This document summarizes the medical management of rhinosinusitis (RS) and nasal polyps. It discusses the different types of RS including acute, chronic, allergic, and infectious. Treatment options are provided for each type based on severity and include nasal irrigation, topical and oral corticosteroids, antibiotics, decongestants, and immunotherapy. Surgical management is reserved for severe cases that do not respond to medical therapy. The goal of treatment is to reduce symptoms and recurrence in order to improve quality of life for patients with RS.
Allergic rhinitis, or hay fever, is a common condition affecting 10-25% of the global population. It is an inflammation of the nasal passages caused by an immune system response to allergens like pollen, dust mites, or pet dander. Symptoms include sneezing, nasal congestion, runny nose, and itchy eyes. Allergic rhinitis can impair quality of life and work or school performance. Intranasal corticosteroids are the most effective treatment for both intermittent and persistent allergic rhinitis. The ARIA guidelines recommend intranasal corticosteroids as first-line treatment alone or in combination with oral antihistamines depending on the severity
This document provides guidance on the initial treatment of asthma exacerbations in preschool-aged children presenting to primary and secondary healthcare. It recommends:
1) Administering inhaled short-acting beta2-agonists (SABA) like salbutamol, which are the first-line treatment for acute asthma or wheezing.
2) Treating hypoxemia with supplemental oxygen to maintain oxygen saturations of 94-98%, especially for those with severe or life-threatening asthma.
3) Regularly assessing treatment response and oxygen needs, and considering adjunctive therapies like corticosteroids depending on the severity of symptoms.
The document provides guidelines for the acute management of asthma exacerbations, including risk factors, classifications of exacerbation severity from mild to life-threatening, and treatment protocols based on peak expiratory flow rate and clinical presentation. It also covers discharge planning and the use of peak expiratory flow monitoring to assess asthma control and exacerbation risk.
This document discusses the pharmacotherapy of streptococcal sore throat, also known as strep throat. It outlines the goals of therapy as providing symptomatic relief, preventing complications, and preventing spread. Diagnosis involves culturing throat secretions to identify group A streptococcus. Common symptoms include sore throat, fever, and tender lymph nodes. First-line treatment is penicillin, with amoxicillin as an alternative. Other antibiotic options for penicillin-allergic patients include cephalosporins, macrolides, and clindamycin. Early treatment with antibiotics can reduce symptoms and complications of strep throat.
An 8-year-old male presents to the emergency room with acute shortness of breath likely due to an asthma exacerbation. His symptoms have been worsening over the past 24 hours. On examination, he has increased work of breathing and wheezing. Arterial blood gas shows respiratory acidosis. He is started on nebulized bronchodilators and steroids to treat the exacerbation.
A 24-year-old male presents to clinic with worsening cough, wheezing, and dyspnea over the past 3 days in the setting of an upper respiratory infection. Examination reveals wheezing. He is diagnosed with an asthma exacerbation from his upper respiratory symptoms and started on inhaled
Management of asthma exacerbation in childrenAzad Haleem
This document discusses the management of acute asthma exacerbations from home through hospitalization. It begins with the clinical assessment and severity classification of exacerbations. For home management, it recommends immediate use of rescue medications and contacting a physician for worsening or incomplete responses. In the emergency department, treatment focuses on correcting hypoxemia, improving airflow, and preventing progression using oxygen, frequent bronchodilators, and systemic corticosteroids. Hospital admission is indicated for moderate-severe exacerbations not improving within 1-2 hours of intensive treatment or for patients with high-risk features. Intensive care is needed for severe respiratory distress or failure to respond to therapy.
Allergic rhinitis, or hay fever, is a common condition affecting 10-25% of the global population. It is an inflammation of the nasal passages caused by an immune system response to allergens like pollen, dust mites, or pet dander. Symptoms include sneezing, nasal congestion, runny nose, and itchy eyes. Allergic rhinitis can impair quality of life and work or school performance. Intranasal corticosteroids are the most effective treatment for both intermittent and persistent allergic rhinitis. The ARIA guidelines recommend intranasal corticosteroids as first-line treatment alone or in combination with oral antihistamines depending on the severity
This document provides guidance on the initial treatment of asthma exacerbations in preschool-aged children presenting to primary and secondary healthcare. It recommends:
1) Administering inhaled short-acting beta2-agonists (SABA) like salbutamol, which are the first-line treatment for acute asthma or wheezing.
2) Treating hypoxemia with supplemental oxygen to maintain oxygen saturations of 94-98%, especially for those with severe or life-threatening asthma.
3) Regularly assessing treatment response and oxygen needs, and considering adjunctive therapies like corticosteroids depending on the severity of symptoms.
The document provides guidelines for the acute management of asthma exacerbations, including risk factors, classifications of exacerbation severity from mild to life-threatening, and treatment protocols based on peak expiratory flow rate and clinical presentation. It also covers discharge planning and the use of peak expiratory flow monitoring to assess asthma control and exacerbation risk.
This document discusses the pharmacotherapy of streptococcal sore throat, also known as strep throat. It outlines the goals of therapy as providing symptomatic relief, preventing complications, and preventing spread. Diagnosis involves culturing throat secretions to identify group A streptococcus. Common symptoms include sore throat, fever, and tender lymph nodes. First-line treatment is penicillin, with amoxicillin as an alternative. Other antibiotic options for penicillin-allergic patients include cephalosporins, macrolides, and clindamycin. Early treatment with antibiotics can reduce symptoms and complications of strep throat.
An 8-year-old male presents to the emergency room with acute shortness of breath likely due to an asthma exacerbation. His symptoms have been worsening over the past 24 hours. On examination, he has increased work of breathing and wheezing. Arterial blood gas shows respiratory acidosis. He is started on nebulized bronchodilators and steroids to treat the exacerbation.
A 24-year-old male presents to clinic with worsening cough, wheezing, and dyspnea over the past 3 days in the setting of an upper respiratory infection. Examination reveals wheezing. He is diagnosed with an asthma exacerbation from his upper respiratory symptoms and started on inhaled
Management of asthma exacerbation in childrenAzad Haleem
This document discusses the management of acute asthma exacerbations from home through hospitalization. It begins with the clinical assessment and severity classification of exacerbations. For home management, it recommends immediate use of rescue medications and contacting a physician for worsening or incomplete responses. In the emergency department, treatment focuses on correcting hypoxemia, improving airflow, and preventing progression using oxygen, frequent bronchodilators, and systemic corticosteroids. Hospital admission is indicated for moderate-severe exacerbations not improving within 1-2 hours of intensive treatment or for patients with high-risk features. Intensive care is needed for severe respiratory distress or failure to respond to therapy.
The ARIA initiative was developed in collaboration with the World Health Organization to provide evidence-based guidelines for diagnosing and treating allergic rhinitis. The goals of ARIA were to update healthcare professionals' knowledge of rhinitis, highlight its impact on asthma, provide guidance on diagnosis and treatment options, and propose a stepwise management approach. ARIA developed evidence-based guidelines in 1999 and produced additional materials to help improve rhinitis care delivery, particularly in developing countries where rhinitis prevalence is high.
