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implicated. Predisposing Factor A. Upper respiratory infection Common Complaints A. Sudden onset of fever B. Sudden onset of dysphagia C. Sudden onset of drooling D. Sudden onset of muffled voice Other Signs and Symptoms A. Respiratory distress B. Stridor C. Very ill appearance Subjective Data A. Determine the onset, duration, and course of illness. B. Is the child's breathing labored? C. Are the child's breathing problems affecting his or her ability to eat or drink? D. Has he or she had a fever? E. Has he or she had trouble swallowing or talking? Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Observe overall appearance. 2. Check nail beds and lips for cyanosis. 3. Note drooling or difficulty in swallowing. 4. Note breathing pattern and rhythm. 5. Note cough if present. 6. Do not examine the throat—airway occlusion may result. C. Auscultate heart and lungs. Diagnostic Test 366 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Lateral neck radiograph confirms diagnosis. However, this test may delay the establishment of an airway. Differential Diagnoses A. Epiglottitis B. Bacterial tracheitis (a pediatric emergency) C. Viral croup D. Foreign-body aspiration E. Retropharyngeal abscess Plan A. General interventions 1. Immediate admission to hospital. 2. While awaiting transport to hospital, establish patent airway, start oxygen, and assemble airway equipment. Move the child as little as possible. 3. Insert IV access for fluids and antibiotic administration. 4. If a respiratory arrest occurs, you may not be able to see the airway to intubate. An Ambu bag and mask may work temporarily, but nasogastric (NG) tube insertion may be necessary to prevent gastric distension. 5. Prompt recognition and appropriate treatment usually result in rapid resolution of swelling and inflammation. B. Patient teaching 1. Educate the patient and the family that epiglottitis is a medical emergency. 2. If patient has drooling and no cough, diagnosis is most likely epiglottitis. If the child has cough and no drooling, then diagnosis is most likely croup. C. Pharmaceutical therapy In-hospital treatment: 1. IV fluids 2. Antibiotics; IV antibiotics after physician consultation 3. Blood and epiglottis cultures obtained before starting antibiotics 4. Drug of choice a. Cefotaxime (Claforan) 100 to 200 mg/kg/d every 8 hours IV b. Ceftriaxone (Rocephin) 50 to 100 mg/kg/d every 12 hours IV 367 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
c. Ampicillin-sulbactam (Unasyn) 150 mg/kg/d every 6 hours IV d. Amoxicillin-clavulanic acid 100 mg/kg/d every 8 hours IV 5. May give Tylenol as needed Follow-Up A. Follow-up care occurs in the hospital. B. An airway specialist should evaluate the patient in the operating room. Consultation/Referral A. If you suspect epiglottitis, refer the patient to a physician immediately. Individual Considerations A. Pediatrics 1. Never place a child in supine position because respiratory arrest has been reported. 2. All close contacts (including children and adults) exposed to a child diagnosed with epiglottitis should be treated with prophylactic antibiotics, such as rifampin, 20 mg/kg, not to exceed 600 mg/day for 4 days Oral Cancer Jill C. Cash and Moya Cook Definition A. Oral cancer is the cancer of the buccal mucosa, tongue, gingiva, hard palate, soft palate, or lips. White patches, known as leukoplakia, or red, velvety patches, known as erythroplakia, on the buccal mucosa may indicate premalignant lesions. Incidence A. Oral cancer is primarily seen in the elderly. Male-to-female predominance is 2 to 1; oral cancer is equal in African Americans and Caucasian adults. The death rate is fairly high for oral cancer secondary to the cancer being diagnosed in the late stages of development. B. There are 42,000 Americans diagnosed with new cases of oral cancer, and 368 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
8,000 deaths occur each year. C. Oral cancer represents 3% of all newly diagnosed cancers and 2% of all cancer-related deaths. D. Frequency of oral cancer of cheek and gum rises 50-fold among long-term users of smokeless tobacco. E. Patients diagnosed with oral cancer are at greater risk of developing cancer in another part of the body, such as the lung, larynx, esophagus, or other site. Therefore, follow-up examinations are recommended for the remainder of the patient's life. Pathogenesis Pathogenesis is unknown; 50% of oral cancers have already been metastasized by the time of diagnosis. The following factors are involved. A. Use of tobacco in all its forms is highly correlated with the risk of oral cancer. B. Risk of oral cancer also is high with heavy alcohol consumption. Whether this is due to a direct effect of alcohol on the oral mucosa or associated smoking or vitamin deficiency remains unclear. C. Chronic iron deficiency leading to Plummer-Vinson syndrome is known to alter mucosal tissues, and this change may be related to increased oral cancer. Research has shown that a diet low in fruits and vegetables contributes to oral cancer. D. Epstein-Barr virus and papillomavirus have been found in the cells of the tongue manifesting in oral hairy leukoplakia, a hyperplastic change found in AIDS patients. Human papillomavirus (HPV) is found in approximately 20% to 30% of cases of oral cancer. E. Occupational hazards also exist from sun exposure. It is estimated that 30% of those with oral cancer worked outdoors. Predisposing Factors A. Male gender B. Age greater than 40 years for men, greater than 50 years for women C. African American ancestry D. Smoking or use of other tobacco products, including smokeless products such as snuff and dip E. Alcohol consumption 369 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Sun exposure G. Poor diet, deficient in vitamins A, C, and E, and high in salted or smoked meats, fats, and oils H. Previous cancer Common Complaints A. Oral sores that do not heal, which is the primary reason patients seek medical care B. Poorly fitting dentures C. Bleeding mucosa or gingiva without apparent cause D. Difficulty swallowing, usually indicating more advanced disease E. Altered sensations: Burning or numbness, usually indicating more advanced disease F. Leukoplakia or erythroplakia Other Signs and Symptoms A. No symptoms, possibly B. Decreased appetite related to altered taste C. Increased salivation D. Sore throat E. Foul breath odor F. Neck mass Subjective Data A. Review the onset, course, and duration of symptoms. Question the patient regarding altered taste, sensations, difficulty swallowing, and foul breath. B. Evaluate for risk factors. See Predisposing Factors. C. Ask the patient about previous history of cancer and treatments. D. Review the patient's use of tobacco products, including age of onset, amount of daily use, and quit dates. E. Evaluate amount of alcohol intake, including age of onset, amount of daily use, and quit dates. F. Review the patient's general health history for other chronic conditions. G. Review medication history, including prescription and over-the-counter drug use, especially aspirin. H. Take dental history, including previous gum surgery, how long ago 370 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
dentures were fitted, and if they always fit well. I. Establish usual weight. Is there any weight loss related to altered taste, and, if so, how much and during what length of time? Physical Examination A. Check temperature, pulse, respirations, blood pressure, and weight. B. Inspect 1. Observe general appearance. 2. Note quality of voice patterns. 3. Note odor of breath. 4. Inspect lips, gums, tongue, and buccal mucosa for swelling, discoloration, bleeding, asymmetry, texture, limited movement of tongue, abnormal ulcerations, leukoplakia, and erythroplasia. Take out dentures first. 5. Assess for tenderness or pain in mouth/tongue. a. Leukoplakia ranges from slightly raised, white, translucent areas to dense, white, opaque plaques, with or without adjacent ulceration. Normal intraoral mucosa is pinkish or salmon colored. b. Mucosal erythroplasia is red, inflammatory, or shows erythroplastic mucosal changes. It appears smooth, granular, and minimally elevated, with or without leukoplakia, and it persists more than 14 days. c. Erythroplakia may mimic inflammatory lesions, but it can be differentiated by failure of the affected area to blanch with light pressure. Erythroplakia is a malignant change seen as a red, velvety, plaque-like lesion on the mucous membrane. d. Other oral lesions appear black, blue, or brown. e. Approximately 90% of cancers are squamous cell carcinomas, and most occur in sites accessible by clinical examination: Tongue, oropharynx (soft palate, lingual aspect of retromolar trigone, anterior tonsillar pillar), and floor of mouth. f. Cancer of the lip is a lesion that fails to heal. g. Signs and symptoms of cancer of the tongue are swelling, ulceration, areas of tenderness or bleeding, abnormal texture, and limited movement. C. Palpate 371 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Palpate mouth for masses. Try to remove or scrape patches. 2. Palpate lymph nodes: Cervical (anterior/posterior chain), submandibular, sublingual, and submental, pre-/postauricular; check nodes for size, firmness, and tenderness. D. Auscultate lungs and heart. The lungs are the most frequently involved extranodal metastatic site. Diagnostic Tests A. Check for HIV, if indicated. B. Staining of oral lesion with toluidine blue: Lesion stains dark blue after rinsing with acetic acid. Normal tissue does not absorb the stain. C. Biopsy for persistent lesions (more than 2 weeks): It is essential to differentiate from blue-black lesion of malignant melanoma. D. Perform chest radiography to rule out metastasis. E. Consider CT, MRI, or bone scan to rule out metastasis. Differential Diagnoses A. Oral leukoplakia B. Pulpitis C. Periapical abscess D. Gingivitis E. Periodontitis F. Lichen planus G. Oral candidiasis H. Discoid lupus I. Pemphigus vulgaris Plan A. General interventions 1. If oral cancer is suspected, refer to a physician or an otolaryngologist/dentist for evaluation. 2. Suspicious lesions should be biopsied. B. Patient teaching 1. Advise the patient to stop smoking and stop using oral tobacco products. 2. Advise the patient to decrease/eliminate alcohol consumption. 372 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Encourage routine dental care and examinations. 4. Review dietary intake and educate the patient regarding benefits of increasing dietary intake of vitamins A, C, and E. Encourage the patient to decrease dietary intake of foods that are high in salt, smoked meats, fats, and oils. 5. Recommend wearing sunscreen/lip balm with sun protection factor (SPF) of 15 or greater. 6. Avoid contracting the HPV infection. Recommend Gardasil vaccination for girls and boys 9 to 26 years of age. C. Pharmaceutical therapy 1. Erythroplakia does not respond to antifungal therapy. 2. Treatment is based on diagnosis. Follow-Up A. If immediate biopsy is not indicated, ask the patient to return for reevaluation in 2 weeks, after eliminating irritants and noxious agents. Consultation/Referral A. Refer the patient to an otolaryngologist and/or a dentist for immediate biopsy for deeply ulcerative or fungating lesions. Follow-up treatment may include one or more of the following: Wide excision, radical neck dissection, radiation, and chemotherapy. Individual Considerations A. Pediatrics 1. Currently, the highest rate is in smokeless tobacco use. 2. Oral screening should be considered annually in adolescents who use tobacco and/or alcohol. B. Adults: The American Cancer Society recommends that people between ages 20 and 40 years undergo an oral cancer screening every 3 years, and that those older than 40 years be screened every year. Oral screening should be considered annually in adults who use tobacco and/or alcohol. Resources American Academy of Family Physicians: www. aafp. org American Cancer Society: www. cancer. org 373 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
National Cancer Institute: www. cancer. gov Oral Cancer Foundation: www. oralcancerfoundation. org Pharyngitis Jill C. Cash and Moya Cook Definition A. Pharyngitis is the inflammation of the pharynx and the surrounding lymph tissue. Incidence A. Pharyngitis is the fourth most common condition seen in medical practice. Pathogenesis Pharyngitis may be due to viral, bacterial, and fungal agents, as well as other atypical agents. A. Viral agents include coxsackievirus, enteric cytopathic human orphan (ECHO) viruses, and Epstein-Barr virus. B. Bacterial agents include Group A beta-hemolytic Streptococcus, Neisseria gonorrhoeae, and Corynebacterium diphtheriae. C. The fungal source is Candida albicans. D. Atypical agents include Mycoplasma pneumoniae and Chlamydia trachomatis (rare). E. Noninfectious causes include allergic rhinitis, postnasal drip, mouth breathing, and trauma. Predisposing Factors A. Cigarette smoking B. Allergies C. Upper respiratory infections D. Oral sex E. Drugs (antibiotics and immunosuppressants) F. Debilitating illnesses (such as cancer) that can cause C. albicans to proliferate 374 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Common Complaints A. Sore and/or scratchy throat B. Fever C. Headache D. Malaise Other Signs and Symptoms A. Oral vesicles B. Exudate on throat or “beefy” red throat without exudate C. Lymphadenopathy D. Fatigue E. Dysphasia F. Abdominal pain G. Vomiting Potential Complications Without proper antimicrobial treatment, streptococcal pharyngitis can lead to serious complications such as the following: A. Suppurative adenitis with tender, enlarged lymph nodes B. Scarlet fever C. Peritonsillar abscess D. Glomerulonephritis E. Rheumatic fever Subjective Data A. Ask the patient about the onset, course, and duration of symptoms. Ask about dyspnea or dysphagia. B. Inquire about mouth lesions, rhinorrhea, cough, drooling, and fever. C. Ask about malaise, headache, fatigue, and fever; these are symptoms of mononucleosis. D. Take a sexual history, if indicated. Ask if family members or sexual partners have the same signs and symptoms. Pharyngeal gonorrhea has no symptoms, so high-risk patients should be tested. E. Ask whether symptoms have caused decreased intake of food and fluid. F. Determine history of heart disease; previous strep pharyngitis; rheumatic 375 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
fever; and other respiratory diseases, such as asthma, emphysema, and chronic allergies. G. If rash is present, find out when it first occurred and if it has spread. H. Ask about signs and symptoms of urinary tract infection and pyelonephritis. I. Ask about a history of herpes, immunosuppressive disorders, and steroid use. J. Review immunization history. Physical Examination A. Temperature and blood pressure, if indicated B. Inspect 1. Observe general appearance. 2. Examine the mouth, pharynx, tonsils, and hard and soft palate for vesicles and ulcers, candidal patches, erythema, hypertrophy, exudate, and stomatitis. Check gum and palate for petechiae and tongue for color and inflammation. 3. Examine the ears, nose, and throat. Assess patency of airway if tonsils are enlarged. 4. Inspect skin for rashes. a. Pastia's lines are petechiae present in a linear pattern along major skin folds in axillae and antecubital fossa that are seen with Group A Streptococcus. b. Erythema marginatum, caused by Group A Streptococcus, is an evanescent, nonpruritic, pink rash mainly on the trunk and extremities. It may be brought out by heat application. C. Auscultate heart and lungs. D. Percuss 1. Abdomen, especially spleen area 2. Chest E. Palpate 1. Palpate lymph nodes, especially of the anterior and posterior cervical chains, axilla, and groin. 2. Palpate abdomen for organomegaly and suprapubic tenderness. 3. Palpate back for costovertebral angle (CVA) tenderness. F. Neurologic examination: Check for nuchal rigidity and meningeal 376 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
irritation. Diagnostic Tests A. Rapid strep test; if negative, then perform throat culture and sensitivity. Throat culture and sensitivity are the gold standard for diagnosis. B. Monospot test C. Complete blood count with differential D. Gonorrhea culture E. Blood cultures if sepsis is suspected F. Radiograph of neck if possible trauma Differential Diagnoses A. Pharyngitis B. Stomatitis C. Rhinitis D. Sinusitis with postnasal drip E. Epiglottis F. Peritonsillar abscess G. Mononucleosis H. Herpes simplex I. Coxsackie A virus J. C. diphtheriae K. Trench mouth L. Vincent's angina M. C. albicans N. HIV Plan A. General interventions 1. Patients with a history of rheumatic fever and those who have a household member with a documented Group A streptococcal infection need immediate treatment without prior testing. 2. Herpangina are small oral vesicles on the fauces and soft palate caused by the coxsackievirus. 3. Herpes causes vesicles and small ulcers (stomatitis) of the buccal mucosa, tongue, and pharynx. 377 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4. Trench mouth (gingivitis) and necrotic tonsillar ulcers (Vincent's angina) cause foul breath, pain, pharyngeal exudate, and a gray membranous inflammation that bleeds easily. 5. C. albicans (thrush) may be painful and causes cheesy, white exudate. 6. Oral candidiasis may be the first symptom of HIV. 7. Peritonsillar cellulitis causes inflamed, edematous tonsils; grayish-white exudate; high fever; rigors; and leukocytosis. Peritonsillar abscess (palpable mass) may also develop. 8. Mononucleosis causes tonsillar exudates in 50% of patients; 33% develop petechiae at junction of the hard and soft palate. 9. C. diphtheriae causes a whitish-blue pharyngeal exudate “pseudomembrane” that covers the pharynx and bleeds if removal is attempted. 10. Do not put instruments in the airway if you suspect epiglottitis. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Pharyngitis. ” C. Pharmaceutical therapy 1. Drug of choice: Prescribe one of the following penicillins for bacterial pharyngitis. a. Penicillin V potassium (Pen-Vee-K) i. Children: 250 mg orally two to three times daily for 10 days. Adolescents and adults: 250 mg four times daily or 500 mg twice daily for 10 days ii. Children: Amoxicillin 50 mg/kg/d once daily for 10 days (maximum 1,000 mg); alternative, 25 mg/kg (max = 500 mg) twice daily for 10 days b. Penicillin G benzathine: Less than 27 kg: 600,000 U × 1 dose intramuscular (IM); greater than or equal to 27 kg: 1,200,000 U × 1 dose IM 2. If the patient is allergic to penicillin: a. Cephalexin, oral: 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days b. Cefadroxil, oral: 30 mg/kg once daily (max 1 g) for 10 days c. Clindamycin, oral: 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days d. Azithromycin, oral: 12 mg/kg once daily (max 500 mg) daily for 5 378 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
