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03 URTI.pptx
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- 2. INTRODUCTION The respiratorysystems essentially comprises of three different structural and functional units: Respiratory tract Lung parenchyma Respiratory regulatory system In addition, the pleura, the thoracic cage and the mediastinum, are considered as important constituents of the respiratory system
- 3. RESPIRATORY TRACT:function air conduction, filtering, warming and humidifying the inspired air Classified: upper respiratory tract -include the nose, the mouth, the pharynx and the larynx up to the level of the vocal cords. lower respiratory tract- Starting with the trachea at the opening of the vocal cords up to terminal bronchi Airway can also be classified as: Extra thoracic airway Intra-thoracic extra-pulmonary airway Intra-thoracic intra-pulmonary
- 4. Common Cold TheCommon Cold is a viral illness in which the symptoms of rhinorrhea and nasal obstruction are prominent systemic symptoms and signs such as headache, myalgia, and fever are absent or mild. =self-limited involvement of the sinus mucosa and is more correctly termed rhinosinusitis Etiology and epidemiology Rhinoviruse--- the most common, others: corona virus, bokovirus, RSV…. occur year-round, greatest from the early fall until the late spring Young children have an average of 6-8 colds per year, 10-15% of children have at least 12 infections per year, decreases as age increases Children in out-of-home daycare centers during the 1st year of life
- 5. PATHOGENS ASSOCIATED WITHTHE COMMON COLD ASSOCIATION PATHOGEN RELATIVE FREQUENCY* Agents primarily associated with colds Rhinoviruses Frequent Coronaviruses Occasional Agents primarily associated with other clinical syndromes that also cause common cold symptoms Respiratory syncytial viruses Occasional Human metapneumovirus Occasional Influenza viruses Uncommon Parainfluenza viruses Uncommon Adenoviruses Uncommon Enteroviruses Uncommon Bocavirus Uncommon
- 6. Pathogenesis spread bysmall-particle aerosols, large-particle aerosols, and direct contact. Viral infection of the nasal epithelium can be associated: with destruction of the epithelial lining, as with influenza viruses and adenoviruses, or there can be no apparent histologic damage, as with rhinoviruses and RSV infection of the nasal epithelium is associated with an acute inflammatory response characterized by release of inflammatory cytokines and infiltration of the mucosa by inflammatory cells This acute inflammatory response causes the symptoms associated with the common cold Inflammation can obstruct the sinus ostium or Eustachian tube and predispose to bacterial sinusitis or otitis media.
- 7. CF and DX incubation period 1-3 days Sore or scratchy throat usually resolves quickly and, by the 2nd and 3rd day of illness rhinitis(rinorhhea ,nasal obstruction), Cough is associated with ∼30% of colds fever and other constitutional symptoms---- Influenza viruses, RSV, and adenoviruses . The usual cold persists for about 1 wk, 10% last for 2 wk. Examination of the nasal cavity might reveal swollen, erythematous nasal turbinates
- 8. Muco-purluent rhinitis(thick, opaque or discolored nasal discharge), this is not an indication for antimicrobial treatment unless it persists without signs of improvement for more than 10-14 days suggesting possible sinusitis. Exclude other conditions that are potentially more serious or treatable Routine laboratory studies are not helpful for the diagnosis and management of the common cold.