This study examined the efficacy and tolerability of oral methylprednisolone (MP) in combination with amoxicillin/clavulanic acid (AMX/C) in children with chronic rhinosinusitis (CRS). 45 patients aged 6-17 years with CRS were randomly assigned to receive either oral AMX/C with MP or AMX/C with placebo for 30 days. The MP group had greater reductions in total symptom scores and CT scan scores compared to the placebo group. The MP group also had higher rates of clinical recovery and improvement. Relapse rates and adverse effects were similar between groups. This randomized controlled trial provides evidence that short-term oral MP added to AMX/C is
In acute loss of asthma contro always systemic steroidsoe add increase the do...Envicon Medical Srl
This document discusses whether escalating the dose of inhaled corticosteroids (ICS) is appropriate for acute loss of asthma control in children to reduce the need for oral corticosteroids. It presents evidence on both sides of the argument. Studies that doubled the ICS dose after asthma symptoms were established did not show benefit, but studies that substantially increased the dose early on (e.g. quadrupling the dose) found a modest reduction in need for oral steroids. However, extremely high ICS doses should be avoided due to growth suppression concerns. The definition of "loss of control" versus an actual exacerbation is also debated.
This patient presents with an acute exacerbation of asthma. She has a history of asthma and is experiencing tachypnea, shortness of breath, wheezing, and her symptoms are not relieved by her usual medications. On examination, she has tachycardia, tachypnea, use of accessory muscles, decreased breath sounds, and wheezing. Her oxygen saturation is low. Treatment should focus on aggressive use of bronchodilators and systemic corticosteroids to reverse the exacerbation. Close monitoring is needed given the severity of the presentation.
- Allergic rhinitis is a common condition affecting 10-15% of children and 26% of adults in the UK. Topical nasal corticosteroids are the first-line treatment for moderate to severe disease.
- Non-allergic rhinitis is a heterogeneous group of conditions that can present with similar symptoms to allergic rhinitis but without evidence of allergen sensitization. Triggers include medications, hormones, irritants and changes in temperature or humidity. Treatment depends on the underlying cause and may include nasal irrigation, antihistamines, decongestants or anti-inflammatory therapy.
- Low vitamin D levels and reduced expression of the vitamin D receptor on dendritic cells have been associated
Treatment of Asthma Exacerbations in the Pediatric Emergency Departmentjrhoffmann
This document discusses the treatment of asthma exacerbations in pediatric emergency departments. It begins with definitions of an asthma exacerbation and status asthmaticus. It then covers approaches to determining the severity of an exacerbation. The primary treatments discussed are bronchodilation with inhaled beta agonists and systemic corticosteroids. Delivery methods like nebulizers and metered dose inhalers are compared. Overall, the document provides an overview of assessing and treating pediatric asthma exacerbations in the emergency department.
This document provides recommendations from the British guideline on the management of asthma. It recommends that the initial assessment of asthma in both children and adults should focus on taking a thorough clinical history and considering alternative diagnoses. For those with a high probability of asthma, treatment should be started, while further testing is reserved for poor responders. For intermediate probability cases, tests like lung function and a treatment trial can help determine if a diagnosis of asthma is appropriate. Self-management education and written asthma action plans are recommended to improve health outcomes.
Stepwise Approach For Adjusting Asthma Treatment 2017 Ashraf ElAdawy
The document discusses asthma control and management. It provides tools for assessing asthma control, such as the Asthma Control Test. It identifies risk factors for exacerbations and poor outcomes. It also outlines the stepwise approach to asthma management, with Steps 1 through 5 representing increasing treatment intensity. Initial treatment is usually with a low-dose inhaled corticosteroid, but may be at a higher step depending on symptom frequency and risk factors. The preferred option for Step 3 treatment in children ages 6-11 is a medium-dose inhaled corticosteroid, while options for adults include increasing the corticosteroid dose or adding a long-acting beta-2 agonist or other controller.
- The risk of anaphylaxis following vaccination is rare, affecting less than 1 in 100,000 people. However, it can occur in any patient.
- A retrospective study found that only 3 of 135 patients who experienced allergic-like events after vaccination were referred for suspected anaphylaxis, suggesting that guidelines may overestimate the risk.
- Most allergic-like events that occur more than 1 hour after vaccination are not likely IgE-mediated reactions and should not be managed as such. Skin testing in these patients can be misleading.
Acute exacerbation of bronchial asthma dr. mukesh bhatt afpa_rdmc_06_20180422Parthiv Mehta
Exacerbation of Bronchial Asthma can be simple and easy to difficult and life threatening. This presentation is a point of view of a Family Physician with practical aspects to understand
This document provides an overview of acute asthma and recent evidence-based guidelines. It discusses the pathophysiology of asthma and clinical presentation. Updated guidelines from NAEPP, GINA, and ERS/ATS are presented which classify asthma severity and provide stepwise recommendations for pharmacological management. Key points include distinguishing between severe versus uncontrolled asthma, evaluating for treatment non-adherence and comorbidities before diagnosing severe asthma, and emphasizing environmental control and inhaler technique.
This document discusses approaches to asthma and newer modalities in treatment. It begins by defining asthma as a chronic airway inflammation disease characterized by variable respiratory symptoms. It then discusses triggers of asthma attacks and the pathophysiology involving immune cells like mast cells, basophils, and eosinophils. The document outlines the diagnostic approach including assessing symptoms, lung function testing, allergy testing, and trial of treatments. It also discusses managing asthma through a stepwise treatment approach based on symptom severity. Finally, it introduces several newer treatment modalities for asthma including allergen immunotherapy, anti-IgE therapy like Omalizumab, and long-acting bronchodilators.
Asthma is a chronic inflammatory disorder of the airways that causes recurrent wheezing, breathlessness, chest tightness and coughing. It is the most common chronic lower respiratory disease in children. This document discusses differentiating transient wheezing from asthma in young children, managing high-risk children, and prevention therapies. It also covers diagnosing and classifying asthma severity, recommended treatment steps based on severity including inhaled corticosteroids and reliever medications, and FDA-approved treatment options for children ages 4 and under.
This document summarizes common ocular allergies and their treatment. It discusses the anatomy of the eye and approaches to diagnosing itchy eyes. Common allergic diseases include allergic conjunctivitis, vernal keratoconjunctivitis, atopic dermatitis, and giant papillae conjunctivitis. Allergic conjunctivitis is caused by an IgE-mediated inflammatory response and accounts for many seasonal cases related to pollen. Treatment includes cold compresses, artificial tears, topical antihistamines, mast cell stabilizers, topical corticosteroids, and immunomodulators for severe cases.
The document summarizes the Global Initiative for Asthma's 2019 strategy for managing asthma. It outlines that asthma is a heterogeneous disease characterized by chronic airway inflammation. It then discusses asthma phenotypes, diagnosis of asthma, assessing asthma control and risk factors, and treatment options. The treatment approach involves a stepwise approach starting with low dose inhaled corticosteroids and adding additional controllers as needed to control symptoms and reduce exacerbation risk. The 2019 update emphasizes adding inhaled corticosteroids for all patients rather than short-acting bronchodilators alone due to risks of exacerbations from the latter approach.
Evidence based Management of acute severe asthmaDr Rakesh Kumar
This document provides evidence-based guidelines for the management of acute asthma exacerbations in children aged 0-18 years. It discusses the epidemiology and classification of exacerbation severity based on symptoms, signs, and functional assessment. Treatment recommendations include supplemental oxygen, short-acting beta-agonists, ipratropium bromide, corticosteroids, magnesium sulfate, and epinephrine or terbutaline for more severe cases. Inhalation delivery devices, heliox, and care for patients not responding to initial treatment are also covered.