days e. Clarithromycin, oral: 7. 5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days 3. Recurrent bacterial pharyngitis a. Clindamycin: 20 to 30 mg/kg/d in three doses (max 300 mg/dose) for 10 days b. Penicillin and rifampin: Penicillin V: 50 mg/kg/d in four doses for 10 days (max 2,000 mg/d); rifampin: 20 mg/kg/d in one dose for last 4 days of treatment (max 600 mg/d) c. Amoxicillin-clavulanic acid: 40 mg amoxicillin/kg/d in three doses (max 2,000 mg amoxicillin/d) for 10 days d. Benzathine penicillin G (IM) plus rifampin (oral): Benzathine penicillin G: 600,000 U for less than 27 kg and 1,200,000 U for greater than or equal to 27 kg × 1 dose; rifampin: 20 mg/kg/d in two doses (max 600 mg/d) for 4 days 4. For pharyngeal gonorrhea a. Adults: Ceftriaxone (Rocephin) 500 mg to 1 g by IM injection b. Children: Ceftriaxone (Rocephin) 50 to 75 mg/kg in one dose by IM injection 5. For M. pneumoniae and C. trachomatis: Erythromycin (E-Mycin) 250 mg orally three to four times daily for 10 days 6. For pharyngeal candidiasis in the immunocompromised patient: a. Oral nystatin suspension (100,000 U/m L) 15 m L by swish-and-swallow method four times a day b. Clotrimazole troche 10 mg held in mouth 15 to 30 minutes three times daily Follow-Up A. If symptoms do not improve in 3 to 4 days, recheck patient. B. Treat sexual partners of patients with pharyngeal gonorrhea. Consultation/Referral A. Consult physician if patient has severe dysphagia or dyspnea, signaling possible airway obstruction. B. Refer the patient to an otolaryngologist if peritonsillar abscess is noted. 379 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Individual Considerations A. Pediatrics 1. Rheumatic fever follows between 0. 5% and 3% of ineffectively treated cases of Group A streptococcal upper respiratory infections. 2. Approximately 20% of children aged 5 to 15 years who are diagnosed with rheumatic fever had pharyngitis in the preceding 3 months. Stomatitis, Minor Recurrent Aphthous Stomatitis Jill C. Cash and Moya Cook Definition A. Stomatitis is tender, round, discrete, oval, shallow, 1-to 5-mm ulcers in the oral cavity. The ulcers are gray white or yellow, on nonkeratinized skin, and surrounded by erythematous halos. They typically involve the labial and buccal mucosa and tongue, and adjacent tissue appears healthy. B. Major recurrent aphthous stomatitis (RAS) has larger, deeper ulcers; lasts a longer period of time; usually recurs up to four times a year; and frequently leaves scars. It can cause significant dysphagia. Incidence A. Stomatitis affects 20% to 50% of the population. It is very common in North America. Pathogenesis A. Cause is poorly understood. Genetic, immunologic, viral, or nutritional causes are possible. Predisposing Factors A. Minor trauma B. History of RAS C. Possible nutritional deficiency of iron, folic acid, or zinc D. Hormonal changes Common Complaint 380 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Painful sore in mouth Other Signs and Symptoms A. Burning sensation in mouth for 24 to 48 hours before lesions appear Subjective Data A. Elicit history of aphthous stomatitis. B. Ask the patient about prodrome of burning or stinging in the mouth. C. Elicit information regarding previous illness and trauma. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Mouth for ulcers 2. Ears, nose, and throat 3. Skin, especially palms and soles, for lesions; indicates hand, foot, and mouth disease C. Auscultate heart and lungs. Diagnostic Tests A. Specific diagnostic testing for stomatitis is not needed. B. Consider HSV culture if herpes simplex virus is considered for diagnosis. C. If syphillis is of concern, order serum rapid plasma reagin (RPR). Differential Diagnoses A. Aphthous stomatitis B. Herpetic stomatitis C. Behçet's disease D. Crohn's disease E. HIV F. Kawasaki syndrome G. Hand, foot, and mouth disease Plan A. General interventions 1. Avoid spicy, salty, or hot foods. 381 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Encourage cold foods, such as fluids, ice pops, and so on, to help with pain. 3. Avoid hard, sharp food that is difficult to chew. 4. Recommend using a soft-bristle toothbrush when brushing teeth. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Aphthous Stomatitis. ” C. Pharmaceutical therapy 1. Mouthwash made of diphenhydramine (Benadryl), with Kaopectate, or Maalox or sucralfate, and viscous lidocaine three to four times a day. Leave out lidocaine when using in children. Tell the patient not to swallow medication. 2. Sucralfate (Carafate) suspension 1 teaspoon four times a day may be used to swish in mouth and spit out for oral comfort. 3. Glucocorticoid gel, such as fluocinonide gel (Lidex), 0. 05% two to four times a day, one of which is always at bedtime. 4. Orabase with or without triamcinolone acetonide (Kenalog). Follow-Up A. Follow up as needed for treatment of recurrences. Consultation/Referral A. Refer the patient to or consult with a physician if ulcers are deeper or larger than 1 to 5 mm, if Kawasaki disease is suspected, or if no improvement is seen with adequate treatment. B. Any lesion lasting longer than 3 weeks should be evaluated by a dentist or oral surgeon to rule out cancer. Individual Considerations A. Pregnancy: Avoid use of fluocinonide and triamcinolone acetonide (Kenalog) in pregnant or nursing women. B. Pediatrics 1. Avoid use of fluocinonide and triamcinolone acetonide (Kenalog). 2. Do not use viscous lidocaine. Thrush 382 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Jill C. Cash and Moya Cook Definition A. Thrush is a fungal infection of the oral cavity and/or the pharynx caused by Candida. Incidence A. It is estimated that 5% to 7% of babies younger than 1 month, both bottle-fed and breastfed infants, will develop oral candidiasis. Approximately 9% to 31% of AIDS patients and 20% of patients diagnosed with cancer will have thrush. Pathogenesis A. Thrush is an overgrowth of yeast cells, Candida albicans, on the oral mucosa, which leads to desquamation of the epithelial cells, creating a psuedomembrane over the normal oral mucosa. Predisposing Factors A. Use of broad-spectrum antibiotics B. Adults 1. HIV 2. Prolonged steroid use (systemic or inhaled corticosteroids) 3. Cancer treatments (radiation/chemotherapy) 4. Dentures 5. Malnutrition C. Children 1. Endocrine disorders (thyroid disease, diabetes mellitus, and Addison's disease) 2. HIV 3. Cancer Common Complaint A. Soreness, pain of the mouth Other Signs and Symptoms 383 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Irritability in infants B. Refusal to eat in infants C. White plaques coating buccal mucosa Subjective Data A. Determine the onset, duration, and course of illness. B. Ask if the child refuses to eat. C. Has the patient used antibiotics or other medications in the previous weeks? D. Does the patient use inhaled or systemic steroids on a daily basis? Physical Examination A. Check temperature, pulse, respirations, and blood pressure. B. Inspect 1. Oral cavity for white, curd-like plaques that cannot be removed 2. Ears, nose, and throat 3. Genital area for red rash and satellite papular lesions Diagnostic Tests A. If diagnosis is certain, no testing recommended. B. If uncertain of diagnosis, swab lesion for KOH testing. C. If treatment prescribed is not working, fungal culture should be sent for diagnosis. Differential Diagnoses A. Thrush B. Milk deposits on tongue or buccal mucosa C. Stomatitis D. Aphthous ulcer E. Hairy leukoplakia Plan A. General interventions 1. If the infant is breastfeeding, instruct the mother to clean breasts and nipples well with warm water between feedings to prevent contamination. Consider prescribing antifungal cream to be applied to breasts; this should 384 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
be washed off before feedings. 2. If bottle feeding, boil all bottles, nipples, and pacifiers to kill the organism. 3. Instruct caregiver to attempt removal of large plaques with a moistened cotton-tipped applicator and/or small, moist gauze pad before inserting medication in mouth. 4. If thrush is recurrent or resistant, consider checking the mother for candidal vaginitis. 5. For adults, instruct the patient/family on proper use and cleaning/rinsing of inhalers/dentures to prevent reoccurrence of thrush. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Oral Thrush in Children. ” C. Pharmaceutical therapy 1. Oral candidiasis: Nystatin (Mycostatin) oral suspension 1 m L four times a day for 1 week. Place medication in front of mouth on each side. Rub directly on plaques with a cotton swab. Adults: Pastilles: 200,000-unit lozenge four times a day for 14 days, or swish-and-swallow 500,000 units four times a day for 14 days or two 500,000-unit tablets three times daily for 14 days. 2. Clotrimazole troche (Mycelex): 10 mg five times daily for 14 days; monitor for side effects. 3. Fluconazole: Adults: 200 mg × 1, then 100 mg daily for 5 to 7 days. Children: 5 mg/kg by mouth every day for 5 days or 6 to 12 mg/kg on first day, then 3 to 6 mg/kg for 10 days. 4. Genital candidal dermatitis: Nystatin cream three to four times a day for 7 to 10 days. Have caregiver discontinue use of all baby wipes, lotions, powders, and creams. Follow-Up A. Instruct caregiver to telephone the office if the child refuses to eat, if there is no improvement, if thrush lasts more than 10 days, or if there is unexplained fever. Consultation/Referral A. Consult a physician if thrush does not resolve with adequate antifungal treatment. 385 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Bibliography American Academy of Pediatric Denistry. (n. d. ). Decision trees for management of avulsed permanent tooth. Retrievedfrom http://www. aapd. org/media/policies_guidelines/rs_traumaflowsheet. pdf American Cancer Society. (2013). Oral cavity and pharyngeal cancer. Retrieved from http://www. cancer. org/cancer/oralcavityandoropharyngealcancer/detailedguide/index Aronson, M., & Auwaerter, P. (2014). Infectious mononucleosis in adults and adolescents. In M. Hirsch & S. Kaplan, (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/infectious-mononucleosis-in-adults-and-adolescents? source=search_result&search=infectious+mononucleosis&selected Title=1%7E150 Doshi, D. (2009). Bet 3. Avulsed tooth brought in milk for replantation. Emergency Medicine Journal, 26(10), 736-737. Goldstein, B., & Goldstein, A. (2015). Oral lesions. In R. Dellavalle & D. Deschler (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/oral-lesions? source=search_result&search=aphthous+ulcers&selected Title=1%7E150 Haddad, R. (2016). Human papillomavirus associated head and neck cancer. In B. Brockstein, D. Brizel, & M. Fried (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/human-papillomavirus-associated-head-and-neck-cancer? source=search_result&search=oral+cancer+and+hpv&selected Title=1%7E150 Kauffman, C. (2016). Treatment of oropharygneal and esophageal candidiasis. In K. Marr (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/treatment-of-oropharyngeal-and-esophageal-candidiasis?source=search_result&search=oral+candidiasis&selected Title=1%7E150 Pichichero, M. (2016). Treatment and prevention of streptococcal tonsillopharyngitis. In D. Sexton & M. Edwards (Eds. ), Up To Date. Retrieved from https://www. uptodate. com/contents/treatment-and-prevention-of-streptococcal-tonsillopharyngitis? source=see_link§ion Name=TREATMENT&anchor=H9#H9 Udeani, J. (2016). Pediatric epiglottitis treatment & management. Medscape. Retrieved from http://emedicine. medscape. com/article/963773-treatment#d13 Wald, E. (2016). Approach to diagnosis of acute infectious pharyngitis in children and adolescents. In M. Edwards (Ed. ), Up To Date. Retrievedfrom http://www. uptodate. com/contents/approach-to-diagnosis-of-acute-infectious-pharyngitis-in-children-and-adolescents? source=search_result&search=bacterial+pharyngitis+children&selected Title=1%7E150 Woods, C. (2015). Epiglottitis (supraglottitis): Clinical features and diagnosis. In M. Edward, G. Isaacson, & G. Fleischner (Eds. ), Up To Date. Retrieved from http://www. uptodate. com/contents/epiglottitis-supraglottitis-clinical-features-and-diagnosis? source=search_result&search=epiglottitis&selected Title=1%7E44 386 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
9Respiratory Guidelines Asthma Cheryl A. Glass and Melissa A. Hall Definition Pathophysiologically, asthma is defined by airway inflammation, intermittent airflow obstruction secondary to increased smooth muscle tone and bronchial hyperresponsiveness. Episodes are associated with widespread, variable, often reversible airflow obstruction and bronchial hyperresponsiveness when airways are exposed to various stimuli or triggers. Asthma is responsible for lost school days, lost productivity, and presenteeism. Asthma is classified into four categories: A. Step 1—Mild intermittent : Symptoms less than or equal to two per week; asymptomatic with normal peak expiratory flow rate (PEFR) between attacks; nighttime symptoms less than or equal to two per month; PEFR greater than 80% is predicted with a variability of less than 20%. B. Step 2—Mild persistent : Symptoms greater than two per week but less than one per day; exacerbations may affect activity; nighttime symptoms greater than two per month; PEFR greater than or equal to 80% is predicted with variability of 20% to 30%. C. Step 3—Moderate persistent : Daily symptoms require beta 2 agonist use; attacks affect activity; exacerbations greater than or equal to two per week; nighttime symptoms greater than one per week; PEFRs between 60% and 80% with a variability greater than 30%. D. Step 4—Severe persistent : Continuous symptoms with limited physical activity; frequent exacerbations; frequent nighttime symptoms; PEFR less 387 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
than or equal to 60% is predicted with greater than 30% variability. Incidence A. Asthma affects 25 million people in the United States, or 300 million worldwide. B. Asthma is the most common chronic disease of childhood, affecting 15% of children. C. Up to 95% of patients with asthma also suffer from persistent rhinitis. D. Asthma is often associated with other comorbid conditions, including gastroesophageal reflux disease (GERD) and obesity. E. Although asthma can present at any age, the peak age of diagnosis is before age 5 years. Pathogenesis A. Asthma arises from a complex cycle of processes initiated by airway inflammation resulting from physical, chemical, and pharmacological agents (such as environmental irritants, allergens, furry animals, cockroaches, dust mites, pollen and mold, cold air, viral respiratory infections, and exercise). It progresses to airway hyperresponsiveness, bronchoconstriction, airway wall edema, chronic mucus plug formation, and chronic airway remodeling. Predisposing Factors A. In children 1. Allergy or family history of allergy 2. Atopy 3. Ethnicity (Puerto Rican descent, non-Hispanic Black) 4. Gender: Male during childhood B. In adults 1. Family history 2. Coexisting sinusitis, nasal polyps, and sensitivity to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Exposure in workplace to wood dust, metals, and animal products 4. Premenstrual asthma (PMA) 5. Gender: Female in adulthood 6. Ethnicity: Non-Hispanic Black for persistent asthma 7. Occupational exposures 388 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
8. Comorbidities in older adults C. In all ages 1. Inhalation of irritants such as tobacco smoke 2. Viral respiratory infections 3. Gastroesophageal reflux 4. Obesity 5. Lower socioeconomic level D. Triggers 1. Allergen exposure 2. Viral infections of the upper airways 3. Medication (potential risk with beta-blockers, angiotensin-converting enzyme [ACE] inhibitors, aspirin, cyclooxygenase [COX] inhibitors) 4. Exercise 5. Situational factors: Cold air, laughter, strong odors, air pollution, smoke exposure, pregnancy 6. Foods 7. Hormones 8. Gastrointestinal (GI) reflux 9. Stress Common Complaints A. Recurrent cough (worse at night and early morning) B. Recurrent wheezing C. Recurrent shortness of breath (SOB) D. Dyspnea (less likely to be reported in the elderly) E. Recurrent chest tightness (may worsen with moderate activity) Other Signs and Symptoms A. Nocturnal awakening from symptoms B. Variation of symptoms with seasons or environment C. Chest discomfort, tightness with moderate activity Subjective Data A. Ask about the onset, duration, and course of symptoms. B. Inquire about sudden severe episodes of coughing, wheezing, and SOB and whether precipitating factors can be identified. 389 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Ask whether the patient has chest colds that take more than 10 days to resolve. D. Ask if the patient is a smoker, how much, and for how long he or she has smoked. E. Ask whether symptoms seem to occur during certain seasons or during exposure to the following environmental irritants: 1. Tobacco smoke 2. Perfume 3. Household pets 4. Fireplaces 5. Woodburning stoves 6. Mold 7. Dust mites 8. Cockroaches F. Find out how often coughing, wheezing, or SOB awaken the patient. G. Ask if symptoms are caused or exacerbated by moderate exercise or physical activity. H. Determine the family history of asthma, allergies, and eczema. I. Determine whether the patient is pregnant or has medical problems. If so, do not prescribe long term beta 2 adrenergics or NSAIDs. The safest medications are short-acting beta agonists (SABA), cromolyn sodium, and anticholinergic drugs. J. Administer the asthma control test for adults or the childhood asthma control test for children aged 4 to 11 years. This test is for self-report (or parent-report) to determine whether asthma symptoms are under control. Both tests are available online from www. asthmacontrol. com. A score greater than 20 points indicates that the patient's asthma is well controlled. Scores of 5 to 19 points indicate that the patient is not well controlled. K. Evaluate whether the patient has ever been tested for allergies. L. Ask whether the patient has ever needed to go to the emergency room or had to be hospitalized for an asthma attack. M. Review all medications, including over-the-counter (OTC) and herbal supplements. Physical Examination A. Check temperature (if indicated), blood pressure, pulse, respirations, and 390 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
pulse oximetry. Measure the patient's height and weight to calculate body mass index (BMI) because obesity is associated with asthma, and evaluate failure to thrive if suspected. B. Inspect 1. Especially in children, observe for hyperexpansion of thorax and signs that accessory muscles are being used (retractions, nasal flaring) or stridor. 2. Note appearance of hunched shoulders and/or chest deformity. 3. In children, inspect the nose for a foreign body. 4. In all patients, inspect ears, nose, and throat. Evaluate the presence of enlarged tonsils and adenoids, and nasal polyps. 5. Inspect skin for eczema, dermatitis, or other irritation that might signal allergy. 6. Observe for allergic shiners and pebbled conjunctiva. 7. Observe for digital clubbing. C. Auscultate 1. Auscultate lung sounds. Note wheezing during normal expiration and prolonged expiration, which is seen with asthma. 2. Listen to all lung fields for an asymmetric wheeze. 3. Auscultate heart. D. Percuss lung fields. Diagnostic Tests A. Spirometry is the gold standard. Peak flow meter measurements are not a substitute for spirometry. Evaluate the forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) before and after the patient inhales a short-acting bronchodilator. B. Evaluate chest radiograph (CXR) and complete blood count (CBC) to exclude other diagnoses and infection. C. Allergy testing is recommended for children with persistent asthma. D. Check PEFR after inhalation of SABA. Diagnosis is confirmed if: 1. There is a 15% increase in PEFR after 15 to 20 minutes. 2. PEFR varies more than 20% between arising and 12 hours later in patients taking bronchodilators (or 10% without bronchodilators). 3. There is a greater than 15% decrease in PEFR after 6 minutes of 391 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
