Assessment of Patients with Upper Respiratory Tract Symptoms (PDF) 2022

Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... Assessment of Patients with Upper Respiratory Tract Symptoms Daniel J.G. Thirio...

Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... Assessment of Patients with Upper Respiratory Tract Symptoms Daniel J.G. Thirion, BPharm, MSc, PharmD, FCSHP Date of Revision: May 3, 2022 Peer Review Date: March 20, 2022 Introduction Upper respiratory tract infection is a nonspecific term used to describe a spectrum of acute infections that may involve the ear, nose, sinuses, pharynx, larynx and trachea. These infections are common in adults and children and are generally caused by a virus (most commonly rhinovirus, parainfluenza). Most viral infections are self-limiting, resolve spontaneously and are managed symptomatically. Some patients who are at risk of complications of viral infections, including influenza (see Table 1), SARS-CoV-2 (COVID-19) (see Table 2) and respiratory syncytial virus (see Table 3), may require specific antiviral treatment. Bacterial infections or complications should be medically evaluated to determine the need for antibiotic therapy and further specific intervention. A differential diagnosis of common acute respiratory tract bacterial and viral infections is presented here. Table 1: Persons at High Risk of Complications or Hospitalization Due to Influenza Adults and children with chronic health conditions such as cardiac or pulmonary disorders, diabetes mellitus or other metabolic disease, cancer, immunodeficiency or immunosuppression, renal disease, anemia or hemoglobinopathy, neurologic or neurodevelopment conditions (includes neuromuscular, neurovascular, neurodegenerative and neurodevelopmental conditions as well as seizure disorders, but excludes migraines and psychiatric conditions without neurological conditions), morbid obesity (BMI ≥40) Any resident of a nursing home or other chronic care facility, regardless of age Adults ≥65 years of age Children and adolescents with conditions treated for long periods with acetylsalicylic acid Children 40) Table 3: Persons at High Risk of Complications or Hospitalization Due to Respiratory Syncytial Virus Very young infants, especially if premature or ≤6 months of age Children 7 days), difficulty breathing, earache (especially in children) or double sickening (worsening after a few days of initial improvement). The patient should be assessed for the presence of complications, the level of care required and the need for antibiotics. See Table 4 for a comparison of common upper respiratory tract ailments. When patients are afflicted with the common cold, they usually first complain of throat discomfort (dryness, scratchiness), followed by nasal congestion and rhinorrhea. Nasal discharge is clear and watery at the beginning and becomes mucopurulent as the infection progresses. Cough may be present and may persist for 1–2 weeks. The cough is usually dry to start and often becomes productive. See also Viral Rhinitis. With pharyngitis, the onset of throat pain is more rapid and the pain is more severe compared to the common cold. Acute sore throat infections, which include pharyngitis and tonsillitis, are usually viral in nature. However, when additional symptoms include high fever, headache, abdominal pain, nausea, vomiting or rash, streptococcal throat infections should be suspected and treated accordingly. See also Group A Streptococcal Pharyngitis and Viral Rhinitis, Influenza, Sinusitis and Pharyngitis. In the vast majority of cases, rhinosinusitis is viral in nature. However, bacterial involvement is suspected if symptoms persist >7 days or if symptoms worsen after initial improvement. Prolonged nasal congestion and purulent drainage are consistent with possible rhinosinusitis, especially if accompanied by fever, 2 sur 8 28/08/2023 13:53 Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... headache, facial swelling/redness, facial pain, and nausea and vomiting. See also Acute Rhinosinusitis. Due to the ongoing COVID-19 pandemic, coronaviruses infections should be considered when patients present with fever, cough, sore throat, anosmia, or shortness of breath or have been exposed to high-risk contacts. Additional symptoms include muscle aches and headaches. The outcomes in affected patients can vary from asymptomatic infections to severe pneumonia with acute respiratory distress syndrome and death. Diagnostic testing for SARS-CoV-2 is needed when symptoms are consistent with COVID-19 based on local epidemiology. Please consult local health authorities for updated recommendations. See also COVID-19. Cough is present in most upper respiratory tract infections such as the common cold, influenza and COVID-19. However, it may be caused by other conditions, many of which require diagnosis by an appropriate health-care practitioner (see Acute Cough, Table 1). Cough persisting longer than 3 weeks should be assessed more thoroughly. For more detailed information, see also Influenza and Viral Rhinitis, Influenza, Sinusitis and Pharyngitis. The supraglottic larynx is a common site for airway obstruction. When infected, it can lead to croup, epiglottitis or supraglottitis mostly in children and rarely in adults. See also Croup. Otitis