Diagnosis & management of status asthmaticusSheela Aglecha
This document provides guidance on diagnosing and managing status asthmaticus and acute severe asthma exacerbations in children. Key points include:
1. Status asthmaticus is acute severe asthma that fails to respond to conventional therapy like inhaled beta-agonists and oral steroids.
2. Management involves 3 pillars - oxygen, nebulized beta-agonists like salbutamol, and steroids like intravenous hydrocortisone.
3. If the child does not improve with initial treatments, additional therapies may be needed like subcutaneous or intravenous beta-agonists, magnesium sulfate, or aminophylline. Mechanical ventilation could be required if the child does not respond to medical management
This document provides information on the diagnosis and management of asthma. It defines asthma, outlines its pathophysiology involving inflammation, remodeling and hyperreactivity. It discusses assessing and monitoring asthma severity, controlling contributing factors, pharmacological treatments including inhaled corticosteroids and bronchodilators, and the importance of patient education. The document also covers acute exacerbations, assessing severity and treating with oxygen, bronchodilators and corticosteroids which are the mainstay of treatment.
This document provides information on the diagnosis and management of asthma. It defines asthma as a chronic inflammatory disorder of the airways characterized by reversible airway narrowing and obstruction. The pathophysiology involves airway inflammation, wall thickening, mucus hypersecretion, and bronchial smooth muscle contraction in response to stimuli. Differential diagnoses include other lung diseases, infections, and restrictive lung disorders. Treatment involves inhaled bronchodilators and corticosteroids. Management is stepped up or down based on asthma control and severity.
This document discusses nonallergic rhinitis, specifically vasomotor rhinitis. It defines vasomotor rhinitis as chronic nasal symptoms that are not due to allergies or infections. Vasomotor rhinitis accounts for at least two-thirds of nonallergic rhinitis cases. Symptoms are triggered by factors like cold air, odors, and alcohol. While the nasal mucosa shows no inflammation, the condition involves increased reactivity to irritants and sensory nerve dysregulation. Symptoms include nasal obstruction and rhinorrhea. Treatment focuses on reducing triggers and using nasal irrigation, decongestants, and antihistamines.
This document provides information on acute rheumatic fever (ARF), including its definition, incidence, pathophysiology, diagnosis, management, and secondary prevention. ARF is an autoimmune response to Group A streptococcal infection that causes inflammation of the heart, joints, brain and skin. It predominantly affects school-aged children and those in low socioeconomic conditions. Accurate diagnosis is important to avoid over- or under-treatment. Management involves treating streptococcal infections, suppressing inflammation, and long-term antibiotic prophylaxis to prevent recurrence.
This document discusses Corynebacterium diphtheriae, the bacteria that causes diphtheria, and pertussis (whooping cough) caused by Bordetella pertussis. It covers the epidemiology, pathogenesis, clinical features, diagnosis and treatment of diphtheria and pertussis. It also discusses the diphtheria and pertussis vaccines, including vaccine formulations, efficacy, recommendations for use in adolescents and adults, and potential adverse reactions.
The ARIA initiative was developed in collaboration with the World Health Organization to provide evidence-based guidelines for diagnosing and treating allergic rhinitis. The goals of ARIA were to update healthcare professionals' knowledge of rhinitis, highlight its impact on asthma, provide guidance on diagnosis and treatment options, and propose a stepwise management approach. ARIA developed evidence-based guidelines in 1999 and produced additional materials to help improve rhinitis care delivery, particularly in developing countries where rhinitis prevalence is high.
This study examined the efficacy and tolerability of oral methylprednisolone (MP) in combination with amoxicillin/clavulanic acid (AMX/C) in children with chronic rhinosinusitis (CRS). 45 patients aged 6-17 years with CRS were randomly assigned to receive either oral AMX/C with MP or AMX/C with placebo for 30 days. The MP group had greater reductions in total symptom scores and CT scan scores compared to the placebo group. The MP group also had higher rates of clinical recovery and improvement. Relapse rates and adverse effects were similar between groups. This randomized controlled trial provides evidence that short-term oral MP added to AMX/C is
In acute loss of asthma contro always systemic steroidsoe add increase the do...Envicon Medical Srl
This document discusses whether escalating the dose of inhaled corticosteroids (ICS) is appropriate for acute loss of asthma control in children to reduce the need for oral corticosteroids. It presents evidence on both sides of the argument. Studies that doubled the ICS dose after asthma symptoms were established did not show benefit, but studies that substantially increased the dose early on (e.g. quadrupling the dose) found a modest reduction in need for oral steroids. However, extremely high ICS doses should be avoided due to growth suppression concerns. The definition of "loss of control" versus an actual exacerbation is also debated.
This patient presents with an acute exacerbation of asthma. She has a history of asthma and is experiencing tachypnea, shortness of breath, wheezing, and her symptoms are not relieved by her usual medications. On examination, she has tachycardia, tachypnea, use of accessory muscles, decreased breath sounds, and wheezing. Her oxygen saturation is low. Treatment should focus on aggressive use of bronchodilators and systemic corticosteroids to reverse the exacerbation. Close monitoring is needed given the severity of the presentation.
- Allergic rhinitis is a common condition affecting 10-15% of children and 26% of adults in the UK. Topical nasal corticosteroids are the first-line treatment for moderate to severe disease.
- Non-allergic rhinitis is a heterogeneous group of conditions that can present with similar symptoms to allergic rhinitis but without evidence of allergen sensitization. Triggers include medications, hormones, irritants and changes in temperature or humidity. Treatment depends on the underlying cause and may include nasal irrigation, antihistamines, decongestants or anti-inflammatory therapy.
- Low vitamin D levels and reduced expression of the vitamin D receptor on dendritic cells have been associated
Treatment of Asthma Exacerbations in the Pediatric Emergency Departmentjrhoffmann
This document discusses the treatment of asthma exacerbations in pediatric emergency departments. It begins with definitions of an asthma exacerbation and status asthmaticus. It then covers approaches to determining the severity of an exacerbation. The primary treatments discussed are bronchodilation with inhaled beta agonists and systemic corticosteroids. Delivery methods like nebulizers and metered dose inhalers are compared. Overall, the document provides an overview of assessing and treating pediatric asthma exacerbations in the emergency department.
This document provides recommendations from the British guideline on the management of asthma. It recommends that the initial assessment of asthma in both children and adults should focus on taking a thorough clinical history and considering alternative diagnoses. For those with a high probability of asthma, treatment should be started, while further testing is reserved for poor responders. For intermediate probability cases, tests like lung function and a treatment trial can help determine if a diagnosis of asthma is appropriate. Self-management education and written asthma action plans are recommended to improve health outcomes.
Stepwise Approach For Adjusting Asthma Treatment 2017 Ashraf ElAdawy
The document discusses asthma control and management. It provides tools for assessing asthma control, such as the Asthma Control Test. It identifies risk factors for exacerbations and poor outcomes. It also outlines the stepwise approach to asthma management, with Steps 1 through 5 representing increasing treatment intensity. Initial treatment is usually with a low-dose inhaled corticosteroid, but may be at a higher step depending on symptom frequency and risk factors. The preferred option for Step 3 treatment in children ages 6-11 is a medium-dose inhaled corticosteroid, while options for adults include increasing the corticosteroid dose or adding a long-acting beta-2 agonist or other controller.
