URTI Lecture 2024.pdf

Management of Upper Respiratory Tract Infections and Allergy Prof. Edward McKone, Department of Respiratory Medicine St. Vincent’s University Hospital. The Upper Respiratory Tract Nasal Passages Sinuses Pharynx Tonsils Adenoids Larynx Epiglottis The Upper Respiratory Tract The Upper Respiratory Trac...

Management of Upper Respiratory Tract Infections and Allergy Prof. Edward McKone, Department of Respiratory Medicine St. Vincent’s University Hospital. The Upper Respiratory Tract Nasal Passages Sinuses Pharynx Tonsils Adenoids Larynx Epiglottis The Upper Respiratory Tract The Upper Respiratory Tract Rhinitis Nasal Passages Influenza Sinuses Sinusitis Pharynx Tonsils Adenoids Larynx Epiglottis Pharyngitis Tonsillitis Pertussis Acute Rhinitis: The Common Cold Benign self-limiting syndrome Represents a group of viral infections Most common cause of work absenteeism in Ireland and US Frequency - 5-7 per year in preschool children - 2-3 per year in adulthood Causes of The Common Cold Rhinovirus (30-50%) 200 subtypes Coronavirus (10-15%) Influenza Virus (5-15%) RSV (5%) Parainfluenza (5%) Other Adenovirus/enterovirus “The Virochip” Epidemiology of The Common Cold Seasonal Viruses Often more symptomatic Rhinovirus - Autumn & late spring RSV/Coronavirus - Winter & Spring Transmission (Inoculation) Peak infectivity 3 days after symptoms; up to 2wks Hand contact (viable on hands for 2 hrs.) Viable on skin 2 hours; Surfaces 2-3 hrs. 0/8 subjects with hand hygiene v 6/10 without (JID, 1980) Small particle aerosol - linger in air Large particle aerosol - “direct hit” longhaul flights Air Travel (recirculated air?) – inconclusive in large studies initiia Clinical Features AFTER INNOCULATION Sore throat/nasal congestion Rhinorrhoea/Sneezing Headache Fever (low-grade) 37.5 38 Cough 24-72hrs 2-7 days 3-7 days (up to 2 wks.) Differential Diagnosis Allergic Rhinitis COVID-19 Infection Influenza (high fever, systemic symptoms) Acute Bacterial Tonsillopharyngitis Pertussis whoopingcough Acute Bacterial Sinusitis Treatment Options for the Common Cold Ipratropium Bromide nasal spray II-IV puffs/day Reduced nasal discharge, sneezing S/E dry mucus membranes, bleeding. Antihistamines Helps sneeze and rhinorrhea, sleep? Metanalysis (Cochrane) Side effects>>Benefits Antitussives/Decongestants Dextromethorphan - good for cough Pseudoephedrine - good for nasal symptoms S/E Rebound rhinorrhea, HTN? Short Acting Anti-cholinergics Ipratropium Bromide (Rinatec/Rinaspray). Delivered by nasal spray. Acts on muscarinic cholinergic receptors in airway leading to reduced mucus secretion and reduced nasal oedema. May be beneficial in acute rhinitis, and acute and chronic sinusitis. Effect lasts about 12 hours Side effects - dry mouth, blurred vision, mild tachycardia Other Treatment Options for the Common Cold Intranasal Steroids Not beneficial Leukotriene receptor antagonists Not beneficial Antibiotics No (again harm>>>benefits) Vitamin C Meta-analysis 7 trials, >3000 colds - no benefit over placebo May play role in prevention Others (Inconclusive or not beneficial) Echinacea, Zinc Promising treatments Antiviral Treatment with Interferon 2b. Allergic Rhinitis Symptomatic increase in nasal and ocular symptoms when exposed to allergen 2 types allergic – Seasonal summever restorgasonal – Perennial >2 hrs./day for >9 months/year. There are non-allergic forms of rhinitis – 78% of seasonal rhinitis is allergic 20tnfrgic – 68% of perennial rhinitis is allergic Allergic Rhinitis Epidemiology 40 % of children – Bimodal peaks at early school and early adulthood 10-20% of adults Risk Factors off