- 9. Management primarily ofsymptomatic treatment Either topical or oral adrenergic agents ---such as xylometazoline, oxymetazoline, or phenylephrine Saline nose drops (wash, irrigation) first-generation antihistamines reduce rhinorrhea by 25-30%. Acetaminophen not asprin Complications otitis media- most common complication of a cold—5 to 30% Sinusitis 5 to 13% Exacerbation of asthma increasing antibiotic resistance--- due to inappropriate abc intake
- 10. 10 Sinusitis Sinusitis isinfectious or noninfectious inflammation of 1 or more sinuses occur at any age. Third most common diagnosis for which antibiotics are prescribed Affects 30-35 million persons/year 25 million office visits/year Direct annual cost $2.4 billion and increasing Added surgical costs: $1 billion Cardiomyopathy- at any age
- 11. 11 Development of Sinuses 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells Frontal Maxillary Ethmoid Sphenoid Maxillary and ethmoid sinuses present at birth The maxillary sinuses are not pneumatized until 4 yr of age Frontal sinus developed by age 5 or 6 Sphenoid sinus last to develop, 8-10 The ostia draining the sinuses are narrow (1-3 mm) and drain into the ostiomeatal complex in the middle meatus
- 12. 12 Physiologic Importance ofSinuses Provide mucus to upper airways Lubrication Vehicle for trapping viruses, bacteria, foreign material for removal Give characteristics to voice Lessen skull weight Involved with olfaction
- 13. The paranasalsinuses are normally sterile, maintained by the mucociliary clearance system 2 types of acute sinusitis: viral and bacterial Viral Rhino-sinusitis Short lived, last less than 10 days Sinus mucosa as well as nasal mucosa is involved Most will clear without antibiotics Treatment: decongestants, nasal lavage, rest, fluids
- 14. 14 Classification of BacterialSinusitis Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days) Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely Chronic sinusitis- symptoms lasting more than 12 weeks Recurrent Acute Bacterial Sinusitis- Episodes lasting fewer than 4 weeks and separated by intervals of at least 10 days during which the patient is totally asymptomatic Or 3 episodes in 6 months or 4/year
- 15. 15 Bacteria Involved inAcute Bacterial Sinusitis Streptococcus pneumoniae 30% Haemophilus influenza 20% Moraxella catarrhalis 20% Staphylococcus aureus, other streptococci, and anaerobes are uncommon causes
- 16. 16 Bacteria Involved inChronic Sinusitis Anaerobes includes Fusobacterium nucleatum, Prevotella spp, Porphyromonas spp, and Peptostreptococcus spp Aerobes Aerobic gram-negative bacilli, such as Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter spp, and Escherichia coli Staphylococcus aureus Staphylococcus epidermidis
- 17. 17 Risk factor forsinusitis Acute Sinusitis URTI Allergic rhinitis smoke exposure Chronic Sinusitis Uncorrected anatomic conditions Ciliary dyskinesia Cystic fibrosis Tumors Immunodeficiency disorders IgA, IgM Granulomatous diseases
- 18. 18 C/F Usually beginswith viral upper respiratory illness nasal congestion, purulent nasal discharge (unilateral or bilateral), fever, cough bad breath (halitosis), a decreased sense of smell (hyposmia), periorbital edema headache and facial pain
- 19. 19 Physical Findings Mucopurulentnasal discharge Highest positive predictive value Swelling of nasal mucosa Mild erythema Sinus tenderness Periorbital swelling
- 20. 20 Sinus Transillumination Helpfulin older children and adults Normal transillumination decreases chance of fluid in the sinus No light reflex suggests mucopurulent material or thickening of nasal mucosa cannot reveal the etiology, whether it is viral or bacterial in origin. In children, transillumination is difficult to perform and is unreliable Inexpensive screening tool
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- 22. Diagnosis based onhistory Persistent symptoms of upper respiratory tract infection, including nasal discharge and cough, for >10-14 days without improvement, or severe respiratory symptoms, including fever of at least 102?F (39?C) and purulent nasal discharge for 3-4 consecutive days, suggest a complicating acute bacterial sinusitis Sinus aspirate culture----the only accurate method of diagnosis Bacteria are recovered from maxillary sinus aspirates in 70% sinus plain films, CT scans Including opacification, mucosal thickening, or presence of an air-fluid confirm the presence of sinus inflammation but cannot be used to differentiate the etiology
- 23. 23 Evaluation of ChronicSinusitis CT or MRI scanning Anatomic defects, tumors, fungi Allergy testing Inhalants, fungi, foods Sinus aspiration for cultures Bacterial Fungal Immunoglobulins
