Upper respiratory tract Upper respiratory tract InfectionInfection

Upper respiratory tract InfectionUpper respiratory tract Infection

Causes: Most URIs are viral in origin. More than 200 different viruses are known to cause the common cold.

Most viral agents that cause Rhinoviruses cause approximately 30-50% of colds in adults. The

y grow optimally at temperatures near 32.8°C (91°F), which is the temperature inside the human nares.

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.

Enteroviruses, including coxsackieviruses, echoviruses, and others, are also leading causes of common colds.

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

A viral URTI can be complicated by secondary bacterial infections

Group A streptococci (approximately 15% of all cases of pharyngitis) Group A streptococci (approximately 15% of all cases of pharyngitis) Group A beta hemolytic streptococci (GABHS)Group A beta hemolytic streptococci (GABHS)

Group C and G streptococci Group C and G streptococci N gonorrhoeaeN gonorrhoeae Arcanobacterium (Corynebacterium) hemolyticumArcanobacterium (Corynebacterium) hemolyticum Corynebacterium diphtheriaeCorynebacterium diphtheriae Atypical bacteria, eg, Atypical bacteria, eg, M pneumoniaeM pneumoniae and and C pneumoniaeC pneumoniae (However, a (However, a

bsent lower respiratory tract disease, the clinical significance of these bsent lower respiratory tract disease, the clinical significance of these pathogens is uncepathogens is unce44rtain.) rtain.)

Anaerobic bacteriaAnaerobic bacteria

acute respiratory infections

symptoms –cough, sore throat, and acute nasal/sinus congestion

Acute Respiratory Illness

Acute Nasal/Sinus Congestion

CoughSore Throat

PATHOPHYSIOLOGYPATHOPHYSIOLOGY Viruses cause most URIs, with rhinovirus, parainfluenza virus, corViruses cause most URIs, with rhinovirus, parainfluenza virus, cor

onavirus, adenovirus, respiratory syncytial virus, coxsackievirus, aonavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenza virus accounting for most cases. cause 5% to 10% of nd influenza virus accounting for most cases. cause 5% to 10% of cases of pharyngitis in adults. Other less common causes of bactecases of pharyngitis in adults. Other less common causes of bacterial pharyngitis include group C beta hemolytic streptococci, rial pharyngitis include group C beta hemolytic streptococci, CorynCorynebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium ebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniaehaemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae, and herpes simplex virus. , and herpes simplex virus. Streptococcus pneumoniae, HaemophStreptococcus pneumoniae, Haemophilus influenzaeilus influenzae, and , and Moraxella catarrhalisMoraxella catarrhalis are the most common or are the most common organisms that cause bacterial superinfection of viral acute sinusitis. ganisms that cause bacterial superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniaeBordetella pertussis, B. parapertussis, M. pneumoniae, or , or C. pneuC. pneu

moniaemoniae (TWAR). (TWAR). Direct invasion of respiratory epithelium resuDirect invasion of respiratory epithelium results in symptoms respective to the area or areas involved. lts in symptoms respective to the area or areas involved.

Transmission of organisms causingTransmission of organisms causingURIs occurs by aerosol, droplet, or direct hand-to-hand contact with infected URIs occurs by aerosol, droplet, or direct hand-to-hand contact with infected secretions, with subsequent passage to the nares or eyes.8secretions, with subsequent passage to the nares or eyes.8

Upper respiratory tract InfectionUpper respiratory tract Infection

The Nasal cavityThe Nasal cavity - Rhinitis Inflammation of the nasal mucosa - Rhinitis Inflammation of the nasal mucosa

- Rhinosinusitis, sinusitis Inflammation of the nares - Rhinosinusitis, sinusitis Inflammation of the nares and paranasal sinuses, including frontal, ethmoid, and paranasal sinuses, including frontal, ethmoid,

maxillary, and sphenoid maxillary, and sphenoid Nasopharyngitis (rhinopharyngitis or the common Nasopharyngitis (rhinopharyngitis or the common

- cold) - cold) Inflammation of the nares, pharynx, hypo Inflammation of the nares, pharynx, hypo pharynx, uvula, and tonsils pharynx, uvula, and tonsils