running or exercise. E. Consider a bronchial provocation test with histamine or methacholine for nondiagnostic spirometry. Differential Diagnoses A. In infants and children 1. Asthma 2. Pulmonary infections: a. Pneumonia b. Respiratory syncytial virus (RSV) c. Viral bronchiolitis d. Tuberculosis (TB) 3. Allergic rhinitis and sinusitis 4. Foreign body in the nose, trachea, or bronchus 5. GERD 6. Cystic fibrosis (CF) 7. Bronchopulmonary dysplasia 8. Vocal cord dysfunction 9. Enlarged lymph nodes or tumors B. In adults 1. Asthma 2. Chronic obstructive pulmonary disease (COPD) 3. GERD 4. Congestive heart failure (CHF) 5. Cough secondary to medications such as ACE inhibitors or beta-blockers 6. Pneumonia, including aspiration pneumonia in elderly or post-cerebrovascular accident (CVA) 7. Pulmonary embolism 8. Laryngeal dysfunction 9. Benign and malignant tumors 10. Vocal cord dysfunction Plan A. General interventions 1. Review proper medication dosages. Short-and long-term agents come 392 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
in several formulations, such as nebulizer, metered-dose inhaler (MDI), and a dry powder inhaler (DPI). Young children should have medication via a nebulizer using an appropriate-size face mask. The “blow-by” technique is not an appropriate means of administering medication. 2. Demonstrate correct use of inhalers, spacers, and nebulizers. If the patient does not use correct technique when using these devices, medication does not get delivered to the bronchioles, and therefore the patient may believe that the medication does not work. Most often, the medication works well when delivered to the bronchioles correctly. See Section III: Patient Teaching Guide for this chapter, “ Asthma: How to Use a Metered-Dose Inhaler” 3. Stress the importance of using a peak flow monitor at home to monitor progress of the disease. See Section III: Patient Teaching Guide for this chapter, “ Asthma: Action Plan and Peak Flow Monitoring. ” 4. SABAs are used for rescue from acute symptoms. 5. Use of a SABA more than twice a week for symptom relief indicates that the patient has inadequate asthma control and needs an inhaled corticosteroid (ICS) as controller therapy. 6. Stress the need for an asthma action plan. See Section III: Patient Teaching Guide for this chapter, “Asthma: Action Plan and Peak Flow Monitoring. ” B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Asthma. ” C. Pharmaceutical therapy: Drugs are prescribed in a stepwise fashion for the type of asthma. The amount of medication used depends on the severity of the asthma (Steps 1-6 in the following list). Before any medication/dosage changes, monitor the patient's compliance (see Table 9. 1). The following treatments are recommended for children aged 5 years and older and for adults: 1. Step 1: Mild a. No long-term preventive medications are needed. b. Use SABAs as rescue medication. May be used up to four times a day to treat exacerbations. c. Alternative medications include cromolyn, nedocromil, leukotriene modifier, or theophylline. 2. Step 2: Mild to moderate 393 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
a. Low-dose ICSs are used daily as a long-term preventive medication. b. Only budesonide inhalation suspension is approved by the Food and Drug Administration (FDA) for use in infants and children younger than 4 years. c. Alternative medications include an ICS plus either a leukotriene modifier or theophylline. 3. Step 3: Moderate a. Consider referral to asthma specialist at Step 3. b. Use low-dose ICS plus a long-acting beta 2 agonist (LABA) or a medium-dose ICS. c. Use ICS plus either a leukotriene modifier or theophylline or zileuton. 4. Step 4: Moderate to severe a. Medium-to high-dose ICS plus either a LABA or Montelukast b. Medium-dose ICS plus either a leukotriene modifier or theophylline c. Second alternative: Medium-dose ICS plus either leukotriene modifier, theophylline, or zileuton 5. Step 5: Severe a. High-dose ICS plus LABA and consider omalizumab for patients with allergies 6. Step 6: Severe a. High-dose ICS plus LABA plus oral CS and consider omalizumab for patients who have allergies 7. Acute exacerbations in pediatrics: 0. 3 or 0. 6 mg/kg orally once daily for 1 or 2 days, up to a max of 16 mg/dose 8. Exercise-induced bronchospasm a. Short-acting inhaled beta 2 agonist: Two inhalations shortly before exercise are effective for 2 to 3 hours. b. LABA, two inhalations are effective for 10 to 12 hours. TABLE 9. 1 Medications for Asthma and COPD (By Class/Alphabetical Order) 394 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
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9. Hypertension and asthma: Drug of choice is a calcium channel blocker. Asthmatics also tolerate diuretics well. 10. Theophylline can cause cardiac arrhythmias; therefore, use it with caution and always follow up with theophylline levels. 11. Vaccinations a. Inhaled flu vaccine is not used in children with asthma. Inactivated influenza vaccine is safe, including for children with severe asthma. b. Pneumococcal vaccine is recommended for children with asthma. D. Goal of asthma therapy 1. Minimal to no chronic symptoms, including night-time symptoms 2. Minimal exacerbations 3. No emergency department visits 4. Minimal use of SABA 5. No limitations of activities 6. Peak expiratory flow maintained in normal range 7. Minimal adverse effects of medications Follow-Up A. After acute episodes, follow up within 1 to 2 hours or next day to monitor improvement until patient is stable. 396 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. For patients with mild intermittent or mild persistent asthma under control for at least 3 months, assess and follow up at least every 6 months to provide education and reinforce positive behaviors. Gradually reduce medication dosage. If control is not achieved, consider increasing the dosage after reviewing medication technique, compliance, and environmental control. Consultation/Referral A. Consider hospitalization for patients with acute episodes who do not completely respond to treatment within 1 to 2 hours. B. If all therapies fail—including a short burst of prednisone—refer the patient to an asthma specialist. C. Consult with a physician when the patient is pregnant or has other medical problems, or when standard treatment is ineffective. D. Refer if the patient presents with atypical symptoms. Individual Considerations Inhaled budesonide is the preferred ICS for treatment of asthma in pregnancy. Cromolyn is generally considered less effective than ICS and is therefore second line in pregnancy (http://acaai. org/asthma/whohasasthma/pregnancy). A. Pregnancy 1. Risks of uncontrolled asthma far outweigh risks to mother or fetus from drugs used to control the disease. 2. Most drugs used to treat asthma and rhinitis, with the exception of brompheniramine and epinephrine, pose little increased risk to the fetus. 3. Classes of drugs that do cause risk include decongestants, antibiotics (tetracycline, sulfonamides, and ciprofloxacin), live virus vaccines, immunotherapy (if doses are increased), and iodides. Always weigh benefits against risks, because adequate fetal oxygen supply is essential. 4. If corticosteroids are necessary, recommend aerosolized forms due to their lower systemic effects. Prednisone or methylprednisolone are preferred and should be prescribed at minimum effective doses. 5. Do not prescribe inhaled triamcinolone because it is teratogenic. 6. Drugs recommended during pregnancy a. A beta 2 agonist, such as terbutaline, is preferred; two inhalations every 4 hours as needed up to eight inhalations per day. Regular daily 397 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
use suggests a need for additional medications. b. Cromolyn; two inhalations four times daily as initial therapy for patients needing regular medication. c. Regular inhaled beclomethasone if cromolyn is not effective. d. Regular oral theophylline if beclomethasone is not effective. e. Oral prednisone if all other therapies fail; 1 week of 40 mg per day, followed by 1 to 2 weeks of tapering. Recommend obstetric consult before prescribing. 7. Leukotrine inhibitors should be prescribed in pregnancy only if clearly needed. a. Accolate is excreted in breast milk and should not be prescribed to mothers who are breastfeeding. b. Fetal anomalies have been reported with Zyflo. B. Geriatrics 1. Asthma in the elderly is often associated with other comorbidities such as cardiac conditions or dementia. 2. Half of elderly patients with asthma have the first onset after age 65. Respiratory viruses are a common trigger. 3. Recurrent episodes of SOB may be primary symptom. 4. Treatment is the same as with younger patients, with inhaled steroids the mainstay and oral steroids reserved for severe episodes. The elderly have more adverse effects from inhaled ICS. 5. If steroids are prescribed, carefully monitor the patient for complications, including cataracts, increased intraocular pressure, hyperglycemia, and accelerated loss of bone mass. 6. Inhaled anticholinergics and beta 2 agonists are second-line treatments. 7. The elderly may have difficulty with inhaling medications and may require a nebulizer. 8. Theophylline is rarely effective in the elderly. Asthma medications may have increased adverse effects in the elderly or may aggravate coexisting medical conditions, requiring medication adjustments. Also consider drug interactions and drug-and-disease interactions. C. Pediatrics 1. Spacing chambers are recommended to assist in proper delivery of medication. 398 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Resources Adult and Children Asthma Control tests: www. asthmacontrol. com American Lung Association: www. lungusa. org Asthma & Allergy Foundation of America: www. aafa. org Global Initiative for Asthma (GINA) Instructions for Inhaler and Spacer Use: www. ginasthma. com National Heart Lung and Blood Institute (NHLBI): www. nhlbi. nih. gov Bronchiolitis: Child Cheryl A. Glass and Melissa A. Hall Definition A. Bronchiolitis is a narrowing and inflammation of the bronchioles, causing wheezing and mild to severe respiratory distress. Infants are affected most often because of their small airways and insufficient collateral ventilation. It is one of the most common causes of acute hospitalizations in infants, especially in the fall and winter. A small decrease in a broncioles already small airway will have a fourfold increase in airway resistance and accounts for this pathologic manifestation in this age group. B. The average length of illness with bronchiolitis is 12 days. Incidence A. Respiratory infection is seen in one third of children younger than 12 months, with 1 in 10 requiring hospitalization. B. Bronchiolitis occurs most often in infants and children aged 1 to 2 years. Approximately 2% to 4% of adults with respiratory illnesses, comorbidity of immunosuppression, and the elderly will also be diagnosed with bronchiolitis. Pathogenesis The pathology results in obstruction of bronchioles from inflammation, edema, and debris, leading to hyperinflation of the lungs, increased airway resistance, atelectasis, and ventilation-perfusion mismatching. A. Respiratory syncytial virus (RSV) is the most common cause (50%-80%) of bronchiolitis. B. Human metapneumovirus (HMPV) is the second most common cause 399 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
(3%-19%). C. Other causes include parainfluenza virus, adenovirus, influenza Chlamydia pneumoniae, Mycoplasma pneumoniae, and human bocavirus (HBo V). Predisposing Factors A. Low birth weight, particularly in premature infants B. Chronic lung disease (CLD; formerly bronchopulmonary dysplasia) C. Parental smoking D. Congenital heart disease E. Immunodeficiency F. Lower socioeconomic group G. Crowded living conditions and day care H. Gender: Bronchiolitis occurs in males 1. 25 times more frequently than in females. Common Complaints Clinical manifestations are initially subtle. A. Infants who become increasingly fussy B. Difficulty feeding during the 2-to 5-day incubation period. This is because infants prefer to breathe through their nose (obligate nasal breathing) as opposed to their mouths and significant nasal edema and/or rhinorrhea may force mouth breathing and disturb feedings. C. Low-grade fever (usually less than 101. 5°F) D. Cough E. Tachypnea F. Wheezing G. Retractions H. Nasal flairing and grunting Other Signs and Symptoms A. Coryza B. Irritability C. Lethargy D. Respiratory distress E. Nasal flaring and grunting 400 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Hypothermia (infants younger than 1 month) Subjective Data A. Determine the onset, course, and duration of illness. B. Are breathing problems affecting the ability to eat and drink? Is the baby able to be breastfed? C. Evaluate a history of fever, nausea, vomiting, or diarrhea. D. Does the patient or any family members have asthma? E. Are there any other family members who are ill? F. Are there smokers in the family environment? Physical Examination A. Check temperature, blood pressure, and respirations. Count respirations for 1 full minute. Respirations greater than 70 breaths per minute in an infant may be associated with risk for severe disease and warrant further evaluation for pneumonia. Tachypnea at any age is a concern for severe lower respiratory illness. B. Inspect 1. Observe overall appearance. 2. Note respiratory pattern and nasal flaring. 3. Note the use of accessory muscles for breathing. 4. Check for tachypnea, which differentiates bronchiolitis from upper respiratory infections and bronchitis. 5. Examine eyes, ears, and throat, noting other potential infections. 6. Inspect nose for nasal flaring. C. Auscultate 1. Heart 2. Lungs. On examination there are fine inspiratory crackles and/or high-pitched expiratory wheezes. A prolonged expiration phase is seen with bronchiolitis. D. Palpate liver and spleen. E. Percuss chest/lungs for hyperresonance. F. Neurologic examination: Assess for irritability and lethargy. Diagnostic Tests A. Diagnosis is made based on age and seasonal occurrence, tachypnea, 401 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
and the presence of profuse coryza and fine rales, wheezes, or both on auscultation. B. Viral isolation from nasopharyngeal secretions or rapid antigen detection (enzyme-linked immunosorbent assay [ELISA], immunofluorescence) for RSV can confirm diagnosis. C. Consider pulse oximetry. D. Routine use of a chest radiograph (CXR) is not recommended by the American Academy of Pediatrics (AAP). Differential Diagnoses A. Viral bronchiolitis B. Asthma C. Viral or bacterial pneumonia D. Aspiration syndromes E. Pertussis F. Cystic fibrosis (CF) G. Cardiac disease H. Reflux I. Aspiration J. Tracheoesophageal fistula Plan A. General interventions 1. Use a humidifier in the patient's bedroom. 2. Clear stuffy nose with saline solution drops and suction out nares with bulb syringe. 3. Infants should not be exposed to secondhand smoking. 4. Monitor respiratory pattern. 5. Use good hygiene practices—handwashing. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Bronchiolitis: Child. ” C. Dietary management 1. Encourage fluids, such as juice and water. Dilute juice for younger infants. 2. Offer small, frequent feedings. 3. Breastfeeding should continue. 402 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Medical/surgical management 1. Patients may only require supportive care. Patients with respiratory distress require hospitalization. 2. Hypoxemic patients need oxygen therapy and possibly mechanical ventilation. 3. Chest physiotherapy is not recommended. E. Pharmaceutical therapy 1. Bronchodilators should not be routinely used. They do not improve the duration of illness or lessen hospitalization. 2. Corticosteroids should not be routinely used. They do not improve the duration of illness or lessen hospitalization. 3. Antibacterials should be used only with proven coexistence of a bacterial infection. 4. There is no vaccine against bronchiolitis. A vaccine against human metapneumovirus (HMPV) is currently in the early stages of development. HMPV has been in existence in humans for more than 60 years, but is only newly categorized. HMPV is most closely related to avian metapneumovirus. The virus most frequently infects young children and the elderly. HMPV is most common in late winter and early spring, and is associated with up to 25% of respiratory infections. Palivizumab (Synagis) prophylaxis should be administered to selective children following the AAP guidelines. HMPV is responsible for the majority of viral upper respiratory infections in children and adults. The virus has a world-wide distribution and is most prevalent in late winter and early spring. 5. Use of the montelukast (Singulair) has not proven beneficial in resolution of symptoms. Follow-Up A. Contact the patient within 12 to 24 hours for evaluation. Consultation/Referral A. Notify a doctor if the patient's breathing becomes labored, his or her wheezing becomes worse, and/or respiratory distress is suspected. B. Refer patients with RSV to the emergency room if moderate respiratory distress, dehydration, or hypoxemia occurs. 403 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Younger patients in moderate to severe respiratory distress require hospitalization. D. Infants less than 3 months of age require hospitalization. E. Patients with pulmonary hypertension, chronic lung disease (CLD; formerly bronchopulmonary dysplasia), or CF need hospitalization if their respiratory rate is greater than 60, their pulse oximetry is less than 92%, or they eat poorly. Individual Considerations A. Patients with pulmonary hypertension, bronchopulmonary dysplasia, or CF may have prolonged courses with high morbidity and mortality. Some may have reactive airway diseases in the future. B. Young children and the elderly are most susceptible to HMPV infection. The majority of children are seropositive for HMPV infection by age 5. History of prematurity and asthma increase risk for hospitalization in children. C. Human pneumavirus was identified in 8% of adults requiring hospitalization for lower respiratory infections. Bronchitis, Acute Cheryl A. Glass and Melissa A. Hall Definition A. Acute bronchitis is inflammation of the tracheobronchial tree. Bronchitis is nearly always self-limited in the otherwise healthy individual. Generally, the clinical course of acute bronchitis lasts 10 to 14 days. The cause is usually infectious, but allergens and irritants may also produce a similar clinical profile. Asthma can be mistaken as acute bronchitis if the patient has no prior history of asthma. Incidence A. Bronchitis is more common in fall and winter in relation to the common cold or other respiratory illness. It occurs in both children (younger than 5 years of age) and adults and is diagnosed in men more frequently than in 404 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
