and hepatomegaly </li></ul></ul><ul><ul><li>- Assess for signs of meningitis ( sign :HA, photophobia,I irritability, clouding of conciousness,neck stiffness) , haemorrhagic spots </li></ul></ul><ul><ul><li>- Ear examination </li></ul></ul><ul><ul><li>- Chest auscultation </li></ul></ul><ul><ul><li>- Airway compromise, stridor or drooling </li></ul></ul>
  18. 20. <ul><li>Examination meningitis </li></ul><ul><ul><li>Brudzinski's sign of meningitis </li></ul></ul><ul><ul><li>Severe neck stiffness </li></ul></ul><ul><ul><li>causes a patient's hips </li></ul></ul><ul><ul><li>and knees to flex when </li></ul></ul><ul><ul><li>the neck is flexed. </li></ul></ul><ul><ul><li>Kernig's sign of meningitis </li></ul></ul><ul><ul><li>Severe stiffness of the </li></ul></ul><ul><ul><li>hamstrings causes an </li></ul></ul><ul><ul><li>inability to straighten </li></ul></ul><ul><ul><li>the leg when the hip </li></ul></ul><ul><ul><li>is flexed to 90 degrees. </li></ul></ul>
  19. 21. Investigation <ul><li>CBC </li></ul><ul><li>Chest X ray – if focal signs on chest examination , fever with productive cough or prolonged symptoms of URTI , Lateral upper airways – Foreign body, Upper Airway obstruction, retro- pharyngeal abscess, epiglotitis. </li></ul><ul><li>Blood Culture – uncertain diagnosis, toxic clinical picture </li></ul><ul><ul><li>Consider: </li></ul></ul><ul><ul><li>LFT’s – glandular fever & atypical pneumonia </li></ul></ul><ul><ul><li>EBV serology and monospot- prolonged history of URTI not resolving with antibiotics </li></ul></ul><ul><ul><li>Throat swab – very rarely helpful. </li></ul></ul><ul><li>BS : prolonged poor oral intake, diabetes, age >55 years, renal disease </li></ul>
  20. 22. Indication for admit <ul><ul><li>Respiratory distress, pulse rate >110 (adult), SaO2 <95% </li></ul></ul><ul><ul><li>Toxic clinical picture </li></ul></ul><ul><ul><li>History of rheumatic heart disease </li></ul></ul><ul><ul><li>History of prosthetic valve </li></ul></ul><ul><ul><li>Hepatomegaly or splenomegaly </li></ul></ul><ul><ul><li>Asymmetrical pharyngeal swelling </li></ul></ul><ul><ul><li>Peri-tonsillar abscess </li></ul></ul><ul><ul><li>Epiglotitis </li></ul></ul><ul><ul><li>Signs of meningitis </li></ul></ul><ul><ul><li>Age >70 years </li></ul></ul><ul><ul><li>Inability to swallow / dehydration </li></ul></ul><ul><ul><li>Torticollis </li></ul></ul><ul><ul><li>Oedema involving the bony areas adjacent to sinuses </li></ul></ul><ul><ul><li>Peri-orbital involvement </li></ul></ul><ul><ul><li>Visual or neurological disturbance </li></ul></ul><ul><ul><li>Beta Lactam allergy 2, 3, 6 </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Relevant Co morbidities </li></ul></ul><ul><ul><li>Immunocompromised patients </li></ul></ul><ul><ul><li>Atypical lymphocytosis </li></ul></ul><ul><ul><li>Lymphadenopathy outside cervical. </li></ul></ul>
  21. 23. Treatment <ul><li>Virus infections </li></ul><ul><ul><li>Antibiotics do not kill viruses. Antibiotics only kill bacteria. </li></ul></ul><ul><ul><li>Antibiotics may cause side-effects such as diarrhea, rashes, feeling sick, etc. </li></ul></ul><ul><ul><li>Overuse of antibiotics when they have not been necessary has led to some bacteria becoming resistant to them. This means that some antibiotics might not be as effective when they are really needed. </li></ul></ul>
  22. 24. Consider: Drug <ul><li>Analgesic drug </li></ul><ul><li>Paracetamol Indication Temporary relief of pain. Reduces fever >38. Oral Adults 500mg to 1000mg 4-6 hourly – Max. 60mg/kg/day Precautions- Renal or hepatic dysfunction. Accidental paracetamol hepatotoxicity Dyspepsia, nausea, allergic and haematological reactions. Overdose can result in severe liver damage, renal tubular necrosis. </li></ul><ul><li>NSAID </li></ul><ul><li>Ibuprofen Indication Temporary relief of pain. Reduces fever Oral Adults 400mg 4-6 hourly (Max 2400mg/24hrs) Short term use only. Non steroidal anti inflammatory / S2 NSAID sensitive asthma, rhinitis, urticaria, active GI bleeding, ulcer, <2 years. Precautions- prolonged use, history of GI bleeding, </li></ul><ul><li>Decongestant </li></ul><ul><li>Oxymetazoline Hydrochloride Nasal and middle ear congestion Topical Adults 2-3dropseach nostril (0.5mg/ml) 8-12 hourly Max. 3 days Decongestant / S2 Hypersensitivity, Glaucoma Precautions- Hypertension, coronary artery disease, hyperthyroidism, diabetes, high doses, prolonged use, pregnancy, lactation, <2yrs Burning, stinging, dry nasal mucosa, sneezing, headache, light-headedness, insomnia, palpitations and rebound congestion </li></ul><ul><li>Antibiotic </li></ul><ul><li>Phenoxymethylpenicillin Oral therapy for mild to moderate infections due to penicillin sensitive organisms – Sore throat Oral Adult 250mg-500mg 4-6 hourly Antibiotic </li></ul><ul><li>Amoxycillin Trihydrate Infections due to susceptible organisms incl. sinusitis Oral Adult 250-500mg 8 hourly (Antibiotic ) side effect GI upset; raised LFTs; CNS </li></ul>