- Pharyngitis Inflammation of the pharynx, hypoph - Pharyngitis Inflammation of the pharynx, hypoph arynx, uvula, and tonsils arynx, uvula, and tonsils

- Epiglottitis (supraglottitis) Inflammation of the su - Epiglottitis (supraglottitis) Inflammation of the su perior portion of perior portion of the larynx and supraglottic area the larynx and supraglottic area

- Laryngitis Inflammation of the larynx - Laryngitis Inflammation of the larynx - Laryngotracheitis Inflammation of the larynx, trac - Laryngotracheitis Inflammation of the larynx, trac

hea, and subglottic area hea, and subglottic area - Tracheitis Inflammation of the trachea and subglo - Tracheitis Inflammation of the trachea and subglo

ttic area ttic area

The Nasal cavityThe Nasal cavityPresenting symptoms Pain and tenderness

over sinuses Headache Mucopurulent nasal

discharge (>7-10 days) Stuffy nose Facial pressure

Symptoms of Sinusitis Symptoms of Sinusitis Symptoms specific for frontal sinus infectionSymptoms specific for frontal sinus infection

Tender foreheadTender forehead Symptoms specific for maxillary sinus infectionSymptoms specific for maxillary sinus infection

Aching upper jawAching upper jaw Aching teethAching teeth Tender cheeksTender cheeks

Symptoms specific for ethmoid sinus infectionSymptoms specific for ethmoid sinus infection Swollen eyelidsSwollen eyelids Swelling around eyesSwelling around eyes Pain between eyesPain between eyes Tenderness of sides of noseTenderness of sides of nose Loss of smellLoss of smell Stuffy noseStuffy nose

Symptoms specific for sphenoid sinus infectionSymptoms specific for sphenoid sinus infection EarachesEaraches Neck painNeck pain Aching top of headAching top of head

Complication sinusitisComplication sinusitis Orbital complicationsOrbital complications

: preseptal cellulitis, orbital cellulitis, s: preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscessubperiosteal abscess, orbital abscess, and cavernous sinus thrombosis (du, and cavernous sinus thrombosis (dural thrombophlebitis). ral thrombophlebitis).

Intracranial complicationsIntracranial complications

::Intracranial (CNS) complications, naIntracranial (CNS) complications, namely, meningitis, subdural empyema, mely, meningitis, subdural empyema, epidural abscess and cerebral absceepidural abscess and cerebral abscess may all complicate acute and chross may all complicate acute and chronic sinusitisnic sinusitis

MeningitisMeningitis Fever and chills Fever and chills Severe headache Severe headache Nausea and vomiting Nausea and vomiting Stiff neck (meningismus) Stiff neck (meningismus) Sensitivity to light (photophobia) Sensitivity to light (photophobia) Mental status changesMental status changes

Bony complicationsBony complications

::Osteomyelitis (and osteitis) are usualOsteomyelitis (and osteitis) are usually related to acute frontal sinusitis ly related to acute frontal sinusitis

Investigation sinusitisInvestigation sinusitis

Sinusitis includes: Sinusitis includes: Physical examation Physical examation X-ray of sinuses X-ray of sinuses CAT scan of sinuses CAT scan of sinuses Nasal swab tests Nasal swab tests Physical examPhysical exam Sinus X-raySinus X-ray MRI scanMRI scan CT scanCT scan

presenting with an acute sore throat

Epiglottiditis is a true medical emergenc Epiglottiditis is a true medical emergency.y.

Sore throat Sore throat Drooling Drooling Odynophagia or dysphagia, difficOdynophagia or dysphagia, diffic

ulty or pain during swallowing, glulty or pain during swallowing, globus sensation of a lump in the tobus sensation of a lump in the throat hroat

Muffled dysphonia or loss of voicMuffled dysphonia or loss of voice e

Dry cough or no cough Dry cough or no cough Dyspnea Dyspnea Fever Fever severe respiratory distress with severe respiratory distress with

sternal and intercostal retractiosternal and intercostal retractions, nasal flaring, cyanosis, and ns, nasal flaring, cyanosis, and tachycardiatachycardia

Fatigue or malaise (may be seen Fatigue or malaise (may be seen with any URI)with any URI)

TonsillitisTonsillitisSymptoms

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.