women. Fewer than 5% of patients with bronchitis develop pneumonia. Pathogenesis A. Most attacks are caused by viral agents, such as adenovirus, influenza, parainfluenza viruses, and respiratory syncytial virus (RSV). B. Bacterial causes include Bordetella pertussis, Mycobacterium tuberculosis, Corynebacterium diphtheriae, and Mycoplasma pneumoniae. B. pertussis should be considered in children who are incompletely vaccinated. Predisposing Factors A. Viral infection B. Upper respiratory infection C. Smoking D. Exposure to cigarette smoke E. Exposure to other irritants F. Allergens G. Chronic aspiration/gastroesophageal reflux disease (GERD) Common Complaint A. The most common symptom initially is a dry, hacking, or raspy-sounding cough. The cough then loosens and becomes productive. Other Signs and Symptoms A. Sore throat B. Rhinorrhea or nasal congestion C. Rhonchi during respiration D. Low-grade fever E. Malaise F. Retrosternal pain during deep breathing and coughing G. Decreased/lack of appetite Subjective Data A. Ask about the onset, duration, and course of symptoms. B. Is the cough productive? C. Is there substernal discomfort? D. Is there malaise or fatigue? 405 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Has the patient had a fever? F. Does the patient smoke? (Smoking aggravates bronchitis. ) G. A review of occupational history may be important in determining whether irritants play a role in symptoms. H. Assess for symptoms of gastroesophageal reflux. Physical Examination Examinations of children may best be completed with the child sitting on the parent's lap. A. Check temperature, pulse, and blood pressure (BP). Always check a pulse oximeter. B. Inspect 1. Observe overall appearance. 2. Inspect eyes, ears, nose, and throat (pharynx may be injected). 3. Transilluminate sinuses. C. Palpate lymph nodes, maxillary, and frontal sinuses. D. Auscultate all lung fields for crackles, wheezing, and rhonchi. Diagnostic Test A. Consider chest x-ray to exclude pneumonia. Differential Diagnoses A. Pneumonia B. Upper respiratory infection C. Asthma D. Sinusitis E. Cystic fibrosis (CF) F. Aspiration G. Respiratory tract anomalies H. Foreign-body aspiration I. Pneumonia J. Chronic obstructive pulmonary disease (COPD) and emphysema K. Pediatrics: Pertussis Plan A. General interventions are primarily supportive and should ensure the 406 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
patient is adequately oxygenating. 1. Tell the patient to increase fluid intake. 2. Suggest humidity and mist therapy. 3. Avoid irritants, such as smoke. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Bronchitis, Acute. ” C. Pharmaceutical therapy 1. Acetaminophen (Tylenol) for fever and malaise. a. Adults: 625 to 1,000 mg orally every 4 hours; not to exceed 4 g/d b. Pediatrics: For those younger than 12 years: 10 to 15 mg/kg/dose by mouth every 4 to 6 hours; not to exceed 2. 6 g/d; for children older than 12 years: 325 to 650 mg by mouth every 4 hours; not to exceed five doses in 24 hours 2. Expectorants, such as guaifenesin with dextromethorphan (Robitussin DM, Humibid DM, Mytussin), can be used to treat minor cough from bronchial/throat irritation. a. Adults and children older than 12 years: 10 m L by mouth every 4 hours b. Children younger than 4 to 6 years: Not recommended; for children 6 to 12 years: 5 m L by mouth every 4 hours as needed In response to child safety concerns, the American Academy of Pediatrics states that cough and cold medications should not be used for children younger than 6 years. 3. Among otherwise healthy individuals, antibiotics have not demonstrated benefit for acute bronchitis as the etiology is usually viral. However, oral antibiotics should be considered if symptoms persist for 2 weeks with treatment (indicates bacterial infection). a. Erythromycin (EES, E-Mycin, Ery-Tab) i. Adults: 250 to 500 mg by mouth four times a day or 333 mg by mouth three times daily ii. Pediatrics: 30 to 50 mg/kg/d by mouth divided four times a day 407 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
b. Clarithromycin (Biaxin) i. Adults: 250 to 500 mg by mouth twice a day ii. Pediatrics: 7. 5 mg/kg by mouth twice a day c. Azithromycin (Zithromax) i. Adults: Day 1: 500 mg by mouth, then 250 mg by mouth on days 2 to 5. ii. Pediatrics: 12 mg/kg by mouth every day; do not exceed 500 mg/dose 4. Albuterol (Ventolin) for patients with wheezes or rhonchi, or for patients with a history of bronchoconstriction. a. Adults: 2 puffs every 4 to 6 hours or 2 to 4 mg by mouth for three to four times a day b. Pediatrics: 0. 1 to 2 mg/kg by mouth for three times daily Follow-Up A. Follow up if patient does not improve in 48 hours. B. Recommend yearly influenza vaccinations. Consultation/Referral A. In uncomplicated cases, mucus production decreases and cough disappears in 7 to 10 days. If symptoms persist, refer the patient to a physician. B. Refer the patient if you note respiratory distress or if he or she appears ill and you suspect pneumonia. Individual Considerations A. Pediatrics 1. Children who have repeated episodes of bronchitis should be evaluated for congenital defects of the respiratory system. 2. Instruct patients regarding the need for immunization against pertussis, diphtheria, and influenza, which reduces the risk of bronchitis. 3. Children may attend school or day care without restrictions except during acute bronchitis with fever. B. Geriatrics: Monitor elderly patients for complications such as pneumonia. The elderly have a greater morbidity and mortality rate. 408 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Bronchitis, Chronic Cheryl A. Glass and Melissa A. Hall Definition A. Chronic bronchitis is excessive mucus secretion with chronic or recurrent productive cough occurring three successive months a year for 2 consecutive years. B. Others limit the definition to a productive cough that lasts more than 2 weeks despite therapy. C. Patients with chronic bronchitis have more mucus than normal because of either increased production or decreased clearance. Coughing is the mechanism for clearing excess secretion. Incidence A. The incidence of chronic bronchitis is uncertain. There is a lack of definitive diagnostic criteria, and there is considerable overlap with asthma. Visits for bronchitis are second only to visits for otitis media and are slightly more common than for asthma. Pathogenesis A. Mucociliary clearance is delayed because of excess mucus production and loss of ciliated cells, leading to a productive cough. This is usually secondary to the number of years of cigarette smoke-induced damage. In children, chronic bronchitis follows either an endogenous response to an acute airway injury or continuous exposure to noxious environmental agents such as allergens or irritants. B. Bacteria most often implicated are Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and Moraxella catarrhalis. The most common causes of chronic bronchitis in the pediatric population include viral infections such as adenovirus, respiratory syncytial virus (RSV), rhinovirus, and human bocavirus (HBo V). C. Specific occupational exposures are associated with symptoms of chronic bronchitis, including coal, cement, welding fumes, organic dusts, engine exhausts, fire smoke, and secondhand smoke. 409 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Predisposing Factors A. Cigarette smoking B. Cold weather C. Acute viral infection D. Chronic obstructive pulmonary disease (COPD)/emphysema E. Occupational exposure to other airborne irritants F. Chronic, recurrent aspiration or gastroesophageal reflux G. Allergies Common Complaints A. Worsening cough: Hacking, harsh, or raspy sounding B. Changes in color (yellow, white, or greenish), amount, and viscosity of sputum C. Children younger than 5 years rarely expectorate, and sputum is usually seen in vomitus D. “Rattling” sound in chest E. Dyspnea/breathlessness F. Wheezing Other Signs and Symptoms A. Difficulty breathing, retrosternal pain during a deep breath or cough B. Rapid respirations C. Fatigue D. Headache E. Loss of appetite F. Fever G. Myalgias H. Arthralgias Subjective Data A. Determine the onset, course, and duration of illness. B. Is the patient having trouble breathing? C. Has there been a fever? D. How is the patient's appetite? Is the patient drinking enough fluids? E. Does the patient smoke, or is the patient exposed to secondhand smoke? 410 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Review occupational history to evaluate exposure to irritants. G. Does the patient have a history of asthma? H. How often is the patient currently using his or her short-acting beta 2 agonist inhaler? Chronic bronchitis has a long history of a productive cough and late-onset wheezing. Patients with asthma with a chronic obstruction have a long history of wheezing with a late-onset of productive cough. Physical Examination Examinations of children may best be started with the child sitting on the parent's lap. A. Check temperature, pulse, blood pressure, and pulse oximetry. B. Inspect 1. Observe overall appearance/mentation. 2. Inspect eyes, ears, nose, and throat. a. Pharynx may be injected. b. Conjunctivitis suggests adenovirus. 3. Transilluminate sinuses. C. Auscultate 1. Lungs in all fields; lung sounds may sound normal to scattered, rhonchi, or large airway wheezing 2. Heart D. Percuss chest. E. Palpate 1. Lymph nodes 2. Maxillary and frontal sinuses Diagnostic Tests A. Patients with uncomplicated respiratory illness need little, if any, laboratory evaluation. B. Pulse oximetry can help diagnose the issue. C. Sputum culture is used to identify bacteria. D. Chest radiograph (CXR) may help exclude other diseases or 411 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
complications. E. Pulmonary function studies may be indicated. F. EKG and pulmonary function tests (PFTs) may be required for COPD patients. G. Sweat test may be necessary to rule out cystic fibrosis (CF). Differential Diagnoses A. Acute bronchitis B. Pneumonia C. Asthma D. Sinusitis E. CF F. Bronchiectasis G. Central airway obstruction H. Lung cancer I. Aspiration syndrome J. Gastroesophageal reflux K. Tuberculosis (TB) L. Foreign body Plan A. General interventions 1. Rest during early phase of illness. 2. Encourage smoking cessation and staying away from secondhand smoke. 3. Suggest exercise for patients with COPD. 4. The patient's goal is to improve symptoms and to decrease cough and production of sputum. 5. Inform patients that increased sputum production may occur after smoking cessation and the patient may have airway reactivity (wheezing), which is especially seen in asthmatics. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Bronchitis, Chronic. ” C. Dietary management 1. Increase fluids. 2. Eat nutritious food. 412 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Pharmaceutical therapy 1. Bronchodilators should be considered for bronchospasm. a. Albuterol sulfate (Proventil, Ventolin, Pro Air) i. Adults: Metered-dose inhaler (MDI)-2 actuations (90 mcg/actuation) inhaled every 4 to 6 hours ii. Pediatrics: MDI or nebulizer 1)Younger than 1 year: 0. 05 to 0. 15 mg/kg dose every 4 to 6 hours 2)1 to 5 years old: 1. 25 to 2. 5 mg/dose every 4 to 6 hours 3)5 to 12 years old: 2. 5 mg/dose every 4 to 6 hours 4)Older than 12 years: 2. 5 to 5 mg/dose every 6 hours 2. Analgesics and antipyretics are used to control fever, myalgias, and arthralgias. 3. Consider oral steroids to decrease inflammation. a. Adults: 5 to 60 mg/d by mouth b. Pediatrics: 1 to 2 mg/kg by mouth daily or in twice a day divided dosing; do not exceed 80 mg/d. c. Tapering steroids is not necessary with steroid courses of 10 days' duration or less. 4. Inhaled corticosteroid (ICS) may be effective. a. Beclomethasone (QVAR) is available as an MDI that delivers 40 or 80 mcg/actuation. i. Adults MDI: 40 to 80 mcg inhaled by mouth twice a day, not to exceed 320 mcg twice a day ii. Pediatrics MDI: 40 mcg inhaled by mouth twice a day, not to exceed 80 mcg twice a day b. Fluticasone (Flovent HFA, Flovent Diskus). Available as MDI (44-mcg, 110-mcg, or 220-mcg per actuation) and diskus powder for inhalation (50 mcg, 100 mcg, or 250 mcg per actuation). i. Adults 1)MDI: 88 mcg inhaled by mouth twice a day, dosage not to exceed 440 mcg twice a day. 2)Diskus: 100 mcg inhaled by mouth twice a day, dosage not to exceed 500 mcg twice a day. ii. Pediatrics 1)MDI: Ages 4 to 11 years: 88 mcg inhaled by mouth twice 413 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
a day; older than 11 years administer as adults. 2)Diskus: Ages 4 to 11 years: 50 mcg inhaled by mouth twice a day; older than 11 years administer as adults. 5. Antibiotics for bacterial infection a. Erythromycin (EES, E-Mycin, Ery-Tab) i. Adults: 250 to 500 mg by mouth four times a day or 333 mg by mouth three times daily ii. Pediatrics: 30 to 50 mg/kg/d by mouth divided four times a day; do not exceed 2 g/d. b. Clarithromycin (Biaxin) i. Adults: 250 to 500 mg by mouth twice a day ii. Pediatrics: 7. 5 mg/kg by mouth twice a day c. Azithromycin (Zithromax) i. Adults: 500 mg by mouth on day 1, then 250 mg by mouth on days 2 to 5 ii. Pediatrics: 10 mg/kg/d by mouth on day 1, then 5 mg/kg on days 2 to 5; do not exceed adult dose d. Amoxicillin-clavuanic acid (Augmentin) i. Adult: 250 to 500 mg by mouth every 8 hours ii. Pediatrics 1)Younger than 3 months: 30 mg/kg/d by mouth divided to every 12 hours 2)3 months or older: 40 to 80 mg/kg/d by mouth divided to every 12 hours 6. Over-the-counter cold and cough products: The American Academy of Pediatrics do not recommend use of cold and cough products for use in children 6 years of age or younger. These products have been associated with serious adverse effects. Follow-Up A. Follow up if there is no improvement in 3 to 4 days after starting therapy. B. Recommend yearly influenza vaccinations. Consultation/Referral A. Refer patients with respiratory distress to a physician. If respiratory failure occurs (rare), hospitalization may be needed. 414 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
B. Refer patients with COPD to a physician or pulmonary specialist. C. Referral to a pediatric pulmonologist should be considered when symptoms persist and do not respond to initial therapy. Individual Considerations A. Pediatrics 1. Recurrent acute or chronic bronchitis should alert the clinician to the diagnosis of asthma. 2. Recurrent episodes of acute or chronic bronchitis may also be associated with immunodeficiencies. 3. Discuss the need for immunization against pertussis, diphtheria, and influenza, which reduces the risk of bronchitis. 4. Children may attend school or day care without restrictions except during fever. 5. In children, a foreign body needs to be ruled out either radiographically or by bronchoscopy. B. Geriatrics 1. Age-specific changes in elderly include changes in airway size due to connective tissue changes, including shallow alveolar sacs. 2. Chest wall compliance is reduced, with diaphragmatic strength reduction of 25%. 3. Older adults may adjust their lifestyle to compensate due to declining lung function. 4. Dyspnea should be addressed and not associated only with deconditioning with age. Chronic Obstructive Pulmonary Disease Cheryl A. Glass and Melissa A. Hall Definition Chronic obstructive pulmonary disease (COPD) is progressive, chronic, expiratory airway obstruction due to chronic bronchitis or emphysema. The relief of bronchoconstriction due to inflammation has some reversibility. Chronic bronchitis is a chronic productive cough lasting 3 months during 2 415 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
consecutive years, after all causes of chronic cough have been excluded. Emphysema is an abnormal, permanent enlargement (hyperinflation) and destruction of the alveoli air sacs, as well as the destruction of the elastic recoil. Many patients have both types of air-restriction symptoms of chronic bronchitis and emphysematous destruction leading to COPD. Patients with asthma whose airflow obstruction is completely reversible are not considered to have COPD. When asthmatic patients do not have complete reversible airflow obstruction, they are considered to have COPD. Irreversible airflow obstruction is a key factor in the patient's disability. The goal of COPD management is to improve daily quality of life (QOL) and the recurrence of exacerbations. Smoking cessation continues to be the most important therapeutic intervention. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging criteria are: A. Stage I—Mild obstruction: Forced expiratory volume in 1 second (FEV1) greater than 80% of predicted value, some sputum, and chronic cough B. Stage II—Moderate obstruction: FEV1 between 50% and 80% of predicted value, shortness of breath (SOB) on exertion, and chronic symptoms C. Stage III—Severe obstruction: FEV1 between 30% and 50% of predicted value, dyspnea, reduced exercise tolerance, and exacerbations affecting QOL D. Stage IV—Very severe obstruction chronic respiratory failure: FEV1 less than 30% of predicted value or moderate obstruction FEV1 less than 50% of the predicted value and chronic respiratory failure. Fourteen percent of patients admitted for COPD exacerbation die within 3 months of admission. E. Comorbidities commonly seen with COPD include hypertension; cardiac disorders, including atrial fibrillation and heart failure; diabetes/metabolic syndrome; gastrointestinal (GI) disorders; lung cancer; depression; and osteoporosis. Incidence A. Approximately 6% of the population in the United States has been diagnosed with COPD. It is still an underrecognized diagnosis although it is the third leading cause of death in the United States. COPD is is more commonly seen in males than females, but gender differences are lessening 416 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