- The risk of anaphylaxis following vaccination is rare, affecting less than 1 in 100,000 people. However, it can occur in any patient.
- A retrospective study found that only 3 of 135 patients who experienced allergic-like events after vaccination were referred for suspected anaphylaxis, suggesting that guidelines may overestimate the risk.
- Most allergic-like events that occur more than 1 hour after vaccination are not likely IgE-mediated reactions and should not be managed as such. Skin testing in these patients can be misleading.
Acute exacerbation of bronchial asthma dr. mukesh bhatt afpa_rdmc_06_20180422Parthiv Mehta
Exacerbation of Bronchial Asthma can be simple and easy to difficult and life threatening. This presentation is a point of view of a Family Physician with practical aspects to understand
This document provides an overview of acute asthma and recent evidence-based guidelines. It discusses the pathophysiology of asthma and clinical presentation. Updated guidelines from NAEPP, GINA, and ERS/ATS are presented which classify asthma severity and provide stepwise recommendations for pharmacological management. Key points include distinguishing between severe versus uncontrolled asthma, evaluating for treatment non-adherence and comorbidities before diagnosing severe asthma, and emphasizing environmental control and inhaler technique.
This document discusses approaches to asthma and newer modalities in treatment. It begins by defining asthma as a chronic airway inflammation disease characterized by variable respiratory symptoms. It then discusses triggers of asthma attacks and the pathophysiology involving immune cells like mast cells, basophils, and eosinophils. The document outlines the diagnostic approach including assessing symptoms, lung function testing, allergy testing, and trial of treatments. It also discusses managing asthma through a stepwise treatment approach based on symptom severity. Finally, it introduces several newer treatment modalities for asthma including allergen immunotherapy, anti-IgE therapy like Omalizumab, and long-acting bronchodilators.
Asthma is a chronic inflammatory disorder of the airways that causes recurrent wheezing, breathlessness, chest tightness and coughing. It is the most common chronic lower respiratory disease in children. This document discusses differentiating transient wheezing from asthma in young children, managing high-risk children, and prevention therapies. It also covers diagnosing and classifying asthma severity, recommended treatment steps based on severity including inhaled corticosteroids and reliever medications, and FDA-approved treatment options for children ages 4 and under.
This document summarizes common ocular allergies and their treatment. It discusses the anatomy of the eye and approaches to diagnosing itchy eyes. Common allergic diseases include allergic conjunctivitis, vernal keratoconjunctivitis, atopic dermatitis, and giant papillae conjunctivitis. Allergic conjunctivitis is caused by an IgE-mediated inflammatory response and accounts for many seasonal cases related to pollen. Treatment includes cold compresses, artificial tears, topical antihistamines, mast cell stabilizers, topical corticosteroids, and immunomodulators for severe cases.
The document summarizes the Global Initiative for Asthma's 2019 strategy for managing asthma. It outlines that asthma is a heterogeneous disease characterized by chronic airway inflammation. It then discusses asthma phenotypes, diagnosis of asthma, assessing asthma control and risk factors, and treatment options. The treatment approach involves a stepwise approach starting with low dose inhaled corticosteroids and adding additional controllers as needed to control symptoms and reduce exacerbation risk. The 2019 update emphasizes adding inhaled corticosteroids for all patients rather than short-acting bronchodilators alone due to risks of exacerbations from the latter approach.
Evidence based Management of acute severe asthmaDr Rakesh Kumar
This document provides evidence-based guidelines for the management of acute asthma exacerbations in children aged 0-18 years. It discusses the epidemiology and classification of exacerbation severity based on symptoms, signs, and functional assessment. Treatment recommendations include supplemental oxygen, short-acting beta-agonists, ipratropium bromide, corticosteroids, magnesium sulfate, and epinephrine or terbutaline for more severe cases. Inhalation delivery devices, heliox, and care for patients not responding to initial treatment are also covered.
Diagnosis & management of status asthmaticusSheela Aglecha
This document provides guidance on diagnosing and managing status asthmaticus and acute severe asthma exacerbations in children. Key points include:
1. Status asthmaticus is acute severe asthma that fails to respond to conventional therapy like inhaled beta-agonists and oral steroids.
2. Management involves 3 pillars - oxygen, nebulized beta-agonists like salbutamol, and steroids like intravenous hydrocortisone.
3. If the child does not improve with initial treatments, additional therapies may be needed like subcutaneous or intravenous beta-agonists, magnesium sulfate, or aminophylline. Mechanical ventilation could be required if the child does not respond to medical management
This document provides information on the diagnosis and management of asthma. It defines asthma, outlines its pathophysiology involving inflammation, remodeling and hyperreactivity. It discusses assessing and monitoring asthma severity, controlling contributing factors, pharmacological treatments including inhaled corticosteroids and bronchodilators, and the importance of patient education. The document also covers acute exacerbations, assessing severity and treating with oxygen, bronchodilators and corticosteroids which are the mainstay of treatment.
This document provides information on the diagnosis and management of asthma. It defines asthma as a chronic inflammatory disorder of the airways characterized by reversible airway narrowing and obstruction. The pathophysiology involves airway inflammation, wall thickening, mucus hypersecretion, and bronchial smooth muscle contraction in response to stimuli. Differential diagnoses include other lung diseases, infections, and restrictive lung disorders. Treatment involves inhaled bronchodilators and corticosteroids. Management is stepped up or down based on asthma control and severity.
This document discusses nonallergic rhinitis, specifically vasomotor rhinitis. It defines vasomotor rhinitis as chronic nasal symptoms that are not due to allergies or infections. Vasomotor rhinitis accounts for at least two-thirds of nonallergic rhinitis cases. Symptoms are triggered by factors like cold air, odors, and alcohol. While the nasal mucosa shows no inflammation, the condition involves increased reactivity to irritants and sensory nerve dysregulation. Symptoms include nasal obstruction and rhinorrhea. Treatment focuses on reducing triggers and using nasal irrigation, decongestants, and antihistamines.
This document provides information on acute rheumatic fever (ARF), including its definition, incidence, pathophysiology, diagnosis, management, and secondary prevention. ARF is an autoimmune response to Group A streptococcal infection that causes inflammation of the heart, joints, brain and skin. It predominantly affects school-aged children and those in low socioeconomic conditions. Accurate diagnosis is important to avoid over- or under-treatment. Management involves treating streptococcal infections, suppressing inflammation, and long-term antibiotic prophylaxis to prevent recurrence.
This document discusses Corynebacterium diphtheriae, the bacteria that causes diphtheria, and pertussis (whooping cough) caused by Bordetella pertussis. It covers the epidemiology, pathogenesis, clinical features, diagnosis and treatment of diphtheria and pertussis. It also discusses the diphtheria and pertussis vaccines, including vaccine formulations, efficacy, recommendations for use in adolescents and adults, and potential adverse reactions.
This document discusses common pediatric infections, focusing on acute otitis media (AOM) and acute bacterial sinusitis (ABS). It provides diagnostic criteria and treatment guidelines for AOM and ABS according to evidence-based clinical practice guidelines. Key points covered include common pathogens, initial antibiotic treatment options, and non-antibiotic approaches for managing symptoms. Review questions at the end test the reader's understanding of diagnosing and treating these common pediatric infections.
