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2015 OPSC Annual Convention

syllabus

February 4-8, 2015 Hyatt Regency Mission BaySan Diego, California

SATURDAY, FEBRUARY 7, 2015: 9:00am - 10:00am

Osteopathic Considerations in Infections of the Respiratory TractPresented by Melissa Pearce, DO, C-NMM/OMM

OPSC’s 54th Annual Convention and Exposition Syllabus 613

PRESENTATIONLearning Objectives andSelf ASSESSMENT questions

LEARNING OBJECTIVES SELF ASSESSMENT QUESTIONS1. Review the emphasized anatomy, basic mucosal tissue morphology, lymphatic tissue organization of the head, neck, thorax, and lungs

2. Review upper and lower respiratory system neural/autonomic structures

3. Identify host defense physiology relative to the upper and lower respiratory system

4. Identify basic Upper Respiratory Infection (URI) inflammatory processes and pathway to clinical symptomology, including common URI, sinusitis, and Lower Respiratory Infection (LRI) presentations

5. Further develop an approach toward assessment and treatment goals in URI, sinusitis, and LRI complaints utilizing Osteopathic Manipulative Medicine with strategies for differentiating between disease processes and optimizing patient health

6. Review pertinent research studies in the treatment of respiratory infections, including the application of Osteopathic Manipulative Treatment

1. Which of the following is the most accurate statement about the use of antibiotics for acute maxillary sinusitis? a. A broad-spectrum antibiotic should be used if the patient has severe symptoms b. Amoxicillin/clavulanic acid is considered to be the superior antibiotic choice c. Antibiotics are recommended if symptoms persist for more than ten days d. Most patients recovered within two weeks, whether or not they received an antibiotic e. Since bacterial infection complicates about 25% of sinusitis cases, this is the expected percentage need for antibiotics

2. The trigeminal nerve a. will produce motor neurologic deficits in the frontal region if the first branch is injured b. exits the infraorbital foramen as the mandibular nerve c. Is the largest and most complex of the cranial nerves with three main branches d. second branch exits the skull through the foramen spinosum e. third branch subdivisions unite to form the sphenopalatine ganglion

3. Which of the following is the most accurate statement about the meaning and use of the -25 modifier when billing Evaluation & Management (E&M) with a concurrent procedure code? a. A separate ICD-9 (or future ICD-10) diagnosis code

is necessary in order to utilize the -25 modifier b. The -25 modifier is used to signify that a significant, separately identifiable E&M service was performed by the same provider on the same day as a procedure c. The -25 modifier should be used when the E&M is done on one day, and the patient brought back on another day for the actual procedure d. There is no official support within the osteopathic profession for the use of the -25 modifier e. When two separate procedures are done on the same day by different providers within the same practice are performed, the -25 modifier should be used


SATURDAY, FEBRUARY 7, 2015: 9:00am - 10:00am .................................. Osteopathic Considerations in Infections of the Respiratory Tract | Presented by Melissa Pearce, DO, C-NMM/OMM

Osteopathic Considerations in Infections of the Respiratory Tract

Melissa G. Pearce, D.O., C-NMM/OMM

Osteopathic Physicians and Surgeons of CaliforniaSpring Conference, San Diego

Saturday, February 7, 2015



Projected Presentation

• Images in this published material are reproduced courtesy of Thieme Publications/Thieme Teaching Assistant unless otherwise noted

• This published material excludes some images which will be projected during the presentation at the Spring conference

• Some graphics and images are referenced in text form in this material and will be projected

• Most references are included in the pertinent slide



Objectives1) Review the emphasized anatomy, basic mucosal tissue morphology,

lymphatic tissue organization of the head, neck, thorax, and lungs2) Review upper and lower respiratory system neural/autonomic

structures3) Identify host defense physiology relative to the upper and lower

respiratory system 4) Identify basic Upper Respiratory Infection (URI) inflammatory

processes and pathway to clinical symptomology, including common URI, sinusitis, and Lower Respiratory Infection (LRI) presentations

5) Identify the approach toward assessment and treatment goals in URI, sinusitis, and LRI complaints utilizing Osteopathic Manipulative Medicine with strategies for differentiating between disease processes and optimizing patient health

6) Review pertinent research studies in the treatment of respiratory infections, including the application of Osteopathic Manipulative Treatment



Clinical Case #1• cc: runny nose, cough

• HPI: A 45-year-old female presents to the clinic with a 4 day history of a dry cough and nasal congestion.• Minimal relief from nasal saline mist and herbal

cough lozenges• Coworker with similar symptoms• Had a flu shot this year• Worried about whether she has a sinus infection

and asks about antibiotics.



Clinical Case #1 (cont.)