media can be confirmed on visualization of the middle ear and observation of bulging of the tympanic membrane. See also Acute Otitis Media in Childhood. It can be preceded by an upper respiratory tract infection that usually leads to bacterial involvement. Viral infections will often produce otitis media with effusion that should be differentiated from otitis media alone. The presence and colour of middle ear fluid that is more often dark yellow or red is a sign of otitis media with effusion. Symptoms suggestive of croup, epiglottitis or otitis media (see Table 5) require further assessment for a tailored workup and treatment. Allergic rhinitis can resemble the common cold but does not have an infectious etiology. Allergic rhinitis is characterized by sneezing and rhinorrhea that may progress to nasal congestion. Eye symptoms such as conjunctivitis and lacrimation may also be present. See Conjunctivitis and Allergic Rhinitis. Table 4: Differential Diagnosis of Upper Respiratory Tract Conditions Symptom/Cause Common Cold Pharyngitis Rhinosinusitis COVID-19 Influenza Allergic Rhinitis Etiology Viral Viral (most Viral (most common), Viral Viral Noninfectious common), bacterial, fungal (rare) bacterial Fever Rare, mild Viral: low grade Possible Common Yes (38–40°C) No Bacterial: high Sudden onset grade Headache Rare, via sinus Viral: mild Common, via sinus Possible Yes Via sinus congestion Bacterial: severe, congestion congestion sudden onset 3 sur 8 28/08/2023 13:53 Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... Symptom/Cause Common Cold Pharyngitis Rhinosinusitis COVID-19 Influenza Allergic Rhinitis Nasal discharge Clear at the Rare, possible Persistent, purulent Possible Clear at the Abundant; and congestion beginning, then can rhinorrhea if viral rhinorrhea (increased rhinorrhea beginning, aqueous and become likelihood of bacteria) then clear mucopurulent Coloured (yellow, mucopurulent Nasal Nasal congestion is green) Nasal congestion may common Nasal congestion is congestion is be present common rare Cough Mild to moderate Rare Possible via postnasal Common, dry Common Possible via Dry at the beginning; drip Nonproductive post-nasal drip often becomes productive as the cold progresses Sore throat Common Severe, sudden No Possible Sometimes Rarely, possible Mild (dry, scratchy, onset on awakening sore) General aches Rare, mild Possible, can be Rare Possible Common Earaches, and pain severe if bacterial (myalgia) (myalgia) especially in children Other Sneezing in the first Pain on Facial tenderness; jaw Shortness of Fatigue, Pruritus (palate, couple of days swallowing and tooth pain breath, fatigue, weakness, nose, eyes, Lacrimation Viral: watery Ear pain loss of appetite, chills throat and ears) eyes, sneezing loss of smell Malaise, Sneezing, Hyposmia, anosmia and/or taste Bacterial: nausea, nausea, lacrimation Halitosis if bacterial vomiting vomiting Duration Usually 5–7 days but 3–5 days Viral: no more than 10 Up to 14 days, 10 days As long as 25% last 14 days days and does not median exposed to the worsen incubation period allergen; can be Bacterial: severe of 4–6 days, perennial or symptoms in first some will seasonal 3–4 days that worsen, experience prolonged 4 sur 8 28/08/2023 13:53 Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... Symptom/Cause Common Cold Pharyngitis Rhinosinusitis COVID-19 Influenza Allergic Rhinitis symptoms persist for symptoms more than 10 days Table 5: Croup, Epiglottitis and Otitis Media in Children Condition Croup Epiglottitis Otitis Media Possible signs and Barking, seal-like cough, usually Sore throat and difficulty swallowing Fever, especially one beginning symptoms nonproductive Fever, chills several days after the start of a cold Gradually worsening inspiratory Stridor Earache or child tugging at or stridor fingering ear Use of accessory muscles and Dyspnea positioning for breathing (laboured, Irritability and/or lethargy Fever sitting upright and leaning slightly Purulent drainage from ear Hoarseness forward) Hoarseness Drooling Cyanosis Other characteristics Fluctuating course with rapid Rapidly progressive, usually absence For more information, consult the improvements and declines; of cough Compendium of Therapeutic Choices: symptoms often worse at night Acute Otitis Media in Childhood. Prodrome (2–5 days) consisting of mild fever, rhinorrhea, malaise, sore throat and cough. Cough generally resolves in 3 days. For more information, consult the Compendium of Therapeutic Choices: Croup. Algorithms Figure 1: Assessment of Patients with Upper Respiratory Tract Symptoms 5 sur 8 28/08/2023 13:53 Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... 6 sur 8 28/08/2023 13:53 Assessment of Patients with Upper Respiratory Tract Symptoms https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/asmt_pt_w_uppr_resp... [a] See COVID-19. [b] See Allergic Rhinitis. [c] See Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis. [d] For more information, see the Canadian Immunization Guide at: www.canada.ca/en/public-health/services/canadian-immunization-guide.html. [e] See Acute Cough. [f] For more information regarding nasal congestion in adults or children, see Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis. [g] Antitussives are not recommended in children