- 24. 24 Treatment of AcuteBacterial Sinusitis 50-60% of children with acute bacterial sinusitis recover without antimicrobial therapy antimicrobial treatment to promote resolution of symptoms and prevent suppurative complications Amoxicillin for 10-14 days or for 7 days after resolution of symptoms First line choice in most areas because of its efficacy, low cost, side-effect profile, and narrow spectrum for the penicillin-allergic include trimethoprim-sulfamethoxazole, cefuroxime axetil, cefpodoxime and macrolides Where beta-lactanase resistance is an issue High dose Amoxicillin/clavulanate or azithromycin Frontal sinusitis can initiation of parenteral ceftriaxone
- 25. 25 Complications of Sinusitis Orbital---most often secondary to ethmoiditis periorbital cellulitis and orbital cellulitis Brain epidural abscess, meningitis, cavernous sinus thrombosis, subdural empyema, and brain abscess Bone osteomyelitis
- 26. Pharyngitis Definition: InflammatorySyndrome of the pharynx caused by several microorganisms Causes: Viral– most common adenoviruses, coronaviruses, enteroviruses, rhinoviruses, RSV, EBV,HSV, metapneumovirus Bacteria- The most bacterial cause is Group A Streptococcus (Streptococcus pyogenes) 15 to 30% GABHS--- uncommon before 2 to 3 yr peak incidence in the early school years, and declines in late adolescence and adulthood OTHERS-GCS, Mycoplasma, Arcanobacterium, Francisella, Neiseria, Corynbacteria
- 27. Clinical feature GAS-The incubation period is 2-5 days rapid onset sore throat, fever, headache, GI symptoms cough is absent pharynx is red, and petechiae may be there tonsil enlarged and covered yellow blood tingled exudate uvula may become red, stippled and swollen anterior cervical L.node enlarged and tender The illnesses attributed to group C streptococcus and A. haemolyticum are generally similar to those caused by GABHS Viral-gradual onset with rhinorrhea, cough and diarrhea conjunctivitis, coryza, hoarseness, and cough other symptoms according to the cause Measles> cccp cough coryza conjunctivitis photophobia
- 29. Diagnosis identification of GABHS Rapidantigen test—high specificity ≥95 percent and a sensitivity that varies between 70 and 90 percent if +ve----- no need culture Throat culture---- gold standard false –ve----- enadequate swab and ABC use false +ve------ in asymptomatic carrier 5 to 21 percent of children b/n 3 and 15 years of age GAS molecular tests--- both sensitivity and specificity are reported to be ≥98% --- more expensive than throat culture Most children and adolescents with negative microbiologic tests for GAS have viral pharyngitis, which is a self-limited condition and can be treated symptomatically
- 30. McIsaac scoring onepoint for each of the following: 1. Age 3 to 14 years 2. tonsillar swelling or exudates 3. Tender, enlarged (>1 cm) anterior cervical lymph nodes 4. Temperature >38°C (100.4°F) 5. Absence of cough overestimates the likelihood of GAS
- 31. Treatement indication forabc are culture +ve and Ag positive for GABS, Dx of scarlet fever, Hx of RF, contact with proven GBS pharyngitis, hx of recent RF in family member Antibiotics- pencillin amoxicillin for 10 days or benz.penicillin -Erythromycin - the primary goal of abc is to prevent rheumatic fever and is completely successful if given within 9 days For eradication of carrier clindamycin for 10d - other supportive measures anti pyretic like paracetamol gurgling with warm salt water and local anasthetic spray TONSILOCTOMY ------ for severe and recurrent GABHS tonsilits →> seven in previous year and > 5 in preceding 2 years
- 33. Recurrent Pharyngitis Definition: ≥7 episodes in the previous year or ≥5 in each of the preceding 2 yr, or ≥3 in each of the previous 3 yr Causes: reinfection with the same M type if type-specific antibody has not developed; poor compliance with oral antibiotic therapy; macrolide resistance if a macrolide was used for treatment; and infection with a new M type Management Treatment with intramuscular benzathine penicillin eliminates nonadherence to therapy Tonsillectomy may lower the incidence of pharyngitis for 1-2 yr among children
- 34. Complication Non suppurative 1.Acute rheumatic fever 2. Scarlet fever 3. Streptococcal toxic shock syndrome 4. PSGN Suppurative 1. Tonsillopharyngeal cellulitis or abscess 2. Otitis media 3. Sinusitis 4. Necrotizing fasciitis