as more females are smoking. The exact worldwide prevalence is unknown. Pathogenesis A. Chronic bronchitis leads to the narrowing of the airway caliber and increase in airway resistance. Mucous gland enlargement is the histologic hallmark of chronic bronchitis. B. In emphysema, loss of the air sac's elastic recoil and alveoli destruction causes air limitation. Emphysema caused by smoking is the most severe in the upper lobes. Most patients with COPD have smoked one pack of cigarettes a day for 20 or more years before the symptomatic dyspnea, cough, and sputum appear. Predisposing Factors A. Cigarette smoking B. Occupational, environmental, or atmospheric pollutants 1. Dust 2. Chemical fumes 3. Secondhand smoke 4. Air pollution C. Genetic factor: Alpha 1-antitrypsin (AAT) deficiency D. Recurrent or chronic lower respiratory infections or disease E. Age (most common in fifth decade of life) Common Complaints A. Chronic cough and colorless sputum, usually worse in morning B. Dyspnea with exertion, progressing to dyspnea at rest C. Wheezing D. Difficulty speaking or performing tasks E. Weight loss (decrease in fat-free mass) Other Signs and Symptoms A. Pursed-lip breathing: induces auto peeping and hence helps keep alveoli open. B. Use of accessory muscles C. Tripod position D. Barrel chest 417 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Cyanosis (fingertips, tip of nose, around lips) F. Tachypnea G. Tachycardia H. Difficulty speaking or performing tasks I. Distended neck veins J. Abnormal, diminished, or absent lung sounds K. Mental status changes L. Anxiety and depression M. Pulmonary hypertension N. Cor pulmonale O. Left-sided heart failure Subjective Data A. Ask the patient about past respiratory problems and infections. Does he or she currently have fever, chills, or other signs of infection? B. Ask about the onset of cough and characteristics of sputum (amount, color, and presence of blood). C. Determine cigar use and cigarette pack-year history (pack/day × number of years smoked). D. Inquire about exposure to occupational or environmental irritants. E. How far can the patient walk before becoming breathless? Is there more breathlessness when the patient walks on a slight incline? F. Does the patient become breathless or tired when performing activities of daily living (ADLs)? G. Ask about insomnia, anxiety, restlessness, edema, and weight change. H. How many pillows does the patient sleep on? Does he or she have to sleep in a recliner or sitting up? I. Assess the patient's ability to perform ADLs and instrumental activities of daily living (IADLs), including grooming and personal hygiene, performing chores around the house, shopping, cooking, and driving. J. Ask about alcohol use. K. Review all medications, including over-the-counter (OTC) and herbal products. L. Review further assessment questions based on existing comorbidities. Physical Examination 418 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Record temperature (if indicated), blood pressure, pulse, respirations, and pulse oximetry. The respiratory rate increases proportionally to disease severity. Take height and weight to calculate the body mass index (BMI). The patient may have a fairly normal examination early in the disease. B. Inspect 1. Observe general appearance: Skin color, affect, posture, gait, amount of respiratory effort when walking; note increased anterior-posterior chest diameter. 2. Examine sputum: Frothy pink signals pulmonary edema. Hemoptysis as seen in tuberculosis (TB). 3. Examine lips, fingertips, and nose for cyanosis. (Finger clubbing is not characteristic of COPD. ) 4. Observe the neck for distended veins and peripheral edema (advanced disease). 5. Check for pursed-lip breathing and use of accessory muscles. C. Auscultate 1. Auscultate the heart. 2. Auscultate the lungs for wheezes, crackles, decreased breath sounds, and prolonged forced expiratory rate. 3. Assess for vocal fremitus (vibration) and egophony (increased resonance and high-pitched bleating quality). Air trapping causes air pockets that don't transmit sound well. Absent ventricular lung sounds are a distinctive characteristic of COPD. 4. Auscultate the carotids arteries. D. Percuss the chest for the presence of hyperresonance and for signs of consolidation. E. Palpation 1. Palpate the neck for lymphadenopathy. 2. Palpate the chest. 3. Evaluate the abdomen for organomegaly. 4. Evaluate pedal edema. F. Mental status: Assess for decreased level of consciousness. G. Six-minute walking distance (6MWD) test to evaluate desaturation. H. Further physical examinations are dependent on comorbidities. Diagnostic Tests 419 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Spirometry is the gold standard for diagnosing COPD. Pulmonary function tests (PFTs) are used to diagnose, determine severity, and follow the disease progression of COPD. Spirometry before and after using a bronchodilator. 1. FEV1 is used as an index to airflow obstruction and evaluates the prognosis in emphysema. 2. Forced vital capacity (FVC) 3. FEV1/FVC ratio less than 0. 70 B. Chest radiograph (CXR; not required to diagnose COPD but rules out other diagnoses) C. Complete blood count (CBC)—evaluate polycythemia due to chronic hypoxia D. Sputum specimen for culture E. If the patient is younger than age 40 years or has a family history of early onset of emphysema, measure AAT levels. Patients with a family history of AAT deficiencies are at risk of lung damage early in life as AAT serves to protect lower lung tissue from damage by proteolytic enzymes. F. Arterial blood gas (ABG) G. EKG: Note sinus tachycardia, atrial arrhythmias H. Two-dimensional echocardiogram is used to evaluate secondary pulmonary hypertension. I. Chest CT is an alternative imaging study for emphysema; however, it is not required as a diagnostic tool. J. Perform a purified protein derivative (PPD) test if TB is suspected. K. Brain natriuretic peptide (BNP) L. Theophylline level (if applicable) Differential Diagnoses A. Asthma B. Heart failure C. Bronchiectasis D. Pulmonary edema E. TB F. AAT deficiency G. Pneumonia 420 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
H. Pulmonary embolism I. CF J. Cancer Plan A. General interventions 1. Educate and encourage active participation in the plan of care, including medication adherence. 2. A smoking-cessation plan is an essential part of a comprehensive treatment plan. Develop a smoking-cessation plan; assess readiness to quit. Set a quit date; encourage a group smoking-cessation program. Discuss smoking at every subsequent visit. (See Section III: Patient Teaching Guide for this chapter, “Nicotine Dependence. ” ) 3. Advise to stay away from secondhand smoke and limit exposure to other pulmonary irritants, including extreme temperature changes. 4. Advise exercise with physician approval. 5. Educate and counsel patients regarding advance directives. 6. Consider pulmonary rehabilitation for all stages of COPD. 7. The selection of inhalers is dependent on the patient's age and ability to use the inhaler. Patients should be evaluated as to their coordination and inspiration abilities necessary to use inhalers; otherwise, aerosol medication via nebulizer is the best delivery method. 8. Have patients bring in their medication/spacers to demonstrate correct use. 9. Consider group visits for teaching sessions. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Chronic Obstructive Pulmonary Disease. ” C. Dietary management 1. About 25% of COPD patients are malnourished because of coexisting medical conditions, depression, and inability to shop for or prepare food. 2. Suggest a low-carbohydrate diet. High-carbohydrate intake may increase respiratory work by increasing CO2 production. D. Pharmaceutical therapy: Treatment guidelines are based on spirometry. 421 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Peak flow meters should not be used to diagnose or monitor COPD. 1. Stage I (mild FEV1 80% or greater)—The patient may be unaware that he or she has COPD. Give influenza vaccine and use short-acting beta 2 agonist bronchodilators as needed. 2. Stage II (moderate FEV1 between 50% and 79%)—Give influenza vaccine, plus short-acting beta 2 agonist bronchodilators, as needed, plus long-acting bronchodilator(s) plus cardiopulmonary rehabilitation. 3. Stage III (severe FEV1 between 30% and 49%)—Give influenza vaccine, plus short-acting beta 2 agonist bronchodilators as needed, plus long-acting bronchodilator(s), plus cardiopulmonary rehabilitation, plus inhaled glucocorticoid steroids if patient has repeated exacerbations. 4. Stage IV (very severe FEV1 less than 30%)—Give influenza vaccine, plus short-acting beta 2 agonist bronchodilator, as needed, plus long-acting bronchodilator(s), plus cardiopulmonary rehabilitation, plus inhaled glucocorticoid steroids if repeated exacerbations plus long-term oxygen therapy (if the patient meets criteria for O2). Medicare guidelines require a patient's Pa O2 (partial pressure of oxygen) to be less than 55 mm Hg or his or her resting oxygen saturation to be below 88% on room air. 5. Utilization of a spacer/holding chamber for inhalers should be encouraged. 6. Administer pneumonia vaccines for patients 65 years and older. Prevnar 13 or Pneumovax 23 should be administered according to Centers for Disease Control and Prevention (CDC) recommendations and based on the individual patient's vaccine history. See the CDC website for current recommendations. Administer yearly flu vaccine. Trivalent influenza vaccine is essential for all COPD patients. Give the vaccine each year as soon as it is available. Prescribe pharmacological agents/nicotine replacement therapy for smoking cessation. 422 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
a. Nicotine chewing gum produces better quit rates than counseling alone. b. Transdermal nicotine patches have a long-term success rate of 22% to 42%. c. Use of an antidepressant such as Zyban (150 mg twice a day) has been shown to be effective for smoking cessation and may be used in combination with nicotine replacement therapy. d. Chantix is a partial agonist selective for alpha 4, beta 2-nicotinic acetylcholine receptors. 7. Antibiotics are not recommended in COPD patients except with acute exacerbation, with symptoms of increased dyspnea, increased sputum volume, and increased sputum purulence, changes in cough, fever, or other evidence of an infection such as an infiltrate on CXR. Antibiotics are prescribed for COPD patients on mechanical ventilation. 8. Consider phosphodiesterase-4 (PDE-4) inhibitors (Roflumilast or Cilomilast) as needed when necessary. 9. Mucolytic agents have small benefits and are not usually recommended. 10. Antitussives are not recommended. 11. Long-term oxygen has been shown to increase survival in patients with severe resting hypoxemia. Target oxygen saturation is 88% to 92% (Long-Term Oxygen Treatment Trial Research Group, 2016). 12. Cardioselective beta-blockers are not contraindicated in COPD. Cardioselective beta-blockers at low dosages do not cause bronchospasm. A noncardioselective beta-blocker or a cardioselective beta-blocker (B1 blocker) at higher dosages may contribute to bronchospasms. Follow-Up A. For acute exacerbations, follow up same day or following day. B. Follow up stable, chronic COPD every 1 to 2 months, depending on the patient's needs. C. Serial PFTs may help guide therapy and offer prognostic information. D. Monitor serum theophylline levels. Theophylline has a narrow therapeutic window and the potential for toxicity. Adverse effects, including nausea and nervousness, are the most common. Other adverse effects include abdominal 423 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
pain with cramps, anorexia, tremors, insomnia, cardiac arrhythmia, and seizures. E. Reevaluate patients on oxygen therapy 1 to 3 months after starting oxygen. F. Evaluate for osteoporosis; bone mineral density is lower in COPD patients, and they are at risk for vertebral fractures. G. Monitor the patient's body weight. Consultation/Referral A. Consult with a physician if the patient has acute respiratory decompensation, or severe cor pulmonale (distended neck veins, hepatomegaly, dependent peripheral edema, ascites, and pleural effusion). B. Refer the patient to a pulmonary specialist for rehabilitation, if available. 1. Outpatient education for the patient and family 2. Exercise training 3. Breathing retraining, that is, pursed-lip breathing, huff coughing 4. Correct administration of medications C. Refer to a registered dietitian (RD) to provide medical nutrition therapy (MNT). RDs focus on the prevention and treatment of weight loss associated with COPD and other comorbidities. D. Send to a pulmonologist for evaluation for continuous positive airway pressure (CPAP) or bi-level positive airway pressure (Bi PAP). E. Send to a pulmonologist to evaluate for surgical intervention such as bullectomy, lung volume reduction surgery, or lung transplantation. Individual Considerations A. Pregnancy 1. COPD is rare except in AAT deficiency. 2. Monitor drug treatment for potential teratogenic effects. B. Adults: Sexual dysfunction is common in patients with COPD; encourage other ways to display affection. C. Geriatrics 1. Presentation may be atypical. 2. Patients should have annual flu vaccinations and pneumococcal vaccination every 5 years. 3. Patients may not have the ability to use inhaler devices because of 424 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
tremors, muscle weakness, poor hand-eye coordination, and/or poor memory. 4. Theophylline is on the Beers list of drugs to use with caution in the geriatric population related to cardiovascular, renal, and hepatic concerns; insomnia; and peptic ulcers. 5. Discuss the course of disease, living wills, advanced directives, and resuscitation status early, before a crisis occurs. Resources The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines: www. goldcopd. org Common Cold/Upper Respiratory Infection Cheryl A. Glass and Melissa A. Hall Definition A. The common cold is a self-limiting acute respiratory tract infection (ARTI) resulting from viral infection of the upper respiratory tract. It is also called acute nasopharyngitis. ARTI is characterized by mild coryzal symptoms, rhinorrhea, nasal obstruction, and sneezing. Incidence A. Upper respiratory tract infections are among the most frequent reasons for office visits. However, the true incidence is not known because patients treat themselves with over-the-counter (OTC) and home remedies, as well as seasonal and locational variability. Most children have six to eight colds a year; most adults have two to four. Pathogenesis A. Over 25% to 80% of ARTIs are caused by a rhinovirus (greater than 100 antigenic serotypes). Other viral agents include coronavirus (10%-20%), RSV, adenoviruses (5%), influenza viruses (10%-15%), and parainfluenza viruses. Incubation period is 1 to 5 days with viral shedding lasting up to 2 weeks. B. Rhinoviral infections are chiefly limited to the upper respiratory tract but may cause otitis media and sinusitis. 425 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Predisposing Factors A. Exposure to airborne droplets B. Direct contact with virus by touching hands or skin of infected people, or by touching surfaces they touched, and then touching eyes or nose C. Very young or old ages D. Smoking, which increases risk by 50% E. Crowded conditions such as day-care centers and schools Common Complaints A. Low-grade fever B. Generalized malaise C. Nasal congestion and discharge (initially clear, then yellow and thick) D. Sneezing E. Sore throat or hoarseness F. Watery and/or inflamed eyes Other Signs and Symptoms A. Headache B. Cough Subjective Data A. Elicit the onset, course, and duration of symptoms. B. Inquire about color and other characteristics of nasal discharge and sputum. Purulent nasal discharge after 14 days signals bacterial sinusitis. C. Inquire about other discomforts and exposure to people with similar symptoms. D. Review allergens, seasonal problems, and exposure to irritants and smoke. E. Review history for other respiratory problems, such as asthma, chronic bronchitis, and emphysema. Physical Examination A. Check temperature, pulse, respirations, and blood pressure. Carry out pulse oximetry if difficult respiratory symptoms are noted. B. Inspect 426 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. Observe general appearance. 2. Inspect eyes. Note “allergic shiners,” tearing, and eyelid swelling. 3. Observe ears, throat, and mouth. Otitis media is indicated by redness and bulging of tympanic membrane, or by membrane perforation with drainage. 4. Inspect nose for nasal redness, swelling, polyps, enlarged turbinates, septal deviation, and foreign bodies. 5. Transilluminate sinuses. a. Group A Streptococcus: Tonsilar enlargement, exudate, petechiae b. Allergies: “Cobblestoned” pharyngeal mucosa c. Mononucleosis: About half of patients with mononucleosis develop tonsillar exudates, and about one third develop petechiae at the junction of the hard and soft palates, which is highly suggestive of the disease. C. Auscultate 1. All lung fields 2. Heart D. Percuss 1. Sinus cavities and mastoid process of temporal bone to rule out otitis media 2. Chest for consolidation E. Palpate 1. Palpate face for sinus tenderness. 2. Examine head and neck for enlarged, tender lymph nodes. Diagnostic Tests A. Diagnosis may be made from history and physical. Because common cold manifestations are so prevalent, an aggressive workup is rarely necessary. B. Consider rapid strep test if the patient has symptoms or was exposed to Group A Streptococcus. C. Consider throat culture if negative rapid strep test and symptomatic. Differential Diagnoses A. Upper respiratory infection B. Allergic rhinitis C. Foreign body 427 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
D. Sinusitis E. Influenza F. Group A strep pharyngitis G. Otitis media H. Pneumonia Plan A. General interventions 1. Controlled trials reveal minimal therapeutic benefits of vitamin C for the treatment and prevention of colds. Zinc has no proven benefit. Echinacea has not shown any differences in rates of infection or severity of symptoms when compared with placebo. Validation and standardization of herbal products have not been completed. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Common Cold. ” C. Pharmaceutical therapy 1. In 2016, the American College of Chest Physicians released clinical practice guidelines (Gibson et al., 2016) for the management of cough. Health care providers should refrain from recommending cough suppressants and OTC cough medicines for young children because of associated morbidity and mortality. The American Academy of Pediatrics reminds consumers to avoid the use of OTC cough and cold products in children younger than 4 years. 2. Antibiotics are ineffective in treating viral infection. 3. Corticosteroids may actually increase viral replication and have no impact on cold symptoms. 4. Topical decongestants for rhinorrhea and nasal congestion a. Adults and children older than 6 years, pseudoephedrine (Afrin) nasal spray 0. 05% two to three sprays per nostril twice daily, or phenylephrine (Neo-Synephrine) nasal spray 0. 25% to 1% two to three sprays per nostril every 4 hours as needed. Using decongestant-type nasal sprays longer than 2 to 3 days can result in rebound congestion and abuse of the drug. b. Children younger than 6 years, saline nasal drops 2 to 3 drops per nostril two to three times daily. c. As an alternative to pseudoephedrine and other nasal 428 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