  23. 25. tonsillitis treat ment <ul><li>In the vast majority of people, infection caused by a virus infection need only be treated with paracetamol (eg Calpol , Panadol ) to bring the temperature down. Aspirin (eg Disprin) is also useful, but should not be given to children under 16 years of age, unless on the advise of a doctor. In a small minority of patients, tonsillitis caused by bacteria is treated with penicillin or erythromycin (eg Erythroped) if the person is allergic to penicillin. If antibiotics are prescribed, it is important to complete the full course, or the infection may not be cured. Surgery to remove the tonsils (tonsillectomy) may be necessary for those patients suffering from repeated, severe infections that refuse to respond to treatment and significantly interfere with their school or work schedule but it is now a relatively uncommon operation compared to previous practice. </li></ul><ul><li>Prevention </li></ul><ul><li>Frequent hand washing is the best way to prevent all kinds of infections, including tonsillitis. Wash your hands often, and encourage your children to do the same. </li></ul>
  24. 26. Prevention : Influenza Vaccine <ul><li>Who should get influenza vaccine? Everyone 50 years of age or older </li></ul><ul><li>All children 6–23 months of age </li></ul><ul><li>Residents of long-term care facilities and nursing homes </li></ul><ul><li>Anyone 2–49 years of age who has a serious long-term health problem, including heart disease, lung disease, asthma, kidney disease, a metabolic disease such as diabetes, or anemia and other blood disorders </li></ul><ul><li>Anyone who has a condition (e.g., spinal cord injury) that can affect their ability to cough out their respiratory secretions </li></ul><ul><li>Anyone whose immune system is weakened because of the following: HIV/AIDS or other diseases that affect the immune system, long-term treatment with drugs such as steroids, or cancer treatment with x-rays or drugs </li></ul><ul><li>Anyone 2–18 years of age on long-term aspirin treatment (who could develop Reye's syndrome if they catch influenza) </li></ul><ul><li>Women who will be pregnant during the influenza season </li></ul><ul><li>All healthcare workers, family members, or anyone else coming in close contact with people at risk of serious influenza disease (including household contacts of all children 0–23 months of age) </li></ul>
  25. 27. persons should not be vaccinated with live influenza vaccine: <ul><li>Persons younger than five years of age </li></ul><ul><li>Persons 50 years of age or older </li></ul><ul><li>Persons with asthma, reactive airways disease or other chronic disorders of the pulmonary or cardiovascular systems; persons with other underlying medical conditions, including metabolic diseases such as diabetes, renal dysfunction, and hemoglobinopathy or persons with known or suspected immune deficiency diseases or who are receiving immunosuppressive therapies </li></ul><ul><li>Children or adolescents receiving aspirin </li></ul><ul><li>Persons with a history of Guillain-Barré syndrome </li></ul><ul><li>Pregnant women </li></ul><ul><li>Healthcare workers, household members, and others who have close contact with severely immunocompromised individuals during the periods in which the immunosuppressed person requires care in a protective environment. </li></ul><ul><li>Vaccine Side Effects </li></ul><ul><li>Soreness, redness, or swelling where the shot was given </li></ul><ul><li>Fever (low grade) </li></ul><ul><li>Aches </li></ul><ul><li>Coverage </li></ul><ul><ul><li>~ 1year </li></ul></ul>
  26. 28. INFLUENZA VACCINE DOSAGE BY AGE GROUP 2005-2006 SEASON <ul><li>AGE GROUPDOSAGENO. OF DOSESROUTE </li></ul><ul><ul><li>6-35 months 0.25 mL1 Intramuscular </li></ul></ul><ul><ul><li>3-8 years 0.50 mL1 Intramuscular </li></ul></ul><ul><ul><li>> 9 years 0.50 mL Intramuscular </li></ul></ul><ul><li>Product name Influenza vaccine </li></ul><ul><ul><li>Vaxigrib vaccine </li></ul></ul><ul><ul><li>Fluzone vaccine </li></ul></ul><ul><ul><li>Fluarix vaccine </li></ul></ul>
  27. 29. Preventing Sinusitis <ul><li>using an oral decongestant or a short course of nasal spray decongestant </li></ul><ul><li>gently blowing your nose, blocking one nostril while blowing through the other </li></ul><ul><li>drinking plenty of fluids to keep nasal discharge thin </li></ul><ul><li>avoiding air travel. If you must fly, use a nasal spray decongestant before take-off to prevent blockage of the sinuses allowing mucus to drain </li></ul><ul><li>If you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks </li></ul>

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