The throat is reddened, the tonsils are swollen and may be coated or have white spots on them.

Possibly a high temperature.

Swollen lymph glands under the jaw and in the neck.

Headache.

Loss of voice or changes in the voice. . .

complications complications TonsillitisTonsillitis Local ComplicationLocal Complication

Peritonsillar abscessPeritonsillar abscess Superlative cervical LymphadenitisSuperlative cervical Lymphadenitis

Systemic complicationSystemic complication A secondary infection may occur in the middle ear or sinA secondary infection may occur in the middle ear or sin

uses.uses. If the sore throat is due to a streptococcus infection, therIf the sore throat is due to a streptococcus infection, ther

e may be a rash (scarlet fever).e may be a rash (scarlet fever). An uncommon complication is a throat abscess which ocAn uncommon complication is a throat abscess which oc

curs usually only on one side. If sufficiently large this can curs usually only on one side. If sufficiently large this can need surgical drainage (Quinsy throat).need surgical drainage (Quinsy throat).

****Beta – hemolytic streptococci groupBeta – hemolytic streptococci group In very rare cases, diseases like In very rare cases, diseases like rheumatic feverrheumatic fever a particular kidney disease a particular kidney disease (glomerulonephritis)(glomerulonephritis) can occ can occ

ur. This is much less commonly observed now than it waur. This is much less commonly observed now than it was several decades ago. s several decades ago.

Acute endocarditisAcute endocarditis

Assessment : Detailed history - Onset and nature of symptoms: location and duration of pain

(throat, sinuses, joints) Itchy, watery eyes ,Nasal discharge ,Nasal congestion ,Sneezi

ng ,Sore throat ,Headache Fever MalaiseFatigue, weakness ,Myalgias

- Cough (productive/non productive) - Fever and nasal discharge - Existing co-morbidities - History of rheumatic heart disease - Known sinus polyps - Immuno-suppression - Prosthetic heart valve -Respiratory diseases like asthma, COPD - Other family members with recent sore throat - History of foreign travel - History of foreign body

Physical assessment - General appearance, toxicity, respiratory distress, vital signs - Inspection of throat, tonsillar exudates, redness, oedema 1 - Palpate sinuses; oedema or bogginess over adjacent bony

areas - Inspect peri orbital area, assess for visual and neurological di

sturbance - Palpate for lymphadenopathy, splenomegaly, and

hepatomegaly - Assess for signs of meningitis (sign :HA, photophobia,I irritability,

clouding of conciousness,neck stiffness), haemorrhagic spots - Ear examination - Chest auscultation - Airway compromise, stridor or drooling

Examination meningitisExamination meningitis Brudzinski's sign of meningitis Brudzinski's sign of meningitis Severe neck stiffness Severe neck stiffness causes a patient's hips causes a patient's hips and knees to flex when and knees to flex when the neck is flexed.the neck is flexed.

Kernig's sign of meningitisKernig's sign of meningitis Severe stiffness of the Severe stiffness of the hamstrings causes an hamstrings causes an inability to straighten inability to straighten the leg when the hip the leg when the hip is flexed to 90 degrees. is flexed to 90 degrees.

Investigation CBC Chest X ray – if focal signs on chest examination, fever with prod

uctive cough or prolonged symptoms of URTI , Lateral upper airways – Foreign body, Upper Airway obstruction, retro- pharyngeal abscess, epiglotitis.

Blood Culture – uncertain diagnosis, toxic clinical picture Consider: LFT’s – glandular fever & atypical pneumonia EBV serology and monospot- prolonged history of URTI not r

esolving with antibiotics Throat swab – very rarely helpful.