• PMH: No significant history• Allergies: NKDA • Medications/Supplements: Daily

multivitamin, nasal saline mist, herbal cough drops




• PSH: Tonsillectomy as a child• FH: Non-contributory• SH: Non-smoker• ROS: Positives – non-productive cough,

nasal congestion, sore throat• Pertinent negatives – no subjective fever,

no myalgias, facial pain, chest pain, shortness of breath, or wheezing



Clinical Case #1 (cont.)PE:

– VS: 99 F, BP 124/76, HR 86, RR 14, SpO2 99% on RA– Gen: Alert, in no acute distress, appears congested– HEENT:

• Head: Normocephalic, atraumatic• Ears: TMs intact and canals clear bilaterally, cone of

light visualized bilaterally• Eyes: No conjunctival injection bilaterally• Nose: Mild nasopharyngeal erythema, turbinates

slightly edematous• Sinuses: No tenderness to palpation or percussion• Throat: Mild oropharyngeal erythema without exudate




• PE (cont.):– Respiratory: No increased work of breathing, lungs

clear to auscultation in all fields– Lymphatic: submental and anterior cervical chain

lymph nodes are slightly enlarged bilaterally




• Osteopathic structural examination reveals:– Head: Subocciptal tension bilaterally, OA flexed,

sidebent right, rotated left, normal tissue texture over supraorbital and infraorbital formina

– Cervical: C2 extended, rotated right, side bent right, C7 extended, rotated left, side bent left, paravertebral tissue texture changes

– Thoracic:• Thoracic inlet rotated and sidebent right• T1-T4 boggy and warm tissue texture changes bilaterally• Exquisitely tender tissue texture changes between right

medial clavicle and 2nd rib

– Ribs: Rib 1 inhalation somatic dysfunction on the right



Locations of Chapman’s reflexes on the 45-second visceral screen, pg 1 of 3

10

Visceral organ Anterior Location Posterior LocationMiddle ear Superior clavicle just lateral to the SC

jointUpper edge of the posterior aspect C1 TP

Sinuses 2-3” lateral to the SC joint under the clavicle

B/w SP and tip of the TP of C2

Larynx Superior border of the 2nd rib just lateral to the SM joint

B/w SP and TP of C2

Tonsils 1st rib interspace just superior to the SM joint

Midway between the midline of neck and tip of TP of C1

Pharynx Between the medial clavicle and the 2nd

ribB/w SP and TP of C2

Pyloris Band along the medial sternum Costotransverse articulation of T10 with rib 10




11

Visceral organ Anterior Location Posterior LocationBronchus/Myocardium / esophagus / thyroid

2nd rib interspace B/w SP and TP of T2 (esophagus/bronchus/thyroid)B/w SP and TP of T3 (myocardium)

Upper Lung 3rd rib interspace B/w T3-4 TPs and b/w SPs and TPs of T3-4Lower Lung 4th rib interspace B/w SPs and TPs of T4-5Stomach Left 5th/6th rib interspaces B/w TPs of T5-6 on the leftLiver, Gallbladder Right 5th/6th rib

interspacesB/w the SP and TP of T6-7 on the right

Spleen Left 7th rib interspace Intertransverse space of T7-8 on the leftPancreas Right 7th rib interspace b/w TP of T7-8; b/w SP and TPs of T7-8 on rightAppendix Tip of the right 12th rib At the TP of T11Small Intestine Intercostal spaces at

costochondral jcn b/w ribs 8-9, 9-10, and 10-11

B/w SP and TP of T8, T9, and T10




12

Visceral organ

Anterior Location Posterior Location

Adrenals 2” superior and 1” lateral to the umbilicus B/w SPs and TPs of T11 and T12Kidneys 1” superior and 1” lateral to the umbilicus B/w SPs and TPs of T12 and L1Bladder Triangular region around the umbilicus T10-L2 bilaterallyColon Mid-thigh within the ITB from greater

trochanter to just above the kneeTriangular region with corners at TP of L2, TP of L4 and iliac crest

Prostate/Broad Lig

Lateral thigh within the ITB from greater trochanter to just above the knee

B/w the PSIS and SP of L5

Ovary/Testes Round ligaments from the upper border of the pubic bone to the muscle attachments of the lower border

Inner ½ of ovary – intertransversespace b/w T9-T10Outer ½ of ovary – intertransversespace b/w T10-T11



Questions for Thought

• What constitutes normal anatomic-physiologic function of the upper respiratory tract?

• What influences the path to abnormal?• When can osteopathic approaches detect

abnormal?• When can allopathic approaches detect

abnormal?• How can we treat the underlying cause?• How can we provide symptomatic relief?• How can we prevent future attacks?



Respiratory Tract Divisions

Several different systems can be used to demarcate the divisions within the respiratory tractFunction:• Airway (conducting)/lung (respiratory)

– Extrathoracic and intrathoracic anatomy with division at the proximal trachea

– Lung parenchyma with transition between terminal and respiratory bronchioles

http://emedicine.medscape.com/article/1884995-overview#a1



Respiratory Tract Divisions

Structure:• Upper/Lower Respiratory Tract

– Typical division is between larynx and trachea– Trachea may be included in both

• If landmark used is sternal angle (at inferior border of superior mediastinum) division typically occurs somewhere along the trachea




Upper Respiratory Tract

• Nose/nostrils

• Nasal Vestibule

• Inferior/Middle/Superior Conchae

• Nasal Airway

• Maxillary Sinuses

• Frontal Sinuses

• Ethmoid Sinuses

• Sphenoid Sinuses

• Pharyngeal airway

• Larynx

• (Trachea)

Includes the Following Structures/Regions:



Surface Anatomy of theAdult Respiratory Sinuses

• Paranasal sinuses – Ventral aspect

• Paranasal sinuses– Lateral aspect



Anterior skull.Anterior view.

Gilroy et al: Atlas of Anatomy. © 2008-2014 Thieme Medical Publishers, Inc. All rights reserved.





Structure & FunctionUpper Respiratory Tract

• Air exchange– Filtration– Humidification

• Trapping of foreign particles• Presentation of antigens to immune system• Mucocilliary transport

– Mucus containing IgA, IgE, muramidase

• Activation of olfactory nerves by odiferous molecules– Sense of smell critical for sense of taste

Histology: ciliated pseudostratified glandular columnar epithelium lines the entire respiratory tract, including sinuses

http://emedicine.medscape.com/article/874771-overview




• Nasal passages• A small, but very important part of the tract• Nares to posterior pharynx is about 4 inches• Air from single inhalation reaches pharynx in < 0.25

seconds• During that time, the air is:

• Warmed (96.8 degrees) -> by rich vascular bed• Humidified (75%)• Cleaned




• Turbinates• Increase surface area• Increased turbulence -> foreign particles are thrown

against “sticky” epithelium

• Effects of mouth breathing?




• Cilia moves microorganisms – Process aided by “mucus blanket”– From sinuses -> through ostia -> to the posterior

pharynx• Mucous that arrives in the pharynx is swallowed

– Any microorganisms that are swallowed are killed by gastric acid

» What would a drug that diminishes stomach acid lead to?

– Mucus blanket replaced 3-4 times in 24 hours




• Autonomic balance– Typically dominated by parasympathetic

activity– Regulates number of immune cells present

http://www.nature.com/nri/journal/v8/n2/full/nri2236.html



Nasal RegionBony Lateral Nasal Surfaces –Medial to Lateral View

Mucosal Lateral Nasal Structures –Medial to Lateral View



Respiratory Sinuses Development (image)

Respiratory Epithelium(image)



Clinical Case #2 • cc: fever, nasal congestion, cough, facial pain• HPI: 45-year-old female follows up at the clinic with

worsening symptoms now been present for 11 days• Onset of fever and facial pain three days ago• Little change with phenylephrine and guaifenesin

• PMSFH: unchanged• Allergies: NKDA • Medications/Supplements: Daily multivitamin,

Emergen-C, acetaminophen, phenylephrine, guaifenesin

• ROS: – Positives – nasal discharge and congestion, pharyngitis,

fever, chills, sinus pressure, headache.– Pertinent negatives – No myalgias, SOB, CP.



Clinical Case #2 (cont.)• PE:

– VS: 102.3 F, BP 128/80, HR 90, RR 14, SpO2 99% on RA– Gen: Alert in mild distress, appears congested– HEENT:

• Head: Normocephalic, atraumatic• Ears: TMs intact and canals clear bilaterally, cone of light

visualized bilaterally• Eyes: No conjunctival injection bilaterally• Nose: Slight nasopharyngeal erythema, turbinates edematous• Sinuses: Tenderness to percussion over left maxillary region• Throat: Mild oropharyngeal erythema without exudates




• PE (cont.):– Respiratory: No increased work of breathing, lungs are clear to

auscultation in all fields without wheeze, crackles, or rhonchi– Lymphatic: submental, sublingual, and anterior cervical chain

lymph nodes slightly enlarged bilaterally



Clinical Case #2 (cont.) • Osteopathic structural examination reveals:

– Head: Left suboccipital tension & bogginess, boggy tissues over the left infraorbital foramen

– Cervical: • C2 flexed, sidebent left, rotated left• Bilateral SCM tension with tissue congestion• Exquisitely tender tissue texture changes between spinous

process and transverse process of C2– Thoracic:

• Exquisitely tender boggy tissue texture changes just under proximal left clavicle

• Thoracic inlet tissue congestion, rotated and side bent right• T1-T4 boggy and warm tissue texture changes on the left

– Ribs: Rib 1 exhalation somatic dysfunction on the left



Structure & Function Sinuses• Maxillary sinuses

• Fluid filled at birth, biphasic growth pattern

• Frontal sinuses• Formed by movement of

ethmoid cells

• Involved in heating and humidifying air• Lightens overall weight of cranium• Provides resonance to speech• Protects vital structures by providing a crumple

zone in case of facial trauma

• Ethmoid sinuses• Air cells within the

ethmoid bone

• Sphenoid sinuses• Forms from nasal

embryonic lining



Coronal and SuperiorSinus Views



Sinuses

Maxillary Sinuses (image)

Drainage Patterns



“Infection is the rule,disease is the exception”

--Nadir Khan, Ph.D.



Infection vs. Disease• Infection can cause disease but may be

present without disease– Infection – Invasion by and multiplication of

pathogenic microorganisms in a bodily part or tissue, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms

– Disease – any deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown

http://medical-dictionary.thefreedictionary.com/diseasehttp://www.thefreedictionary.com/infection



Host Defense

• The protection an organism is afforded against infections

• Types1) Nonimmunologic–eg, mucocutaneous or

integumental barriers, cilia, microvilli; mechanical–eg, urinary outflow, vascular perfusion of tissues; native flora, which 'outcompete' pathogens

2) Immunologic–eg, chemotaxis, phagocytosis, immunoglobulins, complement, T cell defense

http://medical-dictionary.thefreedictionary.com/host+defense



Clinical infection symptoms are a manifestation of an opportunistic process

Inherent healing potential of host defense compromise is the primary etiologic factor

Incidence of 62 million cases in the United States per year

Primary pathogens which may gain the upper hand

Viral

• Rhinoviruses

• Coronaviruses

• Influenza

• Adenoviruses

Upper Respiratory Infection Process

http://www.rightdiagnosis.com/u/uri/incidence-types.htmhttp://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-nurti.html




Less common pathogens

Bacterial

• Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

• Complicates less than 2% of cases of rhinosinusitis according to the CDC

Fungi

• More commonly implicated in chronic sinus infection




Clinical infectious symptoms are manifested by:

• Host defense breakdown leading to increased local tissue immunity reaction/inflammation

• Increased local interstitial/lymphatic fluid leukocytes & congestion

• Increased peripheral neural afferent visceral neural activity leading to increased efferent sympathetic tone



Upper Respiratory Infection Process – cont.

Clinical infectious symptoms are reduced by:

• Modulated tissue cellular/humeral immune system reaction/inflammation with infective agent eradication

• Increased local interstitial/lymphatic drainage with decreased fluid viscosity & congestion

• Reduction of somatic dysfunction & associated sympathicotonia with normalization of the peripheral & CNS sympathetic/parasympathetic balance



Common Presentations of Upper Respiratory Infection (URI)

Nasopharyngitis Laryngitis Pharyngitis Rhinitis Sinusitis

•Acute – Symptom onset of less than 4 wks•Subacute – Symptom onset of 4-12 weeks•Chronic – Symptom greater than 12 weeks

All of the above have similar mechanisms of initial host defense compromise

•Most start as a viral infection (the common cold) or seasonal allergy mucosal reaction•All can proceed to bacterial infections with worsening constitutional symptoms (fever, fatigue, arthralgias, myalgias)and spread to other regions (Lower Respiratory Infections ie; Bronchitis, Pneumonia)



Cochrane Summaries

• Antibiotics for the common cold, an infection of the upper respiratory tract • Included only patient with acute purulent

rhinitis• Side effects are common• No benefit http://summaries.cochrane.org/CD000247/antibiotics-for-the-common-cold-an-infection-of-the-

upper-respiratory-tract Citation: Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews

2013, Issue 6. Art. No.: CD000247. DOI: 10.1002/14651858.CD000247.pub3

• See more at: http://summaries.cochrane.org/CD000247/ARI_antibiotics-for-the-common-cold-an-infection-of-the-upper-respiratory-tract#sthash.it9IuutP.dpuf



Cochrane Summaries

• Antibiotics for acute maxillary sinusitis• Review of 63 studies• 1-2 out of 100 may benefit• Difficult to identify who might benefit• Small benefit may be overridden by negative

effects• Most people recover in 2 weeks regardless• No specific antibiotic found to be superior http://summaries.cochrane.org/CD000243/antibiotics-for-acute-maxillary-sinusitis Citation: Ahovuo-Saloranta A, Rautakorpi U, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M.

Antibiotics for acute maxillary sinusitis in adults. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub3 - See more at: http://summaries.cochrane.org/CD000243/ARI_antibiotics-for-acute-maxillary-sinusitis#sthash.F8JMf77k.dpuf



Osteopathic Research for Sinusitis

• An Osteopathic Approach to Chronic SinusitisMary Lee-Wong, Merhunisa Karagic, Ankur Doshi, Shirley Gomes, and David Resnick– Journal of Allergy & Therapy, April 20th, 2011

• Background– 15 patients requesting “alterative therapies” for relief of chronic

sinusitis– Symptoms assessed via an objective score card– OMT consisted of direct pressure and “milking” techniques– Entire treatment took 18 minutes, one single treatment



Osteopathic Research for Sinusitis (cont.)

• Results:– Sinus pain/congestion improved for all patients (p=0.0012) – Average change in pain was from moderate (3.07) to minimal

(2.33)– All patients reported feeling more relaxed after OMT– No adverse effects reported

• http://www.omicsonline.org/2155-6121/2155-6121-2-109.php



Osteopathic Manipulative Medicine inAddressing Upper Respiratory Tract Infections

Address lymphatic/fluid congestion

• Release thoracic inlet restriction

• Decompress left and right lymphatic ducts at venous junction

• Improve excursion of the thorax, ribcage, and diaphragm

• Facilitate cervical lymphatic flow in a proximal to distal fashion

• Directly mobilize fluid out of sinuses using effleurage

Facilitate normalization of autonomic tone

• Remove or reduce cervical & thoracic segmental and fascial sympathetic facilitation

• Release tissue and nerve congestion of trigeminal nerve (V1 and V2)

• Remove somatic dysfunction in the suboccipital region



Lymphatic Anatomy – Collecting System

Terminal capillaries

Collecting channels

Pre-nodal vessels

Lymph nodes

Post-nodal trunks

Ducts

Venous System 47



Lymphatic Treatment

• To move fluid, the “drain” must be open– Treat from central to peripheral– Release thoracic inlet and open

thoracic/lymphatic ducts



Lymphatic System

General Lymphatic Drainage (image)

Thoracic inlet & duct(image)



Lymphatic System

Head & Neck Lymphatics Thoracic & Lung Lymphatics



Thoracic Inlet



Thoracic Inlet

Common Location of Lymphatic Restriction

• Borders:• Ant Scalene

• Middle scalene

• 1st Rib – medial surface

• Thoracic duct at medial border of anterior scalene muscle

• Superior Thoracic Inlet (image)



Thoracic Inlet

http://en.wikipedia.org/wiki/File:Slide9a.JPGAttribution: Anatomist 90

Thoracic duct or subclavian vein compression



Structural Effects on Sympathetic Innervation

• Influenced by rib-raising and/or paraspinal muscle inhibition

• Costovertebral units move anterior, producing inhibitory or stimulatory pressure on the sympathetic ganglia



Suboccipital/condylar region



Trigeminal Nerve



Branches of the Trigeminal V1:Supraorbital Nerve Exiting from the Supraorbital Foramen



Branches of Trigeminal V2:Infraorbital Nerve Exiting from the Infraorbital Foramen



Nerves Accessed at Supraorbital and Infraorbital Foramina

• Trigeminal nerve (V) is largest and most complex cranial nerve with three main branches

• Ophthalmic nerve (V1) divides– Lacrimal– Frontal– Nasociliary

• Frontal nerve divides– Supratrochlear– Supraorbital, exits

supraorbital foramen

http://emedicine.medscape.com/article/1873373-overview



Nerves Accessed at Supraorbital and Infraorbital Foramina

• Maxillary nerve (V2) divides multiple times– ending in the infraorbital

nerve

• Sensory branches emerge from the infraorbital foramina

• Peripheral nerve stimulation is an emerging treatment for several types of headache

• Manipulation directed at the area of the foramina is considered to provide retrograde nerve stimulation to the more proximal structures

http://emedicine.medscape.com/article/1873373-overview http://www.touchneurology.com/articles/peripheral-nerve-stimulation-neuropathic-pain/page/1/0



Autonomic Innervation

Parasympathetic• Pre-ganglionic fibers from

the facial nerve enter the pterygopalatine ganglion

• Pterygopalatine ganglion produces multiple branches

• Post-ganglionic parasympathetic fibers join the maxillary nerve and innervate– lacrimal gland– mucosa of nasal cavity,

nasopharyngeal, and palate

Sympathetic

• Originates fromT1-T6 spinal cord levels

• Travels through sympathetic chain

• Synapses in cervical sympathetic chain ganglia– Superior (C1-C4)– Middle (C6)– Inferior (C7)

http://teachmeanatomy.info/head/nerves



Innervation

Autonomic Head & Neck Sympathetics (image)



ThoracicSympathetic

Chain Ganglion(image)



Case Resolution • This patient likely had a viral upper respiratory

tract infection, where her immune defenses were overwhelmed likely due to stress, nutrition, or other structural/functional reasons

• The illness progressed as the infection migrated to her left maxillary sinus

• Her structural dysfunctions were treated appropriately with OMT at this visit



Case Resolution • Rx: Amoxicillin/Clavulanate 875mg/125mg PO

q12h x 7 days, fluticasone nasal spray 17.5 mg/spray, probiotic 10 billion CFU bid x 21 days

• At her next visit, the patient reports she did not take the antibiotics as the symptoms resolved quickly before she’d filled the prescription



Osteopathic Manipulative Treatment (OMT) for URI/sinusitis

• *†Thoracic inlet release –myofascial release (thoracic)

• † Thoracic/lymphatic duct release – active lymphatic pump (thoracic)

• Thoracic diaphragm release –myofascial release (thoracic or abdomen/other)

• *Rib raising – ligamentous articular release (ribs)

• Cervical somatic dysfunction –Facilitated Positional Release, milking, effleurage(cervical)

• *Suboccipital release, occipital condylar release (head)

*Shortened treatment sequence for busy clinical practice† Can teach patient self-treatment

• *† Supraorbital/infraorbitalnerve release – neural inhibition/stimulation (head)

• Maxillary lift through zygomatic lever – Osteopathic Cranial Manipulative Medicine (OCMM) (head)

• † Galbreath technique –mandibular release (head)

• *† Facial tissue texture changes/congestion – facial effleruage (head)

Can add treatment of Chapman’s reflexes: treat pelvis first, treat reflexes after somatic dysfunction, if still present



ICD-9 Codes for URI

Acute/subacute

Nasopharyngitis(common cold) – 460Sinusitis(unspecified) – 461Pharyngitis – 462Tonsillitis – 463Laryngitis and tracheitis –464.0 to 464.5URI (multiple or unspecified sites – 465

Chronic

Pharyngitis and nasopharyngitis– 472.0 to 472.2 Sinusitis (unspecified) – 473.9Tonsillitis and adenoiditis –474.0 to 474.2 and 474.8, 474.9Laryngitis and tracheolaryngitis– 475.0 and 475.1Allergic rhinitis –477.0 to 477.2 and 477.8, 477.9

http://www.icd9data.com/2014/Volume1/460-519/default.htm



ICD-9 Codes for Sinusitis

Acute/subacute

Maxillary – 461.0Frontal – 461.1Ethmoidal – 461.2Sphenoidal – 461.3Other – 461.8Unspecified – 461.9

Chronic

Maxillary – 473.0Frontal – 473.1Ethmoidal – 473.2Sphenoidal – 473.3Other – 473.8Unspecified – 473.9



ICD-9/CPT for OMT

ICD-9 codes• 739.0 – Head region• 739.1 – Cervical region• 739.2 – Thoracic region• 739.3 – Lumbar region• 739.4 – Sacral region• 739.5 – Pelvic region• 739.6 – Lower extremities• 739.7 – Upper extremities• 739.8 – Ribs• 739.9 – Abdomen and other

CPT codes

• 98925 – 1 to 2 body regions• 98926 – 3 to 4 body regions• 98927 – 5 to 6 body regions• 98928 – 7 to 8 body regions• 98929 – 9 to 10 body regions



-25 Modifier

Use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period• http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5025.pdf



-25 Modifier

Appropriate• Modifier -25 indicates that

on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed

• A separate diagnosis code is possible but not necessary

Inappropriate

• Documentation shows the amount of work performed is consistent with that normally performed with the procedure



Use of -25 modifier

• “The American Medical Association (the publishers of Current Procedural Terminology (CPT)) has affirmed the AOA’s, the AAO’s and the ACOFP’s position that Evaluation and Management (E&M, a.k.a. inpatient or outpatient visit codes) and OMT codes (98925-98929) can and should be billed at the same visit.3“

• http://www.acofp.org/Practice_Management/OMT_Coding_Stategies_to_Boost_Your_Bottom_Line/By Douglas J. Jorgensen, DO, CPC



In case you’re wondering about coding…• Documentation and coding:

– As above with the addition of the assessment and plan:

– Assessment1. Acute sinusitis – bacterial vs. viral (461.0)2. Somatic dysfunction of head (739.0)3. Somatic dysfunction of cervical (739.1)4. Somatic dysfunction of thoracic spine (739.2)5. Somatic dysfunction of ribs (739.8)6. Somatic dysfunction of other (739.9)

• Office visit code: Ex. Follow up, low complexity – 99213-25– Add 25 modifier and code based on number of areas treated with OMT:

• 98925: 1-2 areas treated with OMT• 98926: 3-4 areas treated with OMT• 98927: 5-6 areas treated with OMT• 98928: 7-8 areas treated with OMT• 98929: 9-10 areas treated with OMT



Clinical Case #3

• cc: fever, shortness of breath• HPI: A 65 year old woman presents to clinic with a

three day history of worsening shortness of breath– Recent URI for 1 week which seemed to be resolving– Fever not responsive to acetaminophen– No recent antibiotic use

• PMH: Hypertension• Allergies: NKDA• Medications: Lisinopril 10 mg po qday,

acetaminophen 325 mg po q6hrs prn fever




• PSH: Cesarean delivery x 2• FH: Father with hypertension, mother with

COPD• SH: Non-smoker, exercises with daily walk

of 1-3 miles/day, retired, lives alone• ROS: pertinent positives: fever, fatigue,

cough, dyspnea;pertinent negatives: myalgias, nasal discharge or congestion, CP, palpitations



Clinical Case #3 (cont.) PE:

– VS 102.1 F, BP 145/82, HR 92, RR 16, SpO2 96% onRA

– Gen: Alert, oriented x 4, appears in mild distress and fatigued

– HEENT: • Head: Normocephalic, atraumatic• Eyes: No conjunctival injection bilaterally• Nose: Nares clear, mucosa intact• Throat: No erythema or exudate

– Respiratory: Increased work of breathing, decreased breath sounds in right lower lung field, egophonyelicited



Clinical Case #3 (cont.) Structural exam:

– Cervical: C3-C5 ERRSR– Thoracic:

• warm, boggy tissue texture changes paravertebral tissues T2-6

• exquisitely tender tissue texture changes right 4th/5th rib interspace

– Ribs: 7-10 exhalation somatic dysfunction– Diaphragm: decreased excursion right

hemidiaphragm



Lower Respiratory Tract Structure

Conducting• Trachea• Bronchi

– Main– Lobar– Segmental

• Bronchioles– Conducting– Terminal

Respiratory• Bronchiole

– Respiratory

• Aveolar duct• Aveolar sac

Includes the Following Structures/Regions:

http://emedicine.medscape.com/article/1884995-overview#aw2aab6b3



Anatomy of the Thoracic Cage



Anatomy of the Thoracic CageEmbryology

• Somites form from mesoderm of the neural tube and produce – Dermis (dermatomes) – Muscle (myotomes)– Vertebrae (sclerotomes)

• Vertebral segments are formed from one sclerotome above and one below– 1 vertebrae = 2 sclerotomes

• Ribs form from the inferior sclerotome as the costal process



http://php.med.unsw.edu.au/embryology/index.php?title=File:Vertebra_development_cartoon.jpg Springer Open Access



Anatomy of the Thoracic CageEmbryology

• Sternum forms from mesenchyme from the ventral body wall

• Fuses through cartilage bars to the costal processes of the ribs and to the developing clavicles

• Formation of the four embryologic segments of the sternum are sometimes referred to as “sternebrae”

• Important relationship in the development of costochondritis

Thoracic cage (image)



Anatomy of the Thoracic

CageSclerotomes

• Mesodermic cells that form the vertebrae and ribs continue to migrate and form sclerotomes

• Sclerotomal maps form important connections between the axial skeleton, ribs, and extremities

Sclerotomes (image)



Thoracoabdominal Pressures• Regulation of

thoracoabdominalpressures are critical for pulmonary, lymphatic, and venous function

• Accomplished by combined function of intercostal, scalene, abdominal, and diaphragm muscles

• Thoracic (image)



Anatomy of Respiration – Muscles

Gray’s Anatomy http://concept2.co.uk/assets/images/breathing1.jpg





Anatomy of RespirationScalenes

• Scalene muscles stabilize the first/second ribs and concentrically contract during inhalation

• Increased work of breathing can be observed by noting overactivity of scalenes and other accessory muscles of respiration

Gray’s Anatomy – public domain



Anatomy of RespirationThoracoabdominal Diaphragm

• Anterior attachments to the lower 6th ribs, along with the tranversus abdominus

• Posterior attachments at the medial arcuate ligaments at body of L1; lateral arcuateligaments at transverse processes of L1 and tip of 12th

ribs• Bilateral crurae from the

central tendon to the anterior longitudinal ligament of upper three or four lumbar vertebrae



Anatomy of RespirationLung Parenchyma

• Pleural restrictions can also produce decreased parenchymal motion



Structure & FunctionLower Respiratory Tract

Air transport from upper respiratory tract to lungs• Trapping of foreign particles

– Mucocilliary transport, continue to expel particles to be swallowed

– Mucus containing monoclonal Abs, proteoglycans– Macrophage phagocytosis– Surfactant plays a role

• Presentation of antigens to immune system– Dendritic cell uptake– Transport through tissues to lymph nodes– Presented to T-lymphocytes

Histology: ciliated pseudostratified glandular columnar epithelium lines the entire respiratory tract, including trachea

http://www.ncbi.nlm.nih.gov/pubmed/24295654



Structure & FunctionLower Respiratory Tract

Air exchange• Anatomic surface for air exchange

– Diffusion between respiratory and vascular system• Surfactant reduces surface tensions of liquids

– Regulation of oxygen/carbon dioxide balance• Results in regulation of arterial pH balance

Histology: aveoli lined with single layer squamous epithelium



The “Work Of Breathing”is in OVERCOMING:

• Airway resistance• Resistance of thoracic cage• Centripetal pull of the lungs• Movement of venous blood into the abdomen• Resistance of abdominal viscera to diaphragm

motion• Possible incisional pain• Somatic dysfunction




• Parasympathetic: Vagus

• Causes: bronchoconstriction & mucus secretion• Potential impingement at the Jugular Foramen

in the Cranial Base (Vagal sensory ganglion)• Reduction in PSNS function can produce

hypersympathetic state with increased cough




• Sympathetic: T1 – T5 (some sources cite T2-7)

• Causes bronchodilation• Mechanical issues (somatic dysfunction) at

thoracic sympathetic ganglia can cause either excessive or inadequate tone



Occipital Condylar Compression

Occipital condylar compression is the most common cause of jugular foramen and foramen magnum restrictions



Vagal Sensory Ganglion • Resides in the Jugular

Foramen • Irritation can negatively

influence function of heart, lungs, and GI tract (to distal colon)

• Irritation can increase vagal activity: causing bradycardia, bronchoconstriction, and peristalsis

• Co-morbid with other entrapments of CN IX, CN XI, & Jugular Vein

• Vagus nerve and ganglion (image)



Somatic Innervation

• Phrenic nerves to Diaphragm (C3 – C5)• Spinal Nerves to intercostal muscles• Accessory Nerve (CN XI) to Accessory

Muscles of Respiration



Somatic Innervation

• Paired phrenic nerves innervate each hemidiaphragm

• Costal nerves supply the lateral diaphragm

• Diaphragm function affects heart and lung position



Somatic Innervation



Bronchitis vs. Pneumonia

• Cases of illness with acute cough are 90% non-bacterial– Viral: influenza, parainfluenza, RSV,

adenovirus– Bacterial: Bordatella pertussis, Mycoplasma

pneumoniae, Chlamydophilia pneumoniae

• Purulent sputum not predictive of bacterial infection

http://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-acute-cough-illness.pdf



Bronchitis vs. Pneumonia

• Antibiotics not warranted for acute bronchitis except if pertussis is suspected– Diagnostic test for confirmation should be

performed• Evaluation to rule out severe illness is crucial• Pneumonia unlikely if four signs absent:

– Fever (>38 C),tachypnea (>24 bpm), tachycardia (>100 bpm), consolidation (rales, egophony, fremitus)

– Consider chest Xray if any of these present or cough >3 weeks

http://www.cdc.gov/getsmart/campaign-materials/info-sheets/adult-acute-cough-illness.pdf



Pneumonia

• Key points:– Origin important for determination of

appropriate management and antibiotic choice

• Community-acquired pneumonia (CAP)• Healthcare-associated pneumonia (HCAP)• Ventilator-associated pneumonia (VAP)

– Remainder of this material will focus on CAP



Community-Acquired Pneumonia (CAP)

• 85% of cases attributed to:– Streptococcus pneumoniae– Hemophilus influenzae– Moraxella catarrhalis

• Less common:– Pseudomonas aeruginosa– Klebsiella pneumoniae– Staphylococcus aureus

• Atypical CAP pathogens– Zoonotic (e.g. Coxiella burneti – Q Fever)– Non-zoonotic (Legionella, Chlamydia pneumoniae)




C(U)RB-65 Pneumonia Severity • Classically a five-point assessment tool for

predicting patient mortality with pneumonia – Provides guidelines for admission vs. outpt mgmt

• Assess the patient for: – Confusion, new onset – (Urea nitrogen [BUN], blood > 7 mmol) – Respiratory rate > 30 – Blood pressure SBP < 90 mmHg, DBP < 60 mmHg – Age > 65 years

http://reference.medscape.com/calculator/curb-65-pneumonia-severity-score



C(U)RB-65 Pneumonia Severity • Assign one point for each item, admission

indicated if 2 points or more • Can omit BUN and plan admission if score is 1 or

more, but this may disadvantage the “young old” group aged 65-74

• CRB-65 clearly correlated with Pneumonia Severity Index (PSI)



Pneumonia Severity Scales • Pneumonia Severity Index (PSI) is the most validated

measure of predicted mortality in pneumonia – Disadvantage of complexity, requiring multiple tests

• Addition of hypoxemia and co-morbid conditions to the CRB-65 may further improve prognostic value

• Generalized disadvantages include: – Whether mortality is the best measure of need for

hospitalization vs. outpatient management – Do not take into account other functional measures – Are less applicable to care facility patients

Thorax.bmj.com 2008:63:665-66 Bmjopenrespres.bmj BMJ Open Respiratory Research 2014-000038



Hospitalized Patients with Pneumonia (MOPSE study)

• Goal: Assess the efficacy of OMT as an adjunctive treatment in elderly hospitalized patients with pneumonia

• Methods: Double-blind, randomized, controlled trial–406 subjects in seven Community hospitals–Hospitalized patients with pneumonia initially

>60, then later changed to >50 years of age

Noll et. al., Osteopathic Medicine and Primary Care, 2010



Hospitalized Patients with Pneumonia

• Control: Conventional Care Only (CCO)

• Sham: CC + Light touch 15 min• OMT: CC + OMT 15 min

–Standardardized protocol + up to 5 min to address issues found but not treated within protocol

Noll, Osteopathic Medicine and Primary Care, 2010



Hospitalized Patients with Pneumonia

• Results:–Intention To Treat (ITT) Analysis

• No effect– Per-protocol (PP) Analysis

• OMT vs Control– Decreased Length of Stay (2 days)– Decreased duration of IV antibiotics (2 days)

• Light Touch fell in between CCO and OMT in effect on outcome measures

Noll, Osteopathic Medicine and Primary Care, 2010



Case Resolution • This patient likely had a viral upper respiratory

tract infection, which made her vulnerable to progression to a bacterial infection

• She met criteria for outpatient management of pneumonia by CRB-65 criteria

• Chest Xray showed right lower lobe consolidation • Her structural dysfunctions were treated

appropriately with OMT during her visit (see description)

• Rx: azithromycin 500 mg x1 , then 250 mg qday x 4 days, probiotic 10 billion CFU bid x 21 days



OMT in Respiratory Disease• Potential to decrease work of breathing,

optimize thoracic cage, and diaphragmatic function

• Application of treatment directed to the nervous system can improve homeostasis, sympathetic/parasympathetic balance, and somatic nerve function

• Treatment of viscerosomatic reflexes can reduce facilitation

• Lymphatic treatment decreases interstitial fluid overload and stimulates immune response



Osteopathic Manipulative Medicine inAddressing Lower Respiratory Tract Infections

Facilitate normalization of autonomic tone

• Reduce cervical & thoracic segmental and fascial sympathetic facilitation through paraspinal tissue inhibition and rib raising

• Remove somatic dysfunction in the suboccipital region

Address lymphatic/fluid congestion

• Release thoracic inlet restriction

• Decompress left and right lymphatic ducts at venous junction

• Improve diaphragmatic excursion (also helps respiratory function)

Improve respiratory function through thoracic structure

• Address any remaining thoracic somatic dysfunction, including lung parenchyma



Osteopathic Manipulative Treatment (OMT) for LRI

• Paravertebral tissue texture changes – inhibitory pressure (thoracic)

• *Rib raising – ligamentous articular release (ribs)

• *Thoracic inlet release –myofascial release (thoracic)

• Thoracic/lymphatic duct release – active lymphatic pump (thoracic)

• *Thoracic diaphragm release –myofascial release (thoracic or abdomen/other)

• *Suboccipital release, occipital condylar release (head)

*Shortened treatment sequence for busy clinical practice

• This representative treatment for this case does not preclude application of other approaches for patients with pneumonia, bronchitis, or other LRI

• Options include Counterstrain, Cranial, HVLA, and many others

• Can add treatment of Chapman’s reflexes: treat pelvis first, treat reflexes after somatic dysfunction, if still present



Osteopathic Manipulative Treatment (OMT) for LRI

• Many of the approaches for OMT are applicable to adjunctive treatment of URI– Covered in more detail in Case #2

• Thoracic inlet, thoracic ducts,



Diaphragmatic Function

• Optimal respiratory diaphragmatic function will facilitate restoration of respiratory function



Diaphragmatic Function

• Optimal diaphragmatic function throughout the body will facilitate return of lymph and removal of metabolic wastes from the peripheral tissues




• Occipital condylar decompression can decrease potential vagus nerve dysfunction from entrapment at the jugular foramen

• Potential for associated dysfunction of CN IX, XI

NetterAtlas



ICD-9 Codes for LRI

Acute/subacute

Laryngitis and tracheitis– 464.0 to 464.5Bronchitis and bronchiolitis– 466.0 and 466.1Pneumonia 480 – 486

Viral – 480Pneumococcal – 481Unspecified – 486

Chronic

Laryngitis and tracheolaryngitis– 475.0 and 475.1Pneumonia, recurrent – V12.61



OMT in Respiratory Infection

Key Points• Utilize osteopathic structural exam findings to

assist with differential diagnosis• Choose key osteopathic manipulative

interventions to effect beneficial change• Incorporate OMT even in busy practice• Utilize ICD-9 billing codes with -25 modifier,

as appropriate• ICD-10 predicted implementation in Oct 2015



Thanks to Colleagues

For current and previous contributions to lecture materials preparation, and for advice, support, and collegiality• Victor Nuño, D.O.• Lee Ann Cuny, D.O.• R. Mitchell Hiserote, D.O.• Thomas McCombs, D.O.



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