Acute Respiratory Complaints.docx

Guided Notes: **Acute Viral Respiratory Complaints** ==================================================== **[Upper Respiratory Tract Infection]** --------------------------------------------------- - ### Description - Catch all term (URI) - One of the most common things you will se...

Guided Notes: **Acute Viral Respiratory Complaints** ==================================================== **[Upper Respiratory Tract Infection]** --------------------------------------------------- - ### Description - Catch all term (URI) - One of the most common things you will see - ### Etiology - Most are viral - ### Incidence - \>50% of outpatient antibiotic prescriptions are inappropriate Features & Clinical Findings ---------------------------- - ### Symptoms - Nasal congestion - Rhinorrhea - Pharyngitis - Cough - Lymphadenopathy - Fever (usually low grade) - Body aches - Sinus pressure - ### Assessment Findings - Injected conjunctivae - Erythematous pharynx +/- exudate - Erythematous turbinates - Watery or purulent discharge - Lungs CTA or wheezing Management ---------- - Rest & fluids - Handwashing - Ibuprofen/acetaminophen - Pseudoephedrine or topical decongestants - 3 day max when topical - Cough: benzonatate to dextromethorphan - ### Pediatric considerations - No cough/cold medications age \1 year - Risk of botulism - Cool mist humidifier - Nasal saline - Bulb suctioning Expected Course --------------- - Usually, self-limiting 5 to 7 days - ### Follow-up - RTC if symptoms persist or worsen - Fever \>102 - Chest pain - SOB - Dizziness - Confusion - Symptoms \> 10-14 days - May be bacterial at that point - New sinus/ ear pain - ABRS (double sickening) or OM **[Acute Bronchitis]** ---------------------------------- - ### Description - Acute self-limiting inflammation of the trachea & major bronchi - Cough lasting 1-3 weeks - Occasionally, dyspnea & wheezing - ### Etiology - Most are viral - Adenovirus, rhinovirus, influenza, parainfluenza, RSV, metapneumovirus - ### Incidence - Fall & winter Features & Clinical Findings ---------------------------- - ### Symptoms - Cough: dry & nonproductive, then may become productive - Colored sputum does not predict bacterial infection - URI symptoms - Fatigue - Burning sensation in chest - Chest wall pain (pleuritic pain) - ### Assessment Findings - Wheezing but not always - Respiratory assessment usually normal besides cough Differentials ------------- - Common Cold - Acute Rhinosinusitis (cough from drainage) - Pneumonia - Influenza - COVID - Pertussis - Heart Failure (cough, SOB but has fluid overload as well) - TB - Asthma (if wheezing) Diagnostics ----------- - CXR not routine (tachypnea, tachycardia, hypoxia, temp \>100.4 F, exam finding c/w pneumonia (crackles, rhonchi)) - Can consider - Pertussis titer or swab - COVID antigen - Rapid influenza Management ---------- - ### Non-pharmacological - Increase fluids - Rest - Cool mist humidifier - Honey (age \>1 year) - Smoking cessation - Patient education - Watch for SOB, increased RR, retractions, etc - Pharmacological - Avoid: - Antibiotics, antihistamines, or decongestants (unless sinusitis/AR) - Antitussives (short term) - Dextromethorphan (Robitussin DM), codeine, or Tessalon - Antiviral if influenza + (if within 48 hrs) - Avoid beta 2 agonist - Unless history of asthma or recurrent wheezing Expected Course --------------- - May persist 3-4 weeks - ### Follow-up - 7 days if not improved - High risk group (immunosuppression) - Refer: - If cough persist after 4 weeks (pulmonary) **[Influenza]** --------------------------- - ### Description - Highly contagious, acute viral illness - Nasal mucosa, pharynx, upper & lower respiratory tracts - ### Etiology - Influenza A - Influenza B - Consider avian-travel outside US, birds or poultry exposure - Consider swine---work with pigs - ### Incidence - Fall & winter, early spring - More severe disease in: - Young, old, pregnant, immunocompromise, comorbidities (asthma, CKD, diabetes, chronic lung disease) Features & Clinical Findings ---------------------------- - ### Symptoms - History - Exposure? - Sudden onset - Like a truck hit me - Fever - Cough - Rhinorrhea - Sore throat - Body aches - Headache - Myalgias & fatigue - Nausea, vomiting - ### Assessment Findings - Nonspecific upper respiratory findings - Cough, edematous pharynx, etc Differentials ------------- - Common cold - Pneumonia - URI - Sinusitis - RSV - Acute Bronchitis Diagnostics ----------- - Rapid antigen flu test - Specific but sensitivity not great - Rapid molecular assay - Better sensitivity - PCR - Best sensitivity, expensive, and most are send outs - SARS-COV 2 Management ---------- - ### Non-pharmacological - Avoid contact - Increase fluids - Rest - Saline nose sprays - Salt-water gargles - Smoking cessation - Breastfeeding is okay - Cool mist humidifier - Handwashing - Patient education - Fever not relieved, increased RR, can't keep down fluids, extremely short of breath, etc - Pharmacological - Antiviral within 48 hours of symptom onset - Oseltamivir 75 mg PO BID x 5 days - Prevention is 75 mg PO QD for 7 days (those in the household for example) - Can be given down to age of 2 weeks - Zanamivir inhaled x 5 days ( 7 days prevention ) ( age \>7) - Powder may be irritating - Peramivir IV x 1 ( age \>2) hospital setting - Baloxavir PO x1 (age \>12) - Hospitalized & those at high risk may do antiviral \> 48 hours of onset (shortens duration and severity) - \ 65 years - Pregnant or postpartum (within 2 weeks) - Immunosuppressed or those with severe asthma. benefits outweigh risk. - Consider prevention in household contacts at high risk - Lack of spleen, HIV, etc - Antipyretics - Tylenol, ibuprofen - Symptomatic care with OTC meds - \ - ### Possible Complications - Pneumonia - most common - AOM - Fluid build up in secondary ear space that causes bacterial AOM - Sinusitis - Sepsis - extreme - Respiratory failure - extreme - Myocarditis - extreme - Exacerbation of chronic disease - Asthma **[Coronavirus]** ----------------------------- - ### Description - Severe acute respiratory syndrome coronavirus (SARS-CoV-2) - Incubation: 2-24 days, most 4-5 days after exposure - Close contact (within 6 feet, extended time of at least 15 min) - Respiratory droplets - Can be mild to severe (mild cold resp failure) Features & Clinical Findings ---------------------------- - ### Symptoms - Fever - Cough - URI Symptoms - Headache - Muscle pain - Nausea/ vomiting - Diarrhea - Moderate to Severe - Hypoxia - Tachypnea - Lung infiltrates - Respiratory failure - ### Assessment Findings - Nonspecific upper respiratory findings - Cough, edematous pharynx, etc Differentials ------------- - URI - Influenza - Pneumonia Diagnostics ----------- - RT-PCR (standard) - Take longer (1 hr maybe). More expensive. More done in hospital - NAAT - Nucleic acid - Better sensitivity - Rapid antigen (quick) - Most common, cheap - Not sensitive - Moderate to severe - CXR - CBC - Inflammatory markers (ex. CRP) - D-dimer, PT, PTT - Last three usually inpatient Management ---------- - ### Non-pharmacological - High risk? - Age, comorbidities, immunosuppression - Adequate nutrition - Increase fluids - Breathing exercises - Education about signs and symptoms that warrant urgent medical care - If fever is unresolved with antipyretics - Lethargy - Home isolation until symptoms are improving & afebrile for 24 hours (without antipyretics) - At home, wear mask and limit contact - Improve ventilation - No longer a reportable disease - After initial isolation recommended for 5 days - Hand hygiene - Masks - Ventilation (in close office space with someone) - Distancing - Who is high risk? - Cancer, CVD, CKD, Chronic lung disease, DM, CF, liver disease, BMI \30, CP, immunodeficiencies, pregnancy, heart conditions, spinal cord injuries, use of immunosuppressive medications - Pharmacological - Symptomatic/supportive careAntipyretics, analgesics, antitussives (Robitussin, Tessalon, codeine) - Risk for progression to severe disease (high risk from list above) - Monoclonal antibody therapy - Ritonavir-boosted nirmatrelvir, sotrovimab, remdesivir, molnupiravir - Mild to moderate COVID 19 at high risk - Nirmatrelvir/ritonavir (Paxlovid) within 5 days of onset - Adjust for GFR \ - ### Refer to ED - Westley score \3 - Looks at stridor, retractions - SaO2 \