- 35. OTITIS MEDIA Theterm otitis media has 2 main categories: I. acute infection, which is termed suppurative or acute otitis media (AOM); and II. inflammation accompanied by effusion, termed nonsuppurative or secretory OM, or otitis media with effusion (OME) Middle-ear effusion (MEE) is a feature both of AOM and of OME and is an expression of the underlying middle-ear mucosal inflammation These 2 main types of OM are interrelated: acute infection usually is succeeded by residual inflammation and effusion bacteria- isolated in 65 – 75 % of ME exudates -Streptococcus pneumoniae(40%), -Hemophilus influenzae(25-30%), and -Moraxella catarrhalis(10-15%) o Virus –mostly together with bacteria - RSV and rhinovirus
- 36. Epidemology Over80% of children will have experienced at least one episode of otitis media (OM) by the age of 3 yr. The peak incidence and prevalence of OM is during the 1st 2 yr of life. OM is the leading reason for physician visits and for use of antibiotics OM is the most common reason for prescribing antimicrobial drugs to children Age the development of at least 1 episode of OM has been reported as 63-85% by 12 mo and 66-99% by 24 mo of age less well-developed immunologic defenses and less favorable eustachian tubal factors
- 37. Gender Greaterin boys than in girls and greater severity in boys Socioeconomic Status Poverty has long been considered an important contributing factor to both the development and the severity of OM. Elements contributing to this relationship include crowding, limited hygienic facilities, suboptimal nutritional status Breast Milk Compared to Formula Feeding In general, studies have found a protective effect of breast milk feeding against OM Exposure to Tobacco Smoke Exposure to Other Children
- 38. Congenital Anomalies OM is universal among infants with unrepaired palatal clefts, and is also highly prevalent among children with submucous cleft palate, other craniofacial anomalies, and Down syndrome. The common feature in these congenital anomalies is a deficiency in the functioning of the Eustachian tubes, which predisposes these children to middle ear disease Vaccination Status
- 39. Etiology nontypeable H.influenzae ---- 40 to 50% S. pneumoniae ---30-50% of cases M. catarrhalis representing the majority of the remaining cases. Other pathogens include group A streptococcus, Staphylococcus aureus, and gram-negative organism respiratory viruses also may be found in middle-ear exudates of children with AOM, either alone or, more commonly, in association with pathogenic bacteria. Of these viruses, rhinovirus and respiratory syncytial virus (RSV) are found most often
- 40. PATHOGENESIS Otitis Mediausually follows an URI in which there is edema of the Eustachian tube, leading to blockage. Stasis of these middle ear secretions lead to infection and irritation Viral infection of the URTI results in release of cytokines and inflammatory mediators, some of which may cause Eustachian tube dysfunction. Respiratory viruses also may enhance nasopharyngeal bacterial colonization and adherence and impair host immune defences against bacterial infection Other factors: allergic rhinitis, nasal polyps, adenoidal hypertrophy The maturation of this immune system during early childhood is most likely the primary event leading to the decrease in incidence of OM
- 41. Clinical Manifestations earpain In young children may be manifested by irritability or a change in sleeping or eating habits and holding or tugging at the ear Fever purulent otorrhea Balance difficulties or disequilibrium Hearing loss Examination of the Eardrum Otoscope- normal tympanitic mb is slightly concave, pearly gray and transleucent Acute otitis media:- bulged, erythema or abnormally white if effusion and absence of motility (atleast 2 of 3)
- 42. Acute otitis mediadiagnosis - otoscopic
- 44. Treatment Antibiotics -Firstline amoxicillin azithromycin bactrim Second line augmentin cefuroxime ceftiaxone(IM) *Duration of treatment is 10 days Myringotomy Tympanocentesis and tympanostomy tube insertion
- 45. CRITERIA FORINITIAL ANTIBACTERIAL-AGENT TREATMENT OR OBSERVATION Nonsevere illness is mild otalgia and fever <39?C in the past 24 hr. Severe illness is moderate to severe otalgia or fever ≥39?C. Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen AGE CERTAIN DIAGNOSIS UNCERTAIN DIAGNOSIS <6 mo Antibacterial therapy Antibacterial therapy 6 mo-2 yr Antibacterial therapy Antibacterial therapy if severe illness; observation option* if nonsevere illness ≥2 yr Antibacterial therapy if severe illness; observation option* if nonsevere illness Observation option*
- 46. Complications includes Intratemporalincludes -infectious eczematoid dermatits -chronic otitis media -mastoiditis -labyrinthitis -hearing loss -Cholesteatoma -facial nerve palsy -intracranial complication -meningitis -cavernous sinus thrombosis -sub dural empyema -epi dural abscess -brain abscess -pseudotumor cerebri
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