BS : prolonged poor oral intake, diabetes, age >55 years, renal disease

Indication for admitIndication for admit Respiratory distress, pulse rate >110 (adult), SaO2 <95% Toxic clinical picture History of rheumatic heart disease History of prosthetic valve Hepatomegaly or splenomegaly Asymmetrical pharyngeal swelling Peri-tonsillar abscess Epiglotitis Signs of meningitis Age >70 years Inability to swallow / dehydration Torticollis Oedema involving the bony areas adjacent to sinuses Peri-orbital involvement Visual or neurological disturbance Beta Lactam allergy 2, 3, 6 Pneumonia Relevant Co morbidities Immunocompromised patients Atypical lymphocytosis Lymphadenopathy outside cervical.

TreatmentTreatment

Virus infectionsVirus infections Antibiotics do not kill viruses. Antibiotics only Antibiotics do not kill viruses. Antibiotics only

kill bacteria. kill bacteria. Antibiotics may cause side-effects such as diAntibiotics may cause side-effects such as di

arrhea, rashes, feeling sick, etc. arrhea, rashes, feeling sick, etc. Overuse of antibiotics when they have not bOveruse of antibiotics when they have not b

een necessary has led to some bacteria beceen necessary has led to some bacteria becoming resistant to them. This means that sooming resistant to them. This means that some antibiotics might not be as effective wheme antibiotics might not be as effective when they are really needed. n they are really needed.

Consider: Drug Analgesic drug

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. NSAID

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,

Decongestant 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

Antibiotic Phenoxymethylpenicillin Oral therapy for mild to moderate infections due to penicillin se

nsitive organisms – Sore throat Oral Adult 250mg-500mg 4-6 hourly Antibiotic

Amoxycillin Trihydrate Infections due to susceptible organisms incl. sinusitis Oral Adult 250-500mg 8 hourly (Antibiotic ) side effect GI upset; raised LFTs; CNS

tonsillitis treat tonsillitis treatmentment

In the vast majority of people, infection caused by a virus infection In the vast majority of people, infection caused by a virus infection need only be treated with paracetamol (eg Calpol, Panadol) to brinneed only be treated with paracetamol (eg Calpol, Panadol) to bring the temperature down. Aspirin (eg Disprin) is also useful, but shg the temperature down. Aspirin (eg Disprin) is also useful, but should not be given to children under 16 years of age, unless on the ould not be given to children under 16 years of age, unless on the advise of a doctor.advise of a doctor.

In a small minority of patients, tonsillitis caused by bacteria is treatIn a small minority of patients, tonsillitis caused by bacteria is treated with penicillin or erythromycin (eg Erythroped) if the person is aed with penicillin or erythromycin (eg Erythroped) if the person is allergic to penicillin. If antibiotics are prescribed, it is important to collergic to penicillin. If antibiotics are prescribed, it is important to complete the full course, or the infection may not be cured.mplete the full course, or the infection may not be cured.

Surgery to remove the tonsils (tonsillectomy) may be necessary foSurgery to remove the tonsils (tonsillectomy) may be necessary for those patients suffering from repeated, severe infections that refr those patients suffering from repeated, severe infections that refuse to respond to treatment and significantly interfere with their scuse to respond to treatment and significantly interfere with their school or work schedule but it is now a relatively uncommon operatihool or work schedule but it is now a relatively uncommon operation compared to previous practice. on compared to previous practice.

PreventionPrevention Frequent hand washing is the best way to prevent all kinds of infections, iFrequent hand washing is the best way to prevent all kinds of infections, i

ncluding tonsillitis. Wash your hands often, and encourage your children tncluding tonsillitis. Wash your hands often, and encourage your children to do the same.o do the same.

Prevention : Influenza VaccinePrevention : Influenza Vaccine

Who should get influenza vaccine?Who should get influenza vaccine?Everyone 50 years of age or older Everyone 50 years of age or older

All children 6–23 months of age All children 6–23 months of age Residents of long-term care facilities and nursing homes Residents of long-term care facilities and nursing homes Anyone 2–49 years of age who has a serious long-term health problem, inAnyone 2–49 years of age who has a serious long-term health problem, in

cluding heart disease, lung disease, asthma, kidney disease, a metabolic cluding heart disease, lung disease, asthma, kidney disease, a metabolic disease such as diabetes, or anemia and other blood disorders disease such as diabetes, or anemia and other blood disorders