This document discusses common pediatric infections, focusing on acute otitis media and acute bacterial sinusitis. It provides guidelines for diagnosing and treating these conditions, including recommended antibiotic therapies. Key points covered include the most common bacterial pathogens for each infection, criteria for observation versus antibiotic treatment of otitis media, and emphasizing a clinical diagnosis over diagnostic testing for sinusitis.
Allergic Rhinitis is an inflammatory disorder of the nasal mucosa caused by an IgE-mediated response to allergens. It is characterized by symptoms like sneezing, rhinorrhea, nasal congestion and pruritus. Onset is often in childhood or adolescence. While symptoms may improve with age, allergic rhinitis can develop or persist at any age. It is associated with conditions like asthma, sinusitis and otitis media. Management involves allergen avoidance, pharmacotherapy and immunotherapy. Second generation antihistamines are first line treatment but adding a leukotriene receptor antagonist provides additional relief, especially for nasal congestion. Intranasal corticosteroids are also
Allergic Rhinitis is an inflammatory disorder of the nasal mucosa caused by an IgE-mediated response to allergens. It is characterized by symptoms like sneezing, rhinorrhea, nasal congestion and pruritus. Allergic Rhinitis can negatively impact quality of life and productivity. It commonly begins in childhood or adolescence. While symptoms often improve with age, the disorder can develop or persist at any age. Treatment involves allergen avoidance, pharmacotherapy including antihistamines, intranasal corticosteroids and leukotriene inhibitors, as well as immunotherapy. Combination therapy with a second-generation antihistamine and montelukast has been shown to more effectively treat
The document outlines terms of use for an educational slide set on acute sinusitis. It specifies that the slides remain the copyrighted property of the American College of Physicians and may only be used for nonprofit educational activities. Users can incorporate slides into their own presentations but may not alter the content or remove the copyright notice. Print copies can be made for handouts but broader reproduction or distribution requires permission. Unauthorized use constitutes copyright infringement.
Pharmacotherapy of Asthmatic patient in hospitalAhmanurSule5
This document provides an overview of asthma, including:
1. It defines asthma as a chronic inflammatory airway disorder characterized by reversible airway obstruction.
2. Environmental triggers and allergens can cause asthma symptoms by inducing inflammation and bronchospasm.
3. Treatment involves controlling inflammation with inhaled corticosteroids and bronchodilation with inhaled beta-agonists for acute symptoms and prevention of exacerbations.
4. Proper inhaler technique and patient education are important for effective asthma management.
The document discusses asthma, including its causes, symptoms, diagnosis, classification, and treatment. Asthma affects 7-10% of the population and is caused by inflammation of the airways. Symptoms include coughing, shortness of breath, wheezing, and chest tightness. Diagnosis involves assessing medical history, lung function tests, and checking for allergies. Asthma is classified based on severity and control. Treatment ranges from short-acting bronchodilators for mild intermittent asthma to high-dose corticosteroids for severe persistent asthma.
Typhoid fever is caused by the bacterium Salmonella typhi. It infects the gastrointestinal tract and can spread to the liver and spleen. Symptoms include prolonged fever, abdominal discomfort, and rose-colored spots on the skin. Complications can involve the intestines, brain, or other organs. Diagnosis involves culturing the bacteria from blood or bone marrow. Treatment consists of antibiotics like fluoroquinolones or azithromycin. Vaccines can help prevent typhoid in areas where it is common. Ongoing issues include increasing antibiotic resistance and the need for improved diagnostic tests.
The document discusses guidelines for antibiotic use in pediatric respiratory illnesses such as sinusitis, otitis media, and tonsillitis. It provides diagnostic criteria and treatment recommendations for these conditions, emphasizing watchful waiting and judicious antibiotic use. Key points include only prescribing antibiotics for certain cases of acute otitis media and sinusitis based on severity, using penicillin as first line treatment for strep throat, and not using imaging to diagnose acute bacterial sinusitis. The goal is to reduce unnecessary antibiotic use and prevent antibiotic resistance.
Management of severe asthma an update 2014avicena1
This document discusses the management of severe asthma. It begins by defining several phenotypes of severe asthma, including refractory asthma and steroid-dependent asthma. It then reviews the diagnostic criteria for severe asthma established by the American Thoracic Society and European Respiratory Society, which requires one or more major criteria and two or more minor criteria. The document further discusses approaches to diagnosing and treating severe asthma, including evaluating for alternative diagnoses, assessing treatment compliance and triggers, addressing comorbidities, and considering immunotherapy options. It emphasizes the importance of phenotyping and endotyping asthma to enable personalized treatment approaches.
1. Asthma is a chronic inflammatory disorder of the airways that affects 15-20 million people in India. It is characterized by airway hyperresponsiveness and inflammation.
2. Proper diagnosis involves assessing patient history of symptoms, performing a physical exam, and measuring lung function through methods like peak flow meters. Treatment involves a stepwise approach using reliever and preventer medications.
3. Relievers provide quick symptom relief but are not for regular use. Preventers help control inflammation and symptoms over the long-term and include inhaled corticosteroids, long-acting beta-agonists, and other drugs. Combination inhalers containing both a preventer and reliever are often ideal
Asthma is a chronic inflammatory disease of the airways characterized by variable airflow obstruction that is usually reversible. It affects people of all ages but predominantly early in life. The prevalence of asthma is approximately 10-12% of the population and it is both common and exacerbated by smoking. Diagnosis involves demonstrating variable airflow obstruction and its reversibility via spirometry and peak flow measurement. Management focuses on avoidance of triggers, bronchodilators for acute exacerbations, and inhaled corticosteroids for chronic control. Chronic obstructive pulmonary disease (COPD) is a progressive lung disease characterized by airflow limitation that is not fully reversible. Risk factors include cigarette smoking and occupational exposures. Symptoms include cough, sputum production and
1) The document provides interim management protocols for children with confirmed COVID-19 infection from the Department of Pediatrics at AIIMS in New Delhi.
2) It outlines guidelines for managing mild, moderate, severe, and critical COVID-19 cases as well as protocols for home isolation, monitoring of symptoms, and discharge criteria.
3) The document also provides guidance on managing multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, including criteria for evaluation and treatment recommendations.
This document summarizes information on allergic rhinitis and sinusitis. It discusses the pathophysiology, symptoms, diagnosis and management of allergic rhinitis. Intranasal corticosteroids are identified as the most effective treatment. It also covers the diagnosis and treatment of acute and chronic sinusitis, including complications. Imaging such as CT is recommended for complicated cases or recurrent sinusitis.
This document discusses bronchial asthma, including its definition, prevalence, etiology, triggers, pathogenesis, clinical features, classification of severity, diagnosis, investigations, management, pharmacotherapy, acute severe asthma/status asthmaticus, and considerations for dental treatment of asthmatic patients. Key points include that asthma is a chronic inflammatory disease characterized by reversible airway obstruction, it affects over 300 million people worldwide, treatment involves bronchodilators, corticosteroids, leukotriene antagonists and others to control symptoms and exacerbations, and special precautions should be taken when providing dental care to asthmatic patients to prevent triggering an attack.
1) Pharyngo-tonsillitis refers to inflammation of the pharynx and/or tonsils that can be caused by viruses or bacteria. Clinical features include fever, sore throat, and tender lymph nodes.