decongestants, consider clearing nasal congestion in infants with a rubber suction bulb; secretions can be softened with saline nose drops or a cool-mist humidifier. 5. Oral decongestants are available such as pseudoephedrine (Sudafed). a. Adults: Pseudoephedrine (Sudafed) 60 mg every 4 to 6 hours or 120 mg every 12 hours b. Children 2 to 6 years: Pseudoephedrine (Sudafed) liquid 2. 5 m L every 4 to 6 hours c. Children older than 6 years: Pseudoephedrine (Sudafed) liquid 5 m L every 4 to 6 hours, or pseudoephedrine (Sudafed) 30 mg every 4 to 6 hours 6. Analgesics, such as acetaminophen (Tylenol) and ibuprofen (Advil), may be used for headache relief. a. Ibuprofen: Adults: 200 to 400 mg by mouth while symptoms persist; not to exceed 3. 2 g/d b. Ibuprofen: Pediatrics i. Younger than 6 months: Not established ii. 6 months to 12 years: 4 to 10 mg/kg/dose by mouth three to four times a day iii. Children older than 12 years: Administered as adults 7. Cough suppressants, if necessary: Dextromethorphan (Benylin DM, Robitussin, Vicks Formula 44 pediatric formula). a. Adults and children older than 12 years: 10 to 20 mg orally every 4 hours, or 30 mg every 6 to 8 hours, or 60 mg extended-release liquid twice daily, to a maximum of 120 mg/d b. Children 6 to 12 years: 5 to 10 mg orally every 4 hours c. Children 2 to 6 years: 2. 5 to 5 mg orally every 4 to 6 hours d. Children younger than 2 years: Few data exist regarding the therapeutic or toxic levels of cough and cold medications in children younger than 2 years. e. Elderly: Anticholinergic effects from antihistamines may be associated with side effects, including confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention, and sedation. Diphenhydramine may be appropriate in acute treatment of severe allergic reactions. 8. Colds have no allergic mechanism, so antihistamines are ineffective. 429 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
The atropine-like drying effect from antihistamines may exacerbate congestion and obstruct the upper airway by impairing mucus flow. Follow-Up A. None is recommended unless symptoms persist longer than 7 days from onset. B. Parents should return to the doctor's office if their child's fever exceeds 102°F, if respiratory symptoms increase, or if symptoms do not resolve in 10 to 14 days. Consultation/Referral A. Consult a physician if the patient has been reevaluated and given a new treatment plan but still has symptoms. B. Refer the patient to an otolaryngologist if tonsillary abscess is suspected. Individual Considerations A. Pediatrics 1. Oral decongestants are not recommended for children younger than 24 months of age. 2. The most common reported calls reported to poison control centers that involve OTC medications concern the ingestion of acetaminophen and cough and cold preparations. a. Accidental pediatric toxic ingestion is reported in children younger than 6 years, and intentional toxic ingestion is more common in adolescents aged 13 to 19 years. b. Adolescents have used dextromethorphan as a recreational drug. B. Geriatrics 1. Use of antihistamines with anticholinergic properties may cause side effects of confusion and delirium as listed earlier, along with increased rates of hospitalization. Cough Cheryl A. Glass and Melissa A. Hall Definition 430 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Coughing is a mechanism that clears the airway of secretions and inhaled particles. The act of coughing has the potential to traumatize the upper airway (e. g., vocal cords). A chronic cough is one that lasts longer than 8 weeks. B. Because coughing can be an affective behavior, psychological issues must be considered as a cause or effect of coughing. Incidence A. Data on the incidence of coughing are not available. However, most healthy people do not cough, and the main reason for coughing is airway clearance. A chronic cough is the most common presenting symptom in adults who seek medical treatment in an ambulatory setting. B. Pertussis affects infants and young children; however, the incidence is increasing in adults secondary to the lack of booster vaccination. Pathogenesis A. Stimulation of mucosal neural receptors in the nasopharynx, ears, larynx, trachea, and bronchi can produce a cough, as can acute inflammation and/or irritation of the respiratory tract. Cough is a reflex response that is mediated by the medulla but is subject to voluntary control. There is clear evidence that vagal afferent nerves regulate involuntary coughing. B. Pertussis (whooping cough) is caused by the bacterium Bordetella pertussis. C. The pathogenic triad of chronic cough responsible for 92% to 100% of chronic cough is as follows: 1. Upper airway cough syndrome (UACS), previously referred to as postnasal drip syndrome 2. Asthma 3. Gastroesophageal reflux disease (GERD) Predisposing Factors A. Pharyngeal irritants B. Foreign-body aspiration C. Tuberculosis (TB; persons in prisons and nursing homes and immigrants from areas where TB is endemic) D. Psychogenic factors (more common in children and those with emotional stress) 431 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Mediastinal or pulmonary masses F. Congestive heart failure (CHF) G. Cystic fibrosis (CF) H. Congenital malformations I. Viral bronchitis J. Asthma (sole symptom in 28%) K. Mycoplasma infection L. UACS, previously referred to as postnasal drip M. Chronic sinusitis N. Allergic rhinitis O. Environmental irritants P. GERD Q. Chronic bronchitis R. Pulmonary edema S. Medications, including angiotensin-converting enzyme (ACE) inhibitors T. Impacted cerumen and external otitis U. Nonasthmatic eosinohilic bronchitis (NAEB; 13%-33%) Common Complaints A. Common complaint is a cough that interferes with activities of daily living (ADLs) and sleeping, leading to a decrease in a patient's quality of life (QOL). B. The pertussis cough is uncontrollable and violent. Following coughing, a “whooping” sound follows with a deep breath. Other Signs and Symptoms A. Fatigue B. Rhinitis C. Epistaxis D. Tickle in throat E. Pharyngitis F. Night sweats G. Dyspnea H. Fever I. Sputum production J. Hoarseness 432 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
K. Postnasal drip Subjective Data A. Elicit information about the onset, duration, and course of the cough. Was the onset recent or gradual? Does the cough occur at night? Nocturnal cough may be caused by chronic interstitial pulmonary edema and may signal left-sided heart failure. Cough caused by asthma is also worse at night. Morning cough with sputum suggests bronchitis. B. Inquire about the cough's characteristics. For example, is it productive, dry, bronchospastic, brassy, wheezy, strong, or weak? If it is productive, is it bloody or mucoid? Note the color, consistency, odor, and amount of sputum or mucus. Dry, irritative cough suggests viral respiratory infection. Severe or changing cough should be evaluated for bronchogenic carcinoma. Rusty-colored sputum suggests bacterial pneumonia. Green or very purulent sputum is due to degeneration of white cells. HIV cough produces purulent sputum. C. Inquire whether the cough is associated with eating and choking episodes. Wheezing or stridor with coughing may indicate a foreign body or aspiration. D. Ask whether the cough is associated with postnasal drip, which produces a chronic cough, clear sputum, edematous nasal mucosa, and a “cobblestoned” pharyngeal mucosa. E. Find out whether if the cough is associated with heartburn or a sour taste in the mouth, indicating GERD. F. Ask about precipitating factors, such as exercise, cold air, or laughing. Also ask about alleviating factors. Cough from asthma can be triggered or exacerbated by exposure to environmental irritants, allergens, cold, or exercise. G. Ask about current and previous work. Is the patient exposed to occupational and environmental irritants, such as dust, fumes, or gases? If so, what are the type, level, and duration of exposures? H. Ask about family history of respiratory illness, such as CF or asthma. I. Is the patient a smoker? If so, how much does he or she smoke, and how long has he or she smoked? Is he or she exposed to secondhand smoke? How much of the day? Smoking is the main cause of chronic cough. J. Find out the date of the patient's last tuberculin skin test. Note recent exposure to TB. K. Inquire about any exposure to the flu. 433 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
L. Does the patient have a history of heart problems? M. Does the patient have a history of respiratory problems or other medical problems? Chronic bronchitis is a major cause of chronic cough and sputum production. Cough may also be an early sign of lung cancer; in late stages, cough occurs along with weight loss, anorexia, and dyspnea. N. Review medications such as ACE inhibitors. Cough related to ACE inhibitors usually subsides within 2 weeks, but the median time is up to 26 days. O. Common causes of chronic cough in the elderly include postnasal drip, asthma, and gastroesophageal reflux. Physical Examination A. Record temperature and blood pressure, if indicated. B. Inspect 1. Observe general appearance for cyanosis, difficulty breathing, use of axillary muscles, and finger clubbing. 2. Examine ears, nose, and throat. C. Auscultate heart and lungs. D. Percuss 1. Sinus cavities and mastoid process 2. Chest and lungs for consolidation E. Palpate 1. Palpate face for sinus tenderness. 2. Examine head and neck for lymph nodes, masses, and jugular vein distension (JVD). Diagnostic Tests Testing can be held to a minimum by careful review of history and physical examination. Children with chronic cough should undergo, at a minimum, a chest x-ray and spirometry (if age appropriate). A. White blood cell (WBC) if infection suspected B. HIV test if suspected C. Sputum for eosinophils, Gram stain, and/or culture D. Mantoux test if indicated E. Chest radiograph (CXR) F. Sweat chloride test to rule out CF 434 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
G. Pulmonary function testing/spirometry H. Methacholine challenge to rule out asthma I. Esophageal p H monitoring to rule out GERD J. CT scan if necessary Differential Diagnoses A. Environmental irritants 1. Cigarette, cigar, or pipe smoking 2. Pollutants (wood smoke, smog, burning leaves, etc. ) 3. Dust 4. Lack of humidity B. Lower respiratory tract problems 1. Lung cancer 2. Asthma 3. Chronic obstructive lung disease (includes bronchitis) 4. Interstitial lung disease 5. CHF 6. Pneumonitis 7. Bronchiectasis C. Upper respiratory tract problems 1. Chronic rhinitis 2. Chronic sinusitis 3. Disease of external auditory canal 4. Pharyngitis D. Medication-induced cough from ACE inhibitors E. Extrinsic compression lesions 1. Adenopathy 2. Malignancy 3. Aortic aneurysm F. Psychogenic factors, more common in children and those with emotional stress G. Gastrointestinal (GI) problems such as reflux esophagitis H. Genetic problems such as CF Plan A. General intervention 435 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
1. If sputum is purulent, obtain a sample for examination. 2. Patients with chronic obstructive pulmonary disease (COPD) and CF should be taught huffing as an adjunct to other methods of sputum clearance. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Cough. ” C. Pharmaceutical therapy 1. The American College of Chest Physicians released clinical practice guidelines in 2006 for the management of cough. Health care providers should refrain from recommending cough suppressants and over-the-counter (OTC) cough medicines for young children because of associated morbidity and mortality. The Centers for Disease Control and Prevention (CDC) noted in 2009 that, in response to safety concerns, manufacturers of cough and cold medications for children voluntarily changed labels to include warnings for use in young children. 2. Antibiotics should not be prescribed for coughs unless a bacterial infection is suspected. 3. Therapy depends on various acute inflammatory and chronic irritating processes and on the cause of the cough. Refer to applicable sections of this chapter, such as “Asthma,” “Tuberculosis,” and see Chapter 11, “Gastrointestinal Guidelines. ” Follow-Up A. The patient with a normal CXR and no risk factors for lung cancer (e. g., smoking or occupational exposure) can be followed expectantly without further testing. B. In patients whose cough resolves after the cessation of ACE inhibitors, and for whom there is a compelling reason to treat with these agents, a repeat trial of ACE inhibitors may be attempted. C. See applicable sections for specific diagnoses. D. Pertussis vaccination is available for infants, children, preteens, adults, and the elderly. Pertussis cases should be reported to the local health department. Consultation/Referral A. Consult a physician if symptoms persist after treatment. Reevaluate the 436 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
patient in 2 weeks if he or she is no better. B. When a cough lasts more than 2 weeks without another apparent cause and it is accompanied by paroxysms of coughing, post-tussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a Bordetella pertussis infection should be made unless another diagnosis is proven. C. Patients whose condition remains undiagnosed after a workup and therapy may need referral to a cough specialist. Individual Considerations A. Pregnancy: Cough may be an early symptom of pulmonary edema. Watch intrapartum patients for signs of edema. B. Pediatrics 1. The most common reported calls to poison control centers involve the ingestion of acetaminophen and cough and cold preparations. Accidental pediatric toxic ingestion is reported in children younger than 6 years, and intentional toxic ingestion is more common in adolescents aged 13 to 19 years. Adolescents have used dextromethorphan as a recreational drug. 2. Children with chronic productive purulent cough should always be investigated to document the presence or absence of bronchiectasis and to identify underlying and treatable causes such as CF and immune deficiency. C. Geriatrics 1. Aspiration should be considered in the elderly with chronic cough, as well as heart failure, laryngeal dysfunction, bronchiectasis, or tumors of the central airway. Croup, Viral Cheryl A. Glass and Melissa A. Hall Definition A. Viral croup is an acute inflammatory disease of the larynx, also called laryngotracheobronchitis. Croup is the most common cause of stridor in febrile children. The uncomplicated disease usually wanes in 3 to 5 days but may persist up to 10 days. Croup is most often self-limited, but occasionally 437 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
is severe and rarely fatal. Lethargy, cyanosis, and decreasing retractions are indications of impending respiratory failure. B. Inspiratory stridor suggests a laryngeal obstruction. C. Poiseuille's equation states that flow (air, fluid) is proportional to the radius of the chamber to the fourth power and inversely to the length. Realizing that pediatric airways are relatively small compared to adult counterparts, a twofold decrease in airway radius decreases the airflow by 16-fold. Therefore, airway resistance is exquisitely sensitive to changes in radius in the pediatric population. D. Expiratory stridor suggests tracheobronchial obstruction. E. Spasmodic croup may be a noninfectious variant with symptoms always occurring at night and has the hallmark of reoccurring in children. Although viral illness may trigger this variant, the reaction may be allergic. Incidence A. The most common form of acute upper airway obstruction, croup generally affects children aged 3 months to 6 years. Croup has a peak incidence during the second year of life. It is most prevalent in younger children in fall and early winter. Pathogenesis A. Parainfluenza viruses types 1, 2, and 3 cause about 80% of croup. The initial port of entry is the nose and nasopharynx. Other viral causes include enterovirus and rhinovirus. Influenza A and B, respiratory syncytial virus (RSV), adenovirus, coronavirus, herpes simplex virus (HSV), and measles are less common causes. In a small number of cases, croup may be caused by Mycoplasma pneumoniae. Inflammation usually occurs in the entire airway, and edema formation in the subglottic space accounts for the predominant signs of upper airway obstruction. Predisposing Factors A. Upper respiratory tract infection B. Male-to-female ratio of 1. 4:1 C. Ages 6 months to 3 years (mean onset: 18 months) D. Hyperactive airway E. Anatomic narrowing of the airway 438 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Acquired airway narrowing [from intubation, gastroesophageal reflux disease (GERD) scarring, or human papillomavirus [HPV] papillomas] Common Complaints A. Hoarseness B. Cough progressing to a seal-like barking cough C. Stridor, especially during sleep D. Fever, usually absent or low grade, but may be high E. Runny nose Subjective Data A. Determine the onset, duration, and course of illness. B. Has the child been exposed to respiratory illness? C. Is the child coughing? Having trouble breathing? D. Has the child had fever, nausea, vomiting, or diarrhea? E. Are immunizations up to date? Physical Examination Have the child sit upright in a parent's lap to perform the physical examination. Persistent crying increases oxygen demand and respiratory muscle fatigue. A. Record temperature, pulse, respirations, and blood pressure. B. Inspect 1. Observe overall appearance, noting respiratory pattern, retractions, nasal flaring, and air hunger. Children often sound terrible but do not look very ill. 2. Check nail beds and lips for cyanosis (ominous sign). 3. Assess skin and mucous membranes for signs of dehydration. 4. Observe for drooling or difficulty swallowing. 5. Inspect throat for foreign body. 6. Inspect eyes, ears, nose, and throat for infection. C. Auscultate 1. Auscultate heart. Tachycardia is out of proportion to fever. 2. Auscultate lungs for unequal breath sounds (signals foreign-body aspiration). Stridor is an audible harsh, high-pitched musical sound that may be noted on inspiration or heard during both inspiration 439 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