breastfeeding – Family history – Male sex – Birth during pollen season – Maternal smoking (1st year) - Early Infant formula - Early antibiotics - Infant IgE>100 atopy 6041hL'dies Allergic Rhinitis i Clinical Features Ocular, nasal and palatal itching upon exposure to allergen. Rhinorrhea, sneezing, nasal obstruction Postnasal drip, cough and fatigue Poor sleep, loss of concentration Associated conditions – Asthma 20-50% of asthmatics have allergic rhinitis – Sinusitis – Other atopic disorders Eczema, allergic dermatitis, allergic conjunctivitis Allergic Rhinitis Diagnosis Classic history of nasal/ocular symptoms brought on by allergen exposure. Investigations – FBC with eosinophils – IgE – Allergy testing (skin prick or RAST) House dust mite, cat, dog, fungi, tree mix, weed mix, pollens – May look for co-existing conditions (asthma, sinusitis) Treatment of Allergic Rhinitis Allergen Avoidance Nasal Wash Nasal Steroid Oral or intranasal Antihistamines Leukotriene Antagonists Nasal Ipratropium bromide Immunotherapy Inhaled Nasal Corticosteroids Many preparations of varying strengths – Beclomethasone = Budesonide < Fluticasone Mainstay of upper airway allergy Rx Aqueous solution delivered directly by spray or droplet to nasal mucosa Side effects mainly topical – nose burning or bleed, increased viral infections In high doses could cause systemic SE – Cataracts, IOP, Glaucoma. – Theoretically could cause loss of diabetic control, osteoporosis, impaired growth but studies to date are reassuring Antihistamines 1st Generation Antihistamines – Diphenhydramine, chlorpheniramine. – Reduce itching, sneezing & rhinorrhea. – S/E Cross BBB - sedation (20% of patients) Impaired cognition – Avoid driving/using heavy machinery Anticholinergic effects 2nd/3rd Generation Antihistamines – – – – – Loratadine, azelastine Lipophobic - don’t cross BBB As effective as 1st Generation. Not as effective as intranasal steroids S/E same as above but less sedation can occur Leukotriene Pathway Antagonists Montelukast (Singulair), Zafirlukast Inhibit Leukotriene Receptor Cys-LT1 – Attenuate leukotriene mediated allergic inflammation Not as effective as intranasal steroids Used in combination with nasal CS Useful monotherapy in allergic rhinitis if intolerant of intranasal steroids. Side effects - very little, N, V, ?Churg Straus Syn, hepatitis. eosinopffonator EPA its artfying Immunotherapy Sub-lingual immunotherapy (SLIT) Gradual desensitization to allergens – Grass and Tree Pollens, House dust mite treatment 2 3 yr Acute Tonsillopharyngitis Acute inflammation of pharynx 70% viral (same viruses as common cold) Bacterial infection less common – Streptococcus GAS (Group A Strep Pharyngitis) only 10% – Other bacteria Grp C Strep, Neisseria, Mycoplasma, Chlamydia. Acute Tonsillopharyngitis Clinical Features Centor Criteria Sore throat with tonsillar exudates Fever Absence of Cough Cervical LN Acute Tonsillopharyngitis Diagnosis and Treatment Diagnosis Throat culture before antibiotic treatment. Rapid Streptococcal Antigen Test (RSAT) Serology - 4-fold increase ASOT Treatment – antibiotics Rationale quincy Prevent complications – Rheumatic fever, peritonsillar abscesses or sepsis (very rare) – Glomerulonephritis or Scarlet fever (role of abts unknown) Shorten symptoms (24hrs only) – – – – If ≤2 Centor criteria - no treatment If >2 Centor criteria - throat culture, treat if positive If >3 Centor criteria – treat empirically with Penicillin/Macrolide Do not recommend empiric treatment below 3/4. Acute Tonsillopharyngitis Other Treatments Rest Warm saline gargles –Temp 105-110 F Diet –Liquids Fluids Ice collar Oral