2) Differentiating between viral and bacterial causes based on symptoms alone is difficult, but bacterial causes are more likely if the patient presents with purulent tonsils, toxic appearance, and severe throat pain.
3) Management involves symptomatic relief and considering rapid antigen detection tests or throat culture if antibiotics are warranted. For confirmed bacterial infections, penicillin is recommended for 10 days to prevent complications like rheumatic fever.
This document discusses asthma, including its definition, prevalence, risk factors, pathophysiology, diagnosis, classification, treatment goals, and management. Some key points:
- Asthma is a chronic inflammatory airway disorder affecting over 17 million people in the US. It is characterized by recurrent wheezing, coughing, and breathlessness.
- Risk factors for developing asthma include respiratory infections, allergens, environment, emotions, exercise, drugs/preservatives, and occupational stimuli.
- Diagnosis involves patient history, physical exam, pulmonary function tests, and trial of asthma medications. Severity is classified based on lung function and symptoms.
- Treatment goals are to control symptoms, prevent exacerbations,
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. “When we consider the quality of life impact from
RS related symptoms and the associated emotional
and functional impairments it can be assumed that
RS has a dramatic impact on peoples lives and in
productivity of life.”
8. Infection
Acute( 7 days to <4wks)
Viral (majority of cases)
Subacute(4-12wks)
Chronic(>12wks)
Recurrent acute – 4 or more episodes per year, with resolution of
symptoms between attacks
Acute Exacerbation of Chronic- Sudden worsening of CRS with
return to baseline after
12. Allergic Rhinitis
Allergen avoidance
Antihistamines:
First generation mostly avoided d/t sedative
psychomotor retardation and learning impairment d/t
BBB crossing nature of it as compared to
Cetrizine,Fexofenadine,desloratidine .Also possess some
antiinflammatory effect
Topical Glucorticosteroid:
Best is started before allergen exposure .
Reduce inflammation,hyperreactivity and sense of smell
13. Sodium chromoglycate :
Used for children below 4 yrs in whom topical
corticoseroid is not used often
Decongestants:
Reduce nasal obstruction but long term use might
cause rhinitis medicamentosa
Ipratropium bromide:
Symptomatic relief in rhinorrhea but careful use in
glaucoma and prostatism and might worsen dry
eyes and mouth
14. Systemic Corticosteroids
Occasional intermittent use combined with topical CS
Antileukotrienes:
Effective against congestion and mucus
production.Combined with antihistamine has better
benefits.
Nasal douching :
Helps provide symptomatic relief and clear up the
sinuses
15. Immunotherapy:
Only in selective patients with limited spectrum of
allergies
~ 40% reduction in symptoms and ~80% reduction in
rescue medication requirements
Also helpful in associated bronchial Asthma
Nevertheless patients with chronic Asthma are
excluded from the treatment due to risk of many
side effects
16. Inclusion criteria
IgE-mediated disease
(+SPT/RAST)
Inability to avoid allergen
Inadequacy of drug
Limited spectrum of
allergies (one or two)
Patients who understand
risks and limitations of
treatment
Contraindications
Coexistent asthma
Patients taking beta-
blockers
Other
medical/immunologic
Small children (less than
five years)
Pregnancy (maintenance
therapy may be continued
in pregnancy)
17. Novel advances
Sublingual immunotherapy
Bacterial DNA sequences conjugated with allergen
induces preferential TH1 response and protective T
cell response
18. Surgery:
Very limited role and required only in conditions
where there is marked septal deviation or bony
turbinate enlargement which makes topical nasal
sprays usage difficult.
21. Children Adults
Streptococcus pneumoniae (30-43%)
Haemophilus influenzae (20-28%)
Moraxella catarrhalis (20-28%)
Other Streptococcus species (5-7%)
Anaerobes(5-7%)
Streptococcus pneumoniae (20-43%)
Haemophilus influenzae (22-35%)
Streptococcus species (3-9%)
Anaerobes (0-9%)
Moraxella catarrhalis (2-10%)
Staphylococcus aureus (0-8%)
Others(4%)
22. Common for all types of Acute RS:
Hydration
Long-acting topical nasal decongestant
Nasal saline applied with nasal irrigation
device
Topical nasal CCS
23.
24. Antibiotics in Acute bacterial
rhinosinusitis
Don’t treat common viral cold with antibiotic
Reserve for severe, presumably bacterial
Rhinosinusitis
symptoms past 7-10 days:
Antibiotics X 7-14 days (until asymptomatic +5-7 days).
Choices:
Amoxicillin/clavulanate, Cephalosporin, Clarithromycin
25. First choice:
Amoxicillin/clavulate or cephalosporin
Good second choice: Clarithromycin
(Azithromycin, 5-0-(5), may also be quite useful)
Back-ups:
Quinolones
Use Metronidazole plus one of the above or
clindamycin when gram negative is suspected
Topical mupirocin very useful in select cases
26. EPOS JTFPP CPG AS
Uncomp
icated
AVRS
Mild Disease-
Symptoms lasting <5d or
improving thereafter
Decongestants ,Saline or
analgesics
Moderately severe-
Symptoms lasting >.5d or
increasing
Add topical corticosteroids
If no improvement after 14
d
Reconsider rediagnosis
Consider nasal endoscopy
Culture/imaging
Consider antibiotics if
necessary
Severe Disease-
Severe pain and temp >38
Add antibiotics and topical
corticosteroids for 7-14 days
(expected results in 48 hrs)
7-10 days course of
watchful waiting
Antibiotics are
strongly
discouraged
Management primarily
symptomatic
Analgesics and
antipyretics
Oral or topical
decongestants
Topical nasal
CS(Optional)
27. EPOS JTFFP CPG AS
Uncomplicate
d ABRS
Mild Disease-
Symptoms lasting <5d or
improving thereafter
Decongestants ,Saline or
analgesics
Moderately severe-
Symptoms lasting >.5d or
increasing
Add topical corticosteroids
If no improvement after 14 d
Reconsider rediagnosis
Consider nasal endoscopy
Culture/imaging
Consider antibiotics if
necessary
Severe Disease-
Severe pain and temp >38
Add antibiotics and topical
corticosteroids for 7-14 days
(expected results in 48 hrs)
Antibiotics 10-14 d
Choice of agent
based on likely
pathogen consistent
with clinical history
Consider patients
with severe signs
and symptoms at
any time of the
disease (worsening
after 3-5
days,temp>38,
severe facial
pain,unilateral facial
swelling ,sinus
tenderness)
Assess pain and
analgesics
accordingly
Watchful waiting (
without antibiotic i
symptom< 7d)or
mild disease or if pt
likely to F/U
Initiate Antibiotics i
no improvement
after 7d or if it
worsen (Amoxy firs
line)Antibiotics if
severe disease
Antihistamine
Donot use if
nonatopic
symptomatic relief i
recommended
28. EPOS JTFFP CPS AG
ARS in general Intranasal
corticosteroids
Oral CS in severe
disease
Antihistamines
only in allergic
and
Decongestants
Intranasal CS
modestly
benefitial as
adjunctive
therapy in
patients with
reccurent disease
Antihistamines
No data to
recommend use
Topical oral
decongestants
Do not use since
prospective study
ecaluating use are
lacking
Topical CS
optional
Decongestant
optional
Nasal saline
irrigation
optional
29. Conclusion
Guidelines promulgated by 5 major groups regarding
acute rhinosinusitis (ARS)
The efficacy of intranasal corticosteroids has been well
established by clinical trial data, and guidelines advise
their use in ARS
Physicians have been overusing antibiotics which has
been playing a role in resistance
30. The aim of treatment is to reduce signs and
symptoms ,quality of life of patient and prevent the
recurrence.