and expiration. Stridor is audible without a stethoscope 3. The Westley score is a way to quantify the severity of respiratory compromise. The severity of croup is evaluated by assessing inspiratory stridor, air entry, retractions, cyanosis, and level of consciousness (see Table 9. 2). D. Percuss chest. E. Palpate neck to evaluate lymph nodes. F. Neurologic examination: Assess level of alertness. Diagnostic Tests The diagnosis of croup is largely clinical, based on the presenting history and physical examination findings. A. Pulse oximetry assesses respiratory status. B. Laboratory testing is usually not needed for croup in a well-hydrated patient. However, a complete blood count (CBC) may be indicated. C. Imaging is not required in mild cases with a typical history that responds appropriately to treatment. D. Chest radiograph (CXR) may show the “steeple or pencil sign. ” E. Anteroposterior (AP) soft tissue neck radiography may show subglottic narrowing. TABLE 9. 2 Westley Scoring for Croup Symptom Scoring Inspiratory stridor No inspiratory stridor = 0 points Stridor upon agitation = 1 point Stridor at rest = 2 points Retractions Mild = 1 point Moderate = 2 points Severe = 3 points Air entry Normal = 1 point Mild decrease = 1 point Marked decrease = 2 points Cyanosis None = 0 points 440 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Cyanosis upon agitation = 4 points Cyanosis at rest = 5 points Level of consciousness Normal = 0 points Disoriented = 5 points Mild disease = A score of less than 2 points. Occasional barking coughs, no stridor at rest, and mild to no suprasternal or subcostal retraction. Moderate disease = A score of 3 to 7 points. Frequent cough, audible stridor at rest, visible retractions, but little distress or agitation. Severe disease = A score of 8 or greater. Frequent cough, prominent inspiratory (occasional expiratory) stridor, obvious retraction, decreased air entry on auscultation, and significant distress and agitation. Source: Adapted from Woods (2015b). F. Bronchoscopy or laryngoscopy may be required in unusual circumstances. G. Arterial blood gases (ABGs) are unnecessary as they do not indicate hypoxia or hypercarbia unless respiratory fatigue is present. Differential Diagnoses A. Bacterial croup B. Epiglottitis C. Spasmodic croup D. Membranous croup E. Bacterial tracheitis F. Retropharyngeal abscess G. Diphtheria H. Foreign bodies (gastrointestinal [GI] or trachea) I. Respiratory syncytial virus (RSV) J. Measles K. Varicella L. Influenza A or B M. Mechanical trauma or lesions Plan A. General interventions 1. Treatment is supportive for patients without stridor at rest. 2. Stress rest and minimal activity. 3. Cool-mist therapy has not been shown to be clinically effective. 441 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4. Hot steam should be avoided due to the potential of scalding. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Croup, Viral. ” C. Dietary management: Give plenty of fluids. D. Medical/surgical management: If pulse oximetry shows desaturation, administer oxygen and monitor carefully. E. Pharmaceutical therapy 1. Antibiotics are not indicated for the treatment of croup. 2. Acetaminophen (Tylenol) 5 to 15 mg/kg/dose for fever. 3. In moderate to severe cases requiring hospitalization: Nebulized racemic epinephrine (asthmanefrin solution) 0. 5 m L of 2. 25% solution in 2. 5 m L sterile water may relieve airway obstruction up to 2 hours. Treatment may be repeated three times. 4. Steroid use is controversial but may be considered if the preceding therapy is ineffective. Steroids are used to decrease subglottic edema by suppressing the local inflammatory process. Corticosteroids should not be given to children with untreated tuberculosis (TB). a. Decadron (dexamethasone) is the drug of choice. Pediatric dosing is 0. 6 mg/kg in single dose orally or intramuscularly. b. Budesonide (Pulmicort Respules inhalation suspension) has been shown to be equivalent to oral dexamethasone. Pediatric dosing is 2 mg (2 m L of suspension) nebulized. c. Prednisone (deltasone) pediatric dosing is 1 to 2 mg/kg/d orally daily or in a divided dose twice a day for 5 days. d. Observation for 3 to 4 hours is recommended following the initial treatment. Follow-Up A. Call the parent in 12 to 24 hours to evaluate patient status. Consultation/Referral A. Consultation with an otolaryngologist and anesthetist before rapid sequence induction may be necessary if the patient is exhibiting rapid deterioration. B. Refer the patient to a physician if he or she is a child who is severely ill with respiratory distress or dehydration. 442 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Refer the patient to a physician if there is no improvement in 12 to 24 hours. D. Patients with stridor at rest should be admitted to the hospital. Individual Considerations A. Pediatrics 1. Most children improve within a few days. 2. Virus is most contagious during the first few days of fever. 3. Children may return to day care or school when temperature is normal and they feel better, even if cough lingers. 4. Children older than 5 years of age with recurrent croup should be referred to an otolaryngologist for evaluation. Emphysema Cheryl A. Glass and Melissa A. Hall Definition A. Emphysema is an abnormal dilation and destruction of alveolar ducts and air spaces distal to the terminal bronchioles. Lung function slowly deteriorates over many years before the illness develops. Emphysema is one of the chronic obstructive pulmonary diseases (COPDs)—a term that refers to conditions characterized by continued increased resistance to expiratory airflow. Chronic bronchitis, emphysema, and asthma comprise COPD. Chronic bronchitis and emphysema with airflow obstruction commonly occur together, and as such are usually discussed together in terms of treatment. B. There are three morphological types of emphysema. 1. Centriacinar emphysema, is associated with long-term smoking and primarily involves the upper half of the lungs. 443 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
2. Panacinar emphysema is predominant in the lower half of the lungs. Panacinar emphysema is observed in patients with alpha 1-antitrypsin (AAT) deficiency. 3. Paraseptal emphysema involves the distal airway. Incidence A. Emphysema typically occurs in people older than age 50 years, with peak occurrence between ages 65 and 75 years. B. The prevalence of emphysema is 18 cases per 1,000. Pathogenesis A. Decreased gas exchange occurs due to focal destruction limited to the air spaces distal to the respiratory bronchioles causing airway obstruction, hyperinflation, loss of lung recoil, and destruction of alveolar-capillary interface. Predisposing Factors A. Long-term cigarette smoking B. Occupational and environmental exposure to toxic agents 1. Dust 2. Chemical fumes 3. Secondhand smoke 4. Air pollution 5. Gases 6. Respiratory infection C. Alpha 1-protease inhibitor deficiency D. Intravenous drug use secondary to pulmonary vascular damage from the insoluble fillers (e. g., cornstarch, cotton fibers, cellulose, talc) E. Connective tissue disorders (e. g., Marfan syndrome and Ehlers-Danlos) F. HIV Common Complaints A. Gradually progressing exertional dyspnea B. Chronic cough C. Wheezing D. Fatigue 444 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Weight loss Other Signs and Symptoms A. Cough with mild to moderate sputum production and clear to mucoid sputum B. Early-morning cough C. Shortness of breath D. Tachypnea E. Use of accessory muscles for breathing; pursed-lip breathing; prolonged expiration F. Barrel chest (increased anterior-to-posterior chest diameter) G. Flushed skin H. Clubbed fingers I. Decreased libido J. Thin, wasted appearance K. Wheezing, particularly during exertion and exacerbations of emphysema Subjective Data A. Elicit information about the onset, duration, and course of symptoms. B. Determine whether the patient is a smoker. If so, how much and for how long? Evaluate exposure to secondhand smoke. How much of the day? C. Ask about current and previous work. Is the patient exposed to occupational and environmental irritants, such as dust, fumes, or gases? If so, what are the type, level, and duration of exposures? D. Inquire about the cough's characteristics. Is it productive, dry, bronchospastic, brassy, wheezy, strong, or weak? E. Question the patient about episodes of tachypnea, frequency of respiratory infections, and incidence of angina during exertion. F. Does the patient have a hereditary disease (e. g., cystic fibrosis [CF] or AAT deficiency), asthma, nasal abnormalities (e. g., deviated septum), or other respiratory problems? G. When was his or her last tuberculin skin test done? H. Find out the patient's usual weight, and assess how much weight loss has occurred and over what time period. I. Evaluate current vaccination status for pneumonia and influenza. J. Review all medications, including over-the-counter (OTC) and herbal 445 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
products. K. Assess the patient's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), including grooming and personal hygiene, performing chores around the home, shopping, cooking, and driving. L. Ask about alcohol use. Physical Examination A. Temperature (if indicated), pulse, respirations, blood pressure, and weight. Consider pulse oximetry. B. Inspect 1. Observe general appearance; note flushed skin color, use of accessory muscles, pallor around lips, pursed-lip breathing, barrel chest (lung hyperinflation), and thinness. 2. Assess for peripheral edema. 3. Dermal examination: Note finger clubbing and cyanosis. C. Auscultate 1. Auscultate heart. 2. Auscultate lungs for wheezes, crackles, decreased breath sounds (generally diffuse decreased breath sound). 3. Assess for vocal fremitus (vibration) and egophony (increased resonance and high-pitch bleating quality). Air trapping causes air pockets that do not transmit sound well. D. Percuss chest for presence of hyperresonance and signs of consolidation. E. Palpate 1. Palpate abdomen. 2. Evaluate pedal edema. 3. Evaluate the abdomen for organomegaly. F. Further physical examinations are dependent on comorbidities. Diagnostic Tests A. Pulse oximetry: Blood gases if indicated B. AAT deficiency to rule out hereditary deficiency C. Tuberculin skin test D. Pulmonary function tests (PFTs) reveal increased total lung capacity with poor respiratory expulsion and increased respiratory volume. 446 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. EKG reveals sinus or supraventricular tachycardia. F. Chest radiograph (CXR) reveals hyperinflation, flat diaphragm, and enlarged heart. G. Sputum evaluation and/or culture Differential Diagnoses A. Emphysema B. Chronic bronchitis C. Chronic asthma D. Bronchiectasis E. CF F. Chronic asthmatic bronchitis G. Tuberculosis (TB) H. AAT deficiency I. Congestive heart failure (CHF) Plan A. General interventions 1. Medical management: Supplemental oxygen therapy is indicated if the patient has a resting Pa O2 less than 55 mm Hg or a Pa O2 less than 60 mm Hg, along with right-heart failure or secondary polycythemia. Goals are to achieve a Pa O2 of greater than 55 mm Hg (usually 1-3 L/min). 2. Develop a smoking-cessation plan: Assess readiness to quit. Set a quit date and encourage a group smoking-cessation program. A smoking-cessation plan is an essential part of a comprehensive treatment plan. a. Nicotine chewing gum produces better quit rates than counseling alone. b. Transdermal nicotine patches have a long-term success rate of 22% to 42%. c. The use of an antidepressant, such as Zyban (150 mg twice a day), has been shown to be effective for smoking cessation and may be used in combination with nicotine replacement therapy. d. Chantix is a partial agonist selective for alpha 4, beta 2 nicotinic acetylcholine receptors. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, 447 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
“Emphysema. ” C. Pharmaceutical therapy 1. Drugs of choice are inhaled beta 2 agonists. Beta 2 agonists are used primarily for relief of symptoms and, in stable patients, have an additive effect when used with an anticholinergic agent (e. g., ipratropium bromide). A spacer/chamber device should be used to improve delivery and reduce adverse effects. The following inhaled preparations have rapid action and fewer cardiac side effects: a. Ipratropium bromide (Atrovent) has bronchodilatory activity with minimum side effects. i. Metered-dose inhaler (MDI): Two to four puffs every 4 to 6 hours ii. Nebulizer: 250 mcg diluted with 2. 5 m L normal saline every 4 to 6 hours b. Tiotropium (Spiriva) is a bronchodilator similar to ipratropium. Available in a capsule form containing a dry powder or oral inhalation via a Handi Haler inhalation device. Adults: 1 capsule (18 mcg) inhaled every day via the inhaler device c. Metaproterenol sulfate (Alupent) is available as a liquid for nebulizer and MDI. i. MDI: Two puffs every 3 to 4 hours ii. Nebulizer: 0. 2 to 0. 3 m L of 5% solution diluted to 2. 5 m L with normal saline three to four times a day d. Albuterol (Proventil, Ventolin) is available as a liquid for nebulizer, MDI, and dry powder inhaler (DPI). i. MDI: One to four puffs every 3 to 4 hours ii. Nebulizer: 0. 2 to 0. 3 m L of 5% solution diluted to 2. 5 m L with normal saline three to four times a day 2. If improvement is not satisfactory or tachyphylaxis occurs, give theophylline. Theophylline improves respiratory muscle function and stimulates the respiratory center as well as bronchodilates. a. Initial dose: 10 mg/kg/daily divided in oral doses every 8 to 12 hours b. Maintenance: 10 mg/kg/daily divided in oral doses every day or twice a day; adjust doses in 25% increments to maintain serum theophylline level of 5 to 15 mcg/m L—not to exceed 800 mg/d 448 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
3. Oral steroids should be used to treat outpatients with acute exacerbations. Corticosteroids reduce mucosal edema, inhibit prostaglandins that cause bronchoconstriction, and increase responsiveness to bronchodilators. Taper the dose as soon as bronchospasm is controlled. A minority of patients who respond to oral steroids can be maintained on long-term inhaled steroids. 4. In patients with COPD, chronic infection or colonization of the lower airways is common. The goal of antibiotic therapy is not to eliminate organisms, but to treat acute exacerbations. If infection is present, give one of the following: a. Doxycycline 100 mg twice daily b. Trimethoprim-sulfamethoxazole 160/800 mg twice daily c. Clarithromycin 250 to 500 mg orally twice daily d. Cefaclor (Ceclor) 250 to 500 mg orally every 8 hours; this drug is active against Pneumococcus and H. influenzae 5. Mucolytic agents in clinical practice are not recommended currently because of a lack of evidence for their benefit. 6. Trivalent influenza vaccine is essential for all COPD patients. Give the patient the vaccine each October, at least 6 weeks before onset of flu season. 7. Pneumococcal vaccine is essential for COPD patients. Give as a single intramuscular injection of 0. 5 m L. 8. AAT is needed for significant antitrypsin deficiency (less than 80 mg/d L). Patients get weekly or monthly infusions. Consult with a physician before therapy. A history of smoking rules out candidacy. Follow-Up A. If the patient is acutely ill, contact him or her by phone in 24 to 48 hours and consider immediate referral. B. Monitor the patient's body weight. C. Serial PFTs may help guide therapy and offer prognostic information. D. Monitor theophylline levels because of the drug's potential for toxicity. Adverse effects, including nausea and nervousness, are the most common. Other adverse effects include abdominal pain with cramps, anorexia, tremors, insomnia, cardiac arrhythmia, and seizures. Theophylline doses: 100 to 200 mg every 6 to 8 hours. 449 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Consultation/Referral A. If the patient's condition remains acute after 48 hours of treatment, consider immediate referral to a physician. B. Refer the patient to a social worker for help in getting “Meals on Wheels,” handicapped parking, and finding other community resources. C. A consultation with a pulmonary specialist is recommended. Individual Considerations A. Adults 1. Sexual dysfunction is common in patients with COPD; encourage other ways to display affection. B. Geriatrics 1. Discuss course of disease, living wills, advanced directives, and resuscitation status early, before a crisis occurs. 2. Theophylline is on the Beers list of drugs to use with caution in the geriatric population related to cardiovascular, renal, and hepatic effects; insomnia; and peptic ulcers. Resources A Patient's Guide to Aerosol Drug Delivery: Retrieved from www. aarc. org/resources/clinical-resources/aerosol-resources A Guide to Aerosol Delivery Devices for Respiratory Therapists. Retrieved from www. aarc. org/app/uploads/2015/04/aerosol_guide_rt. pdf National Emphysema Foundation: www. emphysemafoundation. org The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines: Retrieved from www. goldcopd. org Obstructive Sleep Apnea Cheryl A. Glass and Melissa A. Hall Definition Obstructive sleep apnea (OSA) is the periodic reduction (hypopnea) or cessation (apnea) of breathing due to a narrowing or occlusion of the upper airway during sleep. OSA has been linked to traffic accidents, cardiac diseases, stroke, diabetes, and visceral obesity. OSA is also associated with nocturnal cardiac arrhythmias and chronic and acute cardiac events, and is a 450 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
risk factor for strokes. OSA worsens in the supine sleeping position. The following are diagnostic criteria for OSA if either of these two conditions exists: A. The presence of 15 or more apneas, hypopneas, or respiratory effort-related arousals per hour of sleep in an asymptomatic patient. More than 75% of the apneas and hypopneas must be obstructive. B. Five or more obstructive apneas, obstructive hypopneas, or respiratory effort-related arousals per hour of sleep in a patient with symptoms or signs of disturbed sleep. More than 75% of the apneas or hypopneas must be obstructive. Incidence A. The incidence of OSA in the morbidly obese population is between 38% and 88%. Otherwise, incidence in males is between 20% and 30% and females between 10% and 15%. B. In nonobese and otherwise healthy children younger than 8 years, incidence is between 1% and 3%. Obesity adds a fourfold added risk for disordered breathing. C. Most children with OSA are aged 2 to 10 years, coinciding with adenotonsillar lymphatic tissue growth. (Surgical removal of enlarged tonsils and adenoids usually results in a complete cure. ) D. Most cases in adults are undiagnosed. Pathogenesis A. Increased tissue thickness of the structures of the tongue and soft tissues in the pharyngeal cavity, which decreases the passageway for air to the trachea, is thought to be the mechanism of OSA. During the night, the muscles of the oropharynx relax, which result in the relative obstruction of the airway. Obesity and hypertrophy of tonsils and/or adenoids account for most cases of OSA in children. OSA is associated with poor neurocognitive performance and increased risk for mortality, including cardiovascular disease. Predisposing Factors A. Obesity B. Increased neck circumference 451 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Age: Increases in older persons (older than 65 years) D. Gender: Males E. Postmenopause F. Hypothyroidism G. Tonsillar hypertrophy H. Alcohol I. Craniofacial abnormalities J. Medications 1. Benzodiazepines 2. Antipsychotics 3. Opioid analgesics 4. Beta-blockers 5. Barbiturates 6. Antihistamines 7. Sedative antidepressants K. Allergic rhinitis L. Genetic conditions (e. g., Down syndrome, Pierre Robin anomalies, Marfan syndrome, etc. ) M. Ethnicity (e. g., Black, Asian, Hispanic) N. Acromegaly O. Family history P. Diabetes Q. Hypertension Common Complaints A. Daytime sleepiness B. Loud snoring, gasping, or snorting during sleep C. Fatigue Other Signs and Symptoms A. Adults 1. Asymptomatic: Patients may not recognize they have OSA because they are able to go to sleep anytime. 2. Restless sleep 3. Dry mouth or sore throat 4. Lack of physical or mental energy 452 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
5. Falling asleep when watching TV, reading, driving/riding in a car 6. Morning headaches 7. Decreased libido and impotence 8. Cognitive deficits B. Children 1. Short attention span 2. Emotional lability 3. Behavioral problems 4. Enuresis Subjective Data A. Does the patient feel sleepy during the day? Is daytime sleepiness a problem? B. Does the patient struggle to stay awake during the day? C. Does the patient take naps? How often and how long does the patient sleep? D. Does the patient feel physically and mentally exhausted? E. Does the patient's bed partner complain about snoring, gasping, or snorting? F. Ask the Epworth Sleepiness Scale questions related to how often the patient dozes off or falls asleep (in contrast to just feeling tired). Each situation is scored from 0 = would never doze, to 1 = a slight change of dozing, 2 = moderate chance of dozing, and 3 = a high chance of dozing. There are eight situations to which the patient should respond: 1. Sitting and reading 2. Watching TV 3. Sitting inactive in a public place (e. g., a theater or meeting) 4. As a passenger in a car for an hour without a break 5. Lying down to rest during the day when circumstances permit 6. Sitting and talking to someone 7. Sitting quietly after lunch without alcohol 8. In a car, while stopped for a few minutes in traffic G. Ask the patient to list all medications currently being taken, particularly substances not prescribed, including over-the-counter (OTC) and herbal products. H. Review alcohol use. 453 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
I. Men who present with sleep disorders should also be questioned about the presence of erectile dysfunction. Physical Examination A. Blood pressure, pulse, respirations, height and weight to calculate BMI, and waist measurement B. Inspect 1. Oropharynx examination for: a. Peritonsillar narrowing or hypertrophy b. Tongue (evaluate for macroglossia) c. Elongated or enlarged uvula d. Palate (high arch or narrow palate) 2. Nasal examination; look for septal deviation and nasal polyps. 3. Inspect for signs of pulmonary hypertension or cor pulmonale. a. Jugular venous distension b. Peripheral edema C. Palpate thyroid gland. D. Auscultate heart and lungs. E. Mental status: Assess for confusion. Diagnostic Tests A. Polysomnography (PSG) is the standard method of diagnosis. The apnea hypopnea index (AHI) or the respiratory disturbance index (RDI) is used to quantify hypopneas and classify the degree of sleep disturbance. 1. Full-night PSG 2. Split-night PSG 3. Home testing with portable monitors B. Routine laboratory work is not helpful in the confirmation or exclusion of OSA. Differential Diagnoses A. OSA B. Primary snoring C. Narcolepsy D. Restless leg syndrome E. Swallowing disorder 454 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
F. Nocturnal seizures G. Gastroesophageal reflux disease (GERD) H. Obesity hypoventilation syndrome I. Sleep deprivation J. Neurodegenerative disease (e. g., Parkinson's, dementia, Alzheimer's) K. Substance abuse L. Tonsillar hypertrophy Plan A. General interventions 1. Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (Bi PAP) is the mainstay of treatment for moderate to severe OSA. B. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Sleep Apnea. ” 1. Educate the patient about modifying controllable risk factors such as keeping diabetes and hypertension under control, healthy diet, exercise, and stopping smoking. 2. Treatment with CPAP and Bi PAP is required at all times during the night and during naps. 3. Behavioral strategies include sleeping in a nonsupine position using a positioning device (e. g., alarm, pillow, backpack, tennis ball are used for positional therapy). 4. Give the patient a teaching sheet on sleep apnea. C. Dietary management 1. Even a modest weight loss of 10% to 20% has been associated with an improvement. D. Nonsurgical treatment 1. Oral appliances (OAs): Require a thorough dental examination a. Custom-made OAs may improve airway patency during sleep by enlarging the upper airway and/or by decreasing the upper airway collapse. b. Mandibular repositioning appliances (MRAs) cover the upper and lower teeth and hold the mandible in an advance position. c. Tongue retaining devices (TRDs) hold the tongue in a forward position without mandibular repositioning. 455 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Surgical treatment 1. Tracheostomy can eliminate OSA but not central hypoventilation syndromes. This procedure should be considered only when other options have failed or when it is considered necessary by clinical urgency. 2. Maxillomandibular advancement (MMA) is indicated when the patient cannot tolerate/refuses CPAP and an OA is not appropriate/effective. 3. Surgical treatment should be considered after using an oral appliance or positive airway pressure for 3 months. Surgical treatment has been shown to benefit patients with tonsillar or adenoid hypertrophy, or craniofacial deformaties (www. uptodate. com/contents/management-of-obstructive-sleep-apnea-in-adults? source=search_result&search=treatment%20obstructive%20sleep%20apnea&selected Title=1~150#H15 4. Weight loss resulting from bariatric surgery has been effective in improving sleep efficiency and increasing amounts of rapid eye movement (REM) sleep. The severity of presurgical OSA determines the degree to which OSA improves postbariatric surgery. 5. Radiofrequency ablation (RFA) is for treatment of mild to moderate OSA when the patient cannot tolerate/refuses CPAP and an OA is not appropriate/effective. 6. Laser-assisted uvulopalatoplasty is not recommended for OSA. Follow-Up A. There is no standard for recommending repeat PSG testing or a CPAP titration study after significant weight loss. Consultation/Referral A. Refer to a dentist for an OA. B. Refer to a pulmonologist for management of therapy and/or surgical treatment. C. Refer the patient to a cardiologist as needed. Pneumonia (Bacterial) Cheryl A. Glass and Melissa A. Hall Definition 456 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Pneumonia is inflammation and consolidation of lung tissue caused by a bacterial pathogen. The causative agent and the anatomic location classify pneumonia. It is not uncommon to have acute viral and bacterial pneumonia concurrently. B. Other types of pneumonia and pulmonary inflammation occur secondary to smoking, exposure to chemicals, fungi, near-drowning, and from recurrent aspiration with gastroesophageal reflux. C. The CURB acronym represents the assessments for confusion, urea, respiratory rate, and blood pressure. The CURB-65 severity score for community-acquired pneumonia (CAP) is a tool to estimate pneumonia mortality and assist in determining whether the patient should best be treated in the inpatient or outpatient setting. Each parameter is given a score = 1 if present. There are five parameters: Confusion, blood urea nitrogen (BUN) greater than 19 mg/d L, respiratory rate greater than 30/min, systolic blood pressure less than 91 mm Hg or diastolic blood pressure less than 60 mm Hg, and age greater than 65 years. (http://www. mdcalc. com/curb-65-score-pneumoniaseverity) Incidence Pneumonia is the leading cause of death of children worldwide. Approximately 4 million children younger than 5 years worldwide die per year secondary to pneumonia. Pneumonia is also a leading cause of death for patients older than 65 years. A. Bacterial pneumonia is more prevalent in the very old and very young. B. A higher mortality rate occurs in young infants, persons with immunodeficiency, and in adults with abnormal vital signs and certain pathogens. C. The incidence rate also varies by pathogens. Pathogenesis Pneumonia results from inflammation of the alveolar space and anatomically can be thought of as an alveolitis. Lobar penumonia has four stages: A. Vascular congestion and alveolar edema within the first 24 hours of infection B. Red hepatization (2-3 days), characterized by erythrocytes, neutrophils, and fibrin within the alveoli 457 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
C. Gray hepatization (2-3 days), characterized by a gray-brown to yellow color secondary to exudate D. Resorption and restoration of the pulmonary architecture; a rub may still be ascultated due to the fibrinous inflammation Bacterial causes include Streptococcus pneumoniae (the most common pathogen), Haemophilus influenzae type b (Hib; the second most common pathogen), Staphylococcus aureus, Legionella, Chlamydia trachomatis, Chlamydia pneumoniae, Mycoplasma pneumoniae (most common pathogen in school-age children and adolescents), and Pneumocystis jiroveci pneumonia previously known as Pneumocystis carinii pneumonia [PCP] in patients with HIV. Predisposing Factors A. Age extremes B. Chronic obstructive pulmonary disease (COPD) C. Alcoholism D. Cigarette smoking E. Aspiration F. Heart failure G. Diabetes H. Heart failure/heart disease I. Crowded conditions (day care, dormitories) J. Immunodeficiency K. Congenital anomalies L. Abnormal mucus clearance M. Lack of immunization N. Measles O. Indoor air pollutants from cooking or heating with wood P. Prematurity Common Complaints Acute onset of these symptoms A. Fever B. Shaking chills C. Dyspnea; rapid, labored breathing D. Cough 458 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
E. Rust-colored sputum Other Signs and Symptoms A. Increased respiratory rate (tachypnea) B. Chest pain C. Upper respiratory tract infection (URI) symptoms such as pharyngitis D. Headache E. Nausea F. Vomiting G. Vague abdominal pain H. Diarrhea I. Myalgia J. Arthralgias K. Poor feeding L. Lethargy in infants Subjective Data A. Determine the onset, duration, and course of illness. B. Has the patient had fever or shaking chills? C. Has there been breathing trouble? Are the breathing problems interfering with eating and drinking? D. If a child, review the presence of acute onset of fever, cough, tachypnea, dyspnea, and grunting. E. Is there a cough? Is the cough productive? What color is the sputum? F. Are any other family members ill? G. If a child, has he or she been hospitalized for pneumonia or respiratory distress before? H. Review the history for any chronic diseases. I. Has the patient been immunized for pneumonia? J. Review all medications, including over-the-counter (OTC) and herbal products. Specifically review whether the patient has been on any antibiotics in the past 3 months. Recent exposure to an antibiotic is a risk factor for antibiotic resistance. Continued or repeated use of that class of antibiotics is not recommended. Physical Examination 459 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
A. Temperature, blood pressure, pulse, and weight. Count respirations for a full minute. 1. Tachypnea is the single best predictor of pneumonia in children and the elderly. 2. In the elderly the blood pressure is usually low. B. Inspect 1. Observe overall appearance. Does the patient appear ill? Consider the clinical presentation, age of the person, and history. 2. Observe breathing pattern and the use of accessory muscles, grunting, retractions, and tachypnea. 3. Obtain a pulse oximetry to assess oxygen saturation. An oxygen saturation less than 92% is an indicator of severity and the need for oxygen therapy. 4. Check nail beds and lips for cyanosis. 5. Examine the eyes, nose, ears, and throat. C. Auscultate 1. Heart 2. Lungs for the following (auscultate bases first in geriatric patients): a. Crackles represent fluid in the alveolar sacs (present in 80% of patients), wheezes, and decreased breath sounds b. Whispered pectoriloquy (increased loudness of whisper during auscultation) c. Egophony (patient's “e” sounds like “a” during auscultation) d. Bronchophony (voice sounds louder than usual) 3. Abdomen (usually hypoactive bowel sounds) D. Percuss chest to identify areas of consolidation. E. Palpate 1. Chest for tactile fremitus (increased conduction when patient says “99”) 2. Lymph nodes for adenopathy 3. Sinuses for tenderness; sinusitis is a sign of Mycoplasma infection Diagnostic Tests A. The British Thoracic Society in their 2011 guideline update for CAP in children notes that no diagnostic tests are necessary in the community, but emphasizes the importance of education on management, signs of 460 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
deterioration, and the need for reassessment. B. The WHO defines pneumonia solely on the basis of clinical finding observed by inspection and timing of respirations. C. Chest radiograph (CXR) 1. Infiltrates confirm diagnosis. False negatives result from dehydration, evaluation in first 24 hours, and infection. 2. Ordering a posterior, anterior, and lateral CXR ensures adequate visualization for diagnosis. D. Complete blood count (CBC) with differential. E. BUN is needed to calculate the CURB-65 score. F. Cultures 1. Blood cultures if critically ill, immunocompromised, or for persistent symptoms 2. Sputum cultures are reserved for very ill patients with unusual presentations. G. Consider rapid viral testing. H. Consider skin testing for TB for high-risk exposure. Differential Diagnoses A. Pneumonia 1. Viral pneumonia 2. Aspiration pneumonia 3. Chemically induced pneumonia B. Asthma C. Bronchitis/bronchiolitis D. Pertussis E. Heart failure F. Pulmonary embolus G. Empyema and abscess H. Aspiration of foreign body Plan A. General interventions 1. Encourage rest during acute phase. 2. Encourage patients to avoid smoking/secondhand smoke. 3. A vaporizer may be used to increase humidity. 461 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
4. Encourage good handwashing or use of hand sanitizer. 5. Chest physiotherapy is not prescribed for pneumonia. B. Patient teaching: See Section III: Patient Teaching Guides for this chapter, “Bacterial Pneumonia: Adult ” and “Bacterial Pneumonia: Child. ” C. Dietary management: Encourage a nutritious diet with increased fluid intake. D. Pharmaceutical therapy 1. Treatment with antibiotics is empirical. Oral therapy should continue for 7 to 10 days (see Table 9. 3). a. Amoxicillin is considered a first-line therapy in pediatrics. b. Macrolide antibiotics should not be the first-line therapy, but can be added if there is no response to first-line empirical therapy. c. Macrolides are the first choice in otherwise healthy adults. 2. Administer acetaminophen (Tylenol) for fever. 3. Avoid cough suppressants. Suppression of a cough may interfere with airway clearance. 4. Vaccines a. Children: Heptavalent pneumococcal vaccine is recommended for all children in the United States. b. Geriatrics: Pneumoccocal 13 and 23 vaccines are recommended for the elderly. Follow-Up A. Patients/parents should know the signs of increasing respiratory distress and seek immediate medical attention. B. Follow up with a telephone call in 24 hours. C. If there is no improvement after 48 hours on antibiotics, the patient is advised to return to the office. D. Schedule a return visit in 2 weeks for evaluation. E. Follow up CXR in 4 to 6 weeks for patients older than 60 years and for those who smoke. However, if the patient is younger than 60 years, a nonsmoker, and feels well at 6-week follow-up, there is no need to follow up with a CXR. Consultation/Referral A. Patients who are immunocompromised or have signs of toxicity or 462 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
hypoxia may need hospitalization. Refer them to a physician. B. If the child is in moderate respiratory distress, dehydrated, or hypoxemic, consult with or refer the patient to a physician/hospital. C. Poor prognostic signs that require referral are age greater than 65 years, respiration rate greater than or equal to 30 breaths per minute, systolic BP less than 90 mm Hg or diastolic BP less than 60 mm Hg, temperature greater than 101°F, altered mental status, extrapulmonary infection, and white blood cells (WBC) less than 4,000 or greater than 30,000. D. Physician consultation is needed for suspected PCP. Individual Considerations A. Pregnancy 1. The annual U. S. rate of antepartum CAP is 0. 5 to 1. 5 per 1,000 pregnancies. 2. Perinatal mortality may increase slightly due to an associated increase in prematurity. Pneumonia puts older mothers at high risk of maternal death. TABLE 9. 3 Antibiotic Therapies for Pneumonia Antibiotic Adult Dosages Pediatrics Dosages Amoxicillin: Oral 250 mg-500 mg TID 90 mg/kg/d divided TID (5 years and older) not to exceed 4,000 mg/d Amoxil, Trimox Not to exceed 1,500 mg/d Clarithromycin: Oral (Biaxin)250 mg-500 mg BID 15 mg/kg/d divided every 12 hours Not recommended for children <6 months Cefotaxime: Intramuscular (Claforan)>50 kg: 1-2 g IM every 6-8 hours. Not to exceed 12 g/d<50 kg: 100 mg-200 mg/dg/d IM divided doses every 6-8 hours Doxycycline: Oral (Doryx) 200-mg loading dose then 100 mg BID>8 years and <100 lb 2 mg/lb divided in 2 doses for 2 days; then 1-2 mg/lb daily in 2 divided doses 463 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Not recommended for children <9 years >100 lb: 100 mg orally every 12 hours Azithromycin: Oral (Zithromax)500 mg loading dose then 250 mg daily on days 2-510 mg/kg initial dose (not to exceed 500 mg/d) then 5 mg/kg daily on days 2-5 (not to exceed 250 mg/d) Moxifloxacin: Oral (Avelox)400 mg once a day Not recommended for children <18 years Levofloxacin (Levaquin) Adults >18 years of age500 mg once a day for 7-14 days OR 750 mg once a day for 5 days Other regimens depend on the pathogen Not recommended for children <18 years Renal dosing should be considered in elders. 3. The symptoms of bacterial pneumonia are the same in pregnancy. 4. CXRs are acceptable in pregnancy to diagnose pneumonia. B. Pediatrics 1. Hospitalization is recommended in infants aged 6 months and younger and also in very severe cases of pneumonia. 2. Immunization against Haemophilus influenzae type B (Hib), pneumococcus, measles, and whooping cough (pertussis) is the most effective way to prevent pneumonia. C. Geriatrics 1. Depending on the frailty status of the patient, hospitalization may be required. A calculation to objectively determine patient risk has been developed (CURB-65 Severity Score) and is available at: www. mdcalc. com/curb-65-severity-score-community-acquired-pneumonia/ Pneumonia (Viral) Cheryl A. Glass and Melissa A. Hall Definition A. Viral pneumonia is inflammation and consolidation of lung tissue due to a viral pathogen. 464 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |
Incidence A. Viral pneumonia is the most common pediatric pulmonary infection. Viral agents account for only 2% to 15% of pneumonia cases in adults. Viruses were documented in up to 45% of pneumonia cases in children. It is not uncommon to have concurrent viral and bacterial infections. B. Children younger than 5 years and elderly persons have the highest rate of influenza-associated hospitalizations. C. Pneumonia is the leading cause of death in children worldwide. Pathogenesis A. Pneumonia results from inflammation of the alveolar space and may compromise air at the alveoli-pulmonary capillary interface. Viral pneumonia is caused by influenza viruses, parainfluenza virus, and adenovirus and respiratory syncytial virus (RSV). B. RSV is the most common viral cause of pneumonia. C. Viruses and bacteria are spread from a cough or sneeze. D. Pneumonia can also be spread via blood, especially during and shortly after birth. Predisposing Factors A. Age extremes B. Prematurity C. Exposure to viral illness D. Lack of immunization Common Complaints A. Fever B. Cough C. Dyspnea D. Tachypnea E. Wheezing (more common in viral pneumonia) Other Signs and Symptoms A. Upper respiratory prodrome B. Poor appetite 465 | Jill C Cash Cheryl A Glass - Family Practice Guidelines-Springer 2017.pdf |