care Influenza Infection Acute Respiratory Illness caused by Influenza A and Influenza B viruses Mainly seen in winter Often occurs as outbreaks and epidemics Transmission is person to person – Respiratory secretions of infected persons – Generally, spread by small aerosol during sneezing, coughing and talking. Influenza: Clinical Features Abrupt onset of fever, myalgia and malaise RTI - cough and sore throat Can have subacute onset over days On Examination – Hot and flushed – Cervical LN. Complications seen in high-risk patients – Pneumonia/ARDS Primary or secondary bacterial – Myositis/Rhabdomyositis – CNS Involvement - Guillain Barre Syndrome – Myocarditis/pericarditis. Influenza: High-risk Groups Age 65 years and over Pregnancy (including up to two weeks post-partum) Children aged 12 weeks in duration – Recurrent acute - >4 infectn/yr. 0 The Aetiology of Acute Sinusitis Viral Sinusitis (95% of acute cases) – Inoculation of virus into nasal sinuses either by direct migration or when blowing nose – Same viruses that cause common cold – 8-12 hrs. after - swelling, Sino nasal hypersecretion, interruption of mucociliary clearance Bacterial Sinusitis (2-5%) – Usually superinfection after viral infection – Usually have risk factors - swimmer, CF, PCD, nasal polyps, immunodeficiency. primaryciliary dyskinesia – Bugs: Strep. pneumonia, H. influenza, M. catarrhalis, Staph and Strep. Clinical Presentation Purulent Rhinorrhoea Nasal/Sinus Congestion Fever/Headache Facial Pain/teeth pain Visual disturbance, periorbital oedema/abscess Examination Tenderness of maxillary sinuses Visible oedema/narrowing of middle meatus Sinusitis: sinus infection Diagnosis Nasal Swab for culture Not reliable in healthy Radiology CT Sinuses Sinus fluid levels Swollen mucosa Treatment of Acute Sinusitis Nasal Irrigation Regular washouts of Sinuses Normal or Hypertonic Saline NSAIDS/Paracetamol Nasal Steroid Inhalers Long acting Once a day Reduces nasal stuffiness/oedema Promotes sinus drainage Topical Decongestants As per treatment of common cold Treatment of Acute Bacterial Sinusitis Indications for treatments >10 days of symptoms - think bacterial superinfection Preexisting condition that increases risk CF, PCD, Immunosuppressed. Treatment Options Observation If mild symptoms, Temp 12 weeks 3 subtypes of Chronic Rhinosinusitis (CRS) – CRS with nasal polyposis (20-33%) – CRS without nasal polyposis (60-65%) – Allergic Fungal Rhinosinusitis (8-12%) ex aspergillus Clinical features – As per acute sinusitis but > 12 weeks Investigation for Chronic Rhinosinusitis FBC with eosinophil 999 RAST Testing/Skin prick testing – Fungal allergy CT Scan of Sinuses – Nasal Polyps/Ostial obstruction – Sinus Opacification – Mucus retention cysts Rhinoscopy/Endoscopy IL 5blockade forpolyps post on Differential Diagnosis of Chronic Rhinosinusitis GORD Allergic Rhinitis Granulomatous with Polyangiitis (Wegener's Granulomatosis) Eosinophilic Granulomatosis with Polyangiitis (Churg Strauss) EFPA Sarcoidosisnoncaseating granulomas Immunoglobulin deficiency Primary Ciliary Dyskinesia/Cystic Fibrosis Treatment of Chronic Rhinosinusitis Nasal Irrigation Nasal Steroids Oral Steroids Antibiotics Leukotriene Antagonists seginosinusitis Second line (not as good as steroids) Oral/topical antifungals Biologics (Dupilumab and Mepolizumab) Take Home Messages URTI and Allergies are extremely common Likely cause is driven by the part of the URT initially affected and the presence or absence of systemic symptoms Treatment is generally supportive Antibiotics are an important therapeutic option but only in certain clinical situations iii a