31. Chronic inflamed mucosa
Neutrophils and mononuclear cells in CRSsNP
Eosinophils in CRSwNP
Possible chronic infection
Bacteria
Fungi
Superantigens
Biofilms
Osteitis
32. Children Adults
Anaerobes
Other Streptococcus species
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Anaerobes
Other Streptococcus species
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pneumoniae
Moraxella catarrhalis
Common organisms in CRS
34. Treatment
Few well-conducted clinical trials in chronic
rhinosinusitis. Further studies are needed in well-
characterized patients.
Based on the evidence available initial therapy is
medical
Aim to reduce symptoms and signs decrease
morbidity and prevent disease progression or
recurrence.
CRS usually responds incompletely to therapy and
may need to be continued long-term
35. Hydration (6 - 8 glasses of water per day)
Antibiotics only if clear evidence of infection: use X 14-21+
days (until asymptomatic +7 days).
Choices: cephalosporin, amoxicillin/clavulanate,
clarithromycin, quinalone
Long-acting nasal decongestant, BID X 3-7 days
(oxymetazoline)
Nasal saline with nasal irrigation device
Topical nasal CCS
Reduce to lowest effective dose, to maintain remission
36. Prevalence approx. 2- 4%, 25% of CRS
Asthma in approx. 40-65%
Aspirin sensitivity in 10-15%
Mixed cellular infiltrate with
prominent eosinophilia in 90%
Inflammation with
local IgE production
increased IL-5, eotaxin,
cys-LTs and ECP
37.
38. Treatment of underlying condition
Continue treatment of sinusitis
Topical corticosteroids
Pulmicort, budesonide
Budesonide solution (Pulmicort Respules)
Fluticasone (Flovent
Systemic corticosteroids
Prednisone 20-30 mg
Kaliner MA. Current Review of Allergic Diseases. Philadelphia, Pa: Current Medicine, Inc., 1999.
39. Antibiotics
Long term prophylaxis with macrolids group of
drug (8 wks )found to reduce the polyp size ot 50%
in 21 patients and better response in ptns with
normal IgE levels and inversely proportional in
eosinophil count in blood and mucosa
40. Mupiricin ointment
Topically or dissolved in sinus lavage
Consider oral or topical anti-fungal treatment
Possible benefits in paediatric Upper airway infcetion
Needs more studies
Polypectomy
41. Medical polypectomy
All patients should have a trial of medical treatment
before surgery unless the nature of the polyps is in doubt.
Smaller polyps may respond to topical corticosteroid
only.
Larger polyps may respond to a medical polypectomy
42. Medical polypectomy
Prednisolone 0.5mg/kg each morning for 5–10 days
PLUS Betamethasone nasal drops two drops per nostril
tds in the ‘head upside down’ position for 5 days, then
twice daily until the bottle runs out
Maintenance therapy with fluticasone (drops, spray) or
mometasone (spray) is recommended as these have lower
bioavailability, unlike betamethasone nasal drops .
43. All forms of topical INS may delay the re-growth of nasal
polyps. Polyps tend to recur, and it is recommended that
treatment is continued for the long-term.
However, no evidence for how long treatment should be
continued although this will vary, with more aggressive
inflammatory polyps rich in eosinophils and IL-5
requiring prolonged treatment.
44. Surgery
A randomized prospective study of patients with polypoid
or non-polypoid CRS demonstrated that there was no
difference between patients who received medical
treatment (topical corticosteroid, nasal douching and long-term erythromycin)
compared with those who underwent endoscopic sinus
surgery combined with topical nasal steroids.
, Clinical and Experimental)
47. Allergen avoidance
There is no strong evidence regarding its
effectiveness in CRS but mostly in cases with
positive allergic history together with positive SPT it
might be useful.
48. Nasal douching
Safe, inexpensive,symptomatic relief
Adverse events
Sodium load should be considered in hypertensive
patients.
Place in therapy
Addition to therapy in chronic rhinosinusitis, nasal
polyposis and rhinitis. Effective in primary ciliary
dyskinesia
49. Neti pots
The Neti pot originated in India in Ayurvedic medicine.(
VALIDATED BY SCIENTIFIC EVIDENCE) Neti is Sanskrit for “nasal
cleansing.”
Nasal irrigation provides short-term symptomatic relief
and may improve nasal mucociliary clearance. It removes
mucus not only from the nose but also from the maxillary
and ethmoid sinuses.
BUT one should be careful not to overdo it.
50.
51.
52. Topical intra-nasal corticosteroids
Act by suppression of inflammation at multiple points in the
inflammatory cascade .
Nasal drops are preferable for nasal polyposis and probably
also for chronic rhinosinusitis.
These should be used in the ‘head upside down’ position in order to reach the
ostiomeatal complex (OMC),
50% of ptns not responding to topical sprays are responsive to
fluticasone nasules
55. Place in therapy
First-line therapy for rhinosinusitis. Topical steroid
drops should be used initially in nasal polyposis and in
cases with severe obstruction.Routinely used in long term
and reduce the recurrence of nasal polyps.
A suggested regime for adults is 0.5mg/kg
56. Used for:
Severe nasal obstruction
Short-term rescue medication for uncontrolled
symptoms on conventional pharmacotherapy
59. Intra-nasal decongestants.
The a1-agonist ephedrine and a2-agonist xylometazoline
are sympathomimetics( increase nasal vasoconstriction).
Combined with a topical corticosteroid such as Dexa-
Rhinaspray duoTM, short term use is helpful in
exacerbations of rhinosinusitis with nasal blockage
60. Adverse events
Regular use can lead to rhinitis medicamentosa with
tachyphylaxis rebound effect.Nasal irritation may increase
rhinorrhoea.
Place in therapy
Brief use of 10 days is advised
o To avoid rebound effect for eustachian tube dysfunction
when flying
o In children with acute otitis media to relieve middle ear
pain/pressure post –URTI
o To reduce nasal/sinus congestion
o To increase nasal patency before the intranasal administration
of nasal steroids.
61. Antibiotics
Role in CRS is still controversial
Two routes;
Topical –Abandoned due to incidence of hyposmia but use
of tobramycin instilled into maxillary sinuses in cystic
fibrosis is helpful
Benefitial in upper airway diseases in children
Short-term (2 weeks) can be used for AE of rhinosinusitis
with or without the guidance of middle meatal swabs
62. Long term prophylaxis
Trials of long-term oral antibiotics (>12 weeks), especially
macrolides, have demonstrated symptomatic and objective
improvement similar to endoscopic sinus surgery
Reduction in mortality from diffuse panbronchitis and
improved sinus symptoms
The improvement shown increases with time and may
relate to anti-inflammatory reactions in macrolides.
63. Anti-leukotrienes
There are no RCTs on the use of anti-leukotrienes in
rhinosinusitis, but efficacy in nasal polyposis has been
demonstrated.(`50 %respond to some degree)
Adverse events
Usually well tolerated; occasional headache,
gastrointestinal symptoms or rashes. Occasional reports
of Churg-Strauss syndrome which may relate more to
steroid withdrawal rather than a direct effect of the drug,
although further long-term evaluation is needed.
64. Place in therapy
Anti-leukotrienes may be used in patients with aspirin-
sensitive rhinosinusitis, asthma and nasal polyposis. Some
patients with aspirin sensitivity appear to show marked
improvement.
65. Aspirin desensitisation
Oral aspirin desensitization followed by regular daily
dosing may cause significant improvement.
There is some evidence suggesting that oral doses as low
as 100mg daily maybe effective and this could potentially
circumvent some of the adverse effects associated with
oral aspirin.
However, side-effects including gastrointestinal bleeding
at high doses .The efficacy of the regular administration of
topical intranasal lysine aspirin therapy remains under
investigation.
66. Nasal
Lysine aspirin the soluble aspirin used for diagnosis
of aspirin sensitivity has found to have resulted into
prolonged polyp free interval in both aspirin
sensitive and aspirin tolerant patients.
It has shown to be associated with reduction of
cysteinyl leukotriene receptors which are
upregualted in nasal mucosa of aspirin sensitive
individuals.
67. Immunotherapy
Immunoglobulin replacement therapy in humoral
deficiency syndromes( frank hypogammaglobinemia
to IgA and other subclasses deficiencies)
Bacterial vaccines
Used previously but no strong evidence of benefitial
effect
68. Other therapies
Diuretics
Frusemide found to reduce the recurrence of polyps
if administered nasally to post polypectomy patients
over a prolonged periods
Similarly amiloride used in cystic fibrosis also
suggested as topical therapy for nasal polyps
69. Azelastine:
An open study suggests that this may have some benefit in
nasal polyposis
Nitric Oxide donors:
NO has bactericidal properties and is manufactured inPNS.
NO levels are raised in inflammation but decreased in
CRSprobabaly due to ostiomeatal complex obstruction.
hence increased. NO levels is a landmark for successful
therapy.
eg.Arginine
71. In case of ocupational ,food induced,drug induced,irritant
induced avoidance of the causitive factor
Intranasal anticholinergics (Ipratropium bromide)
Nasal decongestants
Topical steroids and antihistamines
Azelastine
Silver nitrate and botulinum if no response to conventional
therapy
Intranasl capsacain once daily for 5 weeks
Surgical aproach if turbinate hypertrophy with resistant with
medical response
Ethmoid and Vidian neurectomies
72. Allergic fungal sinusitis
Aggressive nasal Rx
Budesonide nasal washings, 500 ug BID
Itraconazole, oral
100 mg BID x 6 months
100 mg QD x 12 months
Monitor LFT, IgE Q 3 mos
Consider surgery if unresponsive
Surgery with the removal of all affected tissue, followed by
topical corticosteroids
73. Fungal rhinosinusitis
Open studies of douching with antifungals such as
amphotericin have been reported as beneficial
Antifungals
Placebo-controlled trials of amphotericin nasal
douching are negative .
Oral terbinafine has also failed to show any activity
under double-blind conditions
74. Churg-Strauss syndrome
This is a combination of severe asthma, nasal polyposis,
eosinophilia and eosinophilic vasculitis with granulomas.
It should be suspected in patients with severe disease
requiring frequent courses of oral corticosteroids.
About 50% of patients are ANCA positive.). If the
diagnosis of Churg-Strauss syndrome is suspected,
specialist referral to a vasculitis clinic is advisable for
further mangement
77. Hereditary syphillis
Local cleansing
Yellow mercury oxide oint.
Nasal douching
Antisyphillitic medication
Leprosy
Direct intranasal administration of rifampin reduce
M.Leprae load much faster than when given orally
Rifamicin 600mg first 2 days on alternate days three times
aweek
Clofazimine 100mg alternate day three times a week
Dapsone 100mg daily
78. Atrophic Rhinitis
Regular nasal cleansing
Nasal douching with hypertonic alkaline saline
(sodium bicarb:Sodium diborate:sodium chloride)1;1;2 in
280 ml of water followed by solution of 25 percent glucose
in glycerine to inhibit proteolytic organisms
Human placental extract systemically and locally
Rifampicin 600mg oral for 12 weeks good results
79. Underlying diseases(Cystic fibrosis,Wegners
granulomatosis)
Azathioprine ,cyclophosphamide or cotrimoxazole in
addition to the symtomatic management
80. Structural
Obstruction of Osteomeatal complex
Decongestant
Nasal douching
Topical CS
Review at 6 wks
81. Further medical therapy
Oral CS few days plus Topical for long term
For nasal polyposis
Trial of leukotriene for nasal polyposis
Antibiotics
Aspirin
82. Rhinosinusitis in children
Common problem;may be related to underlying immune
deficiency (innate or acquired) or to allergy
Like OME, usually resolves with maturation (~7 years)
Medical treatment including douching should be instigated, with
surgery reserved for acute severe problems or for those patients
with severe chronic symptoms not responding to medical therapy
.
83.
84. Few clinial studies in Rhinosinusitis and their
guidelines brief comparision
85. EPOS
CRSsNP
Mild(VAS 0-3)
Topical CS
Nasal Lavage if failure after 3 months treat as moderate
or severe
Moderate /severe(VAS >3-10)
Topical CS
Nasal lavage
Longterm macrolide therapy
Culture
Cases that improve
Follow up + nasal lavage ,topical CS +/- long term
macrolide therapy
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
86. CRScNP
Mild (VAS 0-3)
TopicalCS sprayfor 3 months
if benefitial continue and review every 6 months
If no improvement ,add short course of oral CS
If still n oimprovement ,consider CT assess as
surgical candidate
If improved after 1 month switch to topical CS
drops,review after 3 months
87. Moderate (VAS 3-7)
Topical CS drops for 3 months
if beneficial continue and review every 6 months
If no improvement after 3 m ,add short course of oral CS
If still no improvement ,consider CT and evaluate as
surgical candidate
If improved after 1 month switch to topical CS drops
88. Severe (VAS >7-10)
Short course of oral CS +topical CS for 1 month
If beneficial topical CS drops only and review after 3
months
If no improvement consider CT and evaluate as
surgical candidate
89. JTTFP
Antibiotics:
Role is controversial; may be useful for acute exacerbation of chronic
disease
Intranasal corticosteroids:
May be modestly beneficial as adjunctive therapy
Antihistamines:
Possible role in CRS if underlying risk factor is allergic rhinitis
Topical and oral decongestants:
Prospective studies evaluating use are lacking
Antifungal agents:
Role has not yet been established
90. Take preventive measures to minimize symptoms and exacerbations of
CRS
Saline nasal irrigation
Good hand hygiene to prevent acute viral RS
Assess the patient for factors that could modify management
(eg, allergic rhinitis, cystic fibrosis, immunocompromised state,
ciliary dyskinesia, anatomic variation)
91. Conclusion
Guidelines promulgated by different groups regarding CRS are not in
complete agreement regarding best practices
The efficacy of intranasal CS has been well established by clinical trial data,
and guidelines advise their use in CRS
Physicians have been overusing antibiotics which has been playing a role in
resistance
There has been a push for clinical trials examining CRS with nasal polyposis,
CRS without nasal polyposis, and allergic fungal rhinosinusitis as distinct
entities; however, few such trials have been conducted to date, and more
data are needed to help clinicians treat these conditions appropriately.
The value of antibiotics for treatment of CRS is still unproven
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