Anyone who has a condition (e.g., spinal cord injury) that can affect their Anyone who has a condition (e.g., spinal cord injury) that can affect their ability to cough out their respiratory secretions ability to cough out their respiratory secretions

Anyone whose immune system is weakened because of the following: HIAnyone whose immune system is weakened because of the following: HIV/AIDS or other diseases that affect the immune system, long-term treatmV/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 ent with drugs such as steroids, or cancer treatment with x-rays or drugs

Anyone 2–18 years of age on long-term aspirin treatment (who could devAnyone 2–18 years of age on long-term aspirin treatment (who could develop Reye's syndrome if they catch influenza) elop Reye's syndrome if they catch influenza)

Women who will be pregnant during the influenza season Women who will be pregnant during the influenza season All healthcare workers, family members, or anyone else coming in close cAll healthcare workers, family members, or anyone else coming in close c

ontact with people at risk of serious influenza disease (including householontact with people at risk of serious influenza disease (including household contacts of all children 0–23 months of age) d contacts of all children 0–23 months of age)

persons should not be vaccinated with live influenza vaccine: persons should not be vaccinated with live influenza vaccine: Persons younger than five years of age Persons younger than five years of age Persons 50 years of age or older Persons 50 years of age or older Persons with asthma, reactive airways disease or other chronic disorders of the pulPersons with asthma, reactive airways disease or other chronic disorders of the pul

monary or cardiovascular systems; persons with other underlying medical conditionmonary or cardiovascular systems; persons with other underlying medical conditions, including metabolic diseases such as diabetes, renal dysfunction, and hemoglobis, including metabolic diseases such as diabetes, renal dysfunction, and hemoglobinopathy or persons with known or suspected immune deficiency diseases or who anopathy or persons with known or suspected immune deficiency diseases or who are receiving immunosuppressive therapies re receiving immunosuppressive therapies

Children or adolescents receiving aspirin Children or adolescents receiving aspirin Persons with a history of Guillain-Barré syndrome Persons with a history of Guillain-Barré syndrome Pregnant women Pregnant women Healthcare workers, household members, and others who have close contact with Healthcare workers, household members, and others who have close contact with

severely immunocompromised individuals during the periods in which the immunosseverely immunocompromised individuals during the periods in which the immunosuppressed person requires care in a protective environment. uppressed person requires care in a protective environment.

Vaccine Side EffectsVaccine Side Effects Soreness, redness, or swelling where the shot was given Soreness, redness, or swelling where the shot was given Fever (low grade) Fever (low grade) Aches Aches

CoverageCoverage ~ 1year~ 1year

INFLUENZA VACCINE DOSAGE BY AGE GROUP INFLUENZA VACCINE DOSAGE BY AGE GROUP- 2005 2006 SEASON- 2005 2006 SEASON

AGE GROUPDOSAGENO. OF DOSESROUTEAGE GROUPDOSAGENO. OF DOSESROUTE

6-35 months6-35 months 0.25 mL1 0.25 mL1 IntramuscularIntramuscular 3-8 years3-8 years 0.50 mL1 0.50 mL1 IntramuscularIntramuscular >>9 years9 years 0.50 mL0.50 mL IntramuscularIntramuscular

Product name Influenza vaccineProduct name Influenza vaccine Vaxigrib vaccineVaxigrib vaccine Fluzone vaccineFluzone vaccine Fluarix vaccineFluarix vaccine

Preventing Sinusitis Preventing Sinusitis

using an oral decongestant or a short course of nasal susing an oral decongestant or a short course of nasal spray decongestant pray decongestant

gently blowing your nose, blocking one nostril while blogently blowing your nose, blocking one nostril while blowing through the other wing through the other

drinking plenty of fluids to keep nasal discharge thin drinking plenty of fluids to keep nasal discharge thin avoiding air travel. If you must fly, use a nasal spray deavoiding air travel. If you must fly, use a nasal spray de

congestant before take-off to prevent blockage of the sicongestant before take-off to prevent blockage of the sinuses allowing mucus to drain nuses allowing mucus to drain

If you have allergies, try to avoid contact with things thaIf you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or t trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal prescription antihistamines and/or a prescription nasal spray to control allergy attacks